Galactorrhea

Aka: Galactorrhea, Nonpuerperal Galactorrhea, Lactation Not Associated With Childbirth, Milk from Non-Pregnant Breast

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II. Definitions

  1. Nonpuerperal Galactorrhea
    1. Non-Lactational milk production and discharge from the Breast
    2. In addition to post-menopausal or non-lactating women (>12 months postpartum), may be seen in men and in children

III. Epidemiology

  1. Estimated lifetime Incidence in women: 20-25%

IV. Causes

  1. See Causes of Hyperprolactinemia
  2. See Medication Causes of Hyperprolactinemia

V. Differential Diagnosis

  1. See Nipple Discharge

VI. History

  1. Nipple Discharge
    1. See Nipple Discharge
    2. Pathologic discharge
      1. Unilateral discharge or discharge from a single duct
      2. Bloody, serosanguineous or purulent discharge
    3. Normal discharge
      1. Galactorrhea is typically milky white, bilateral and multi-ductal
      2. Coloration can vary (yellow to brown, or even green)
      3. Precipitated by Breast stimulation
  2. Medications
    1. Oral Contraceptives are most common cause
    2. See Medication Causes of Hyperprolactinemia
  3. Gynecologic history
    1. Amenorrhea or oligomenorrha or other altered Menstrual Cycle
    2. Decreased libido
    3. Recent pregnancies, Miscarriages or abortions
  4. History in males
    1. Infertility
    2. Erectile Dysfunction
    3. Gynecomastia
  5. Past medical history
    1. Chest surgery or injury
    2. Hypothyroidism
    3. Chronic Kidney Disease
  6. Family History
    1. Multiple Endocrine Neoplasia (esp. Type I)
    2. Thyroid disease
  7. Social history
    1. Recent emotional stress
  8. Associated symptoms for common pathologic causes
    1. Prolactinoma
      1. Age 20 to 35 years
      2. Headache
      3. Vision change (e.g. bitemporal Hemianopsia from medial Optic Chiasm compression)
      4. Seizure Disorder
      5. Polyuria or Polydypsia
    2. Hyperprolactinemia
      1. Amenorrhea
      2. Decreased libido
      3. Infertility
    3. Hypothyroidism
      1. Fatigue
      2. Cold Intolerance
      3. Constipation

VII. Examination

  1. Assess growth: Height and weight
    1. Decreased growth
      1. Hypopituitarism
      2. Hypothyroidism
      3. Chronic Renal Failure
    2. Increased growth (Acromegaly)
      1. Pituitary tumor
  2. Assess Vital Signs
    1. Bradycardia: Hypothyroidism
    2. Tachycardia: Thyrotoxicosis
  3. Chest exam
    1. Observe for local injury or infection
    2. Breast Exam (see Nipple Discharge)
  4. Associated signs for common pathologic causes
    1. Pituitary mass
      1. Visual Field Deficit
      2. Papilledema
      3. Cranial Nerve dysfunction
    2. Hyperprolactinemia
      1. Hyperandrogenism (e.g. Hirsutism, Acne Vulgaris)
    3. Hypothyroidism
      1. Thyroid Goiter
      2. Myxedema
      3. Coarse hair or Dry Skin

VIII. Imaging: Brain (if indicated)

  1. See Hyperprolactinemia

IX. Evaluation: Step 1 - Nipple Discharge

  1. Evaluate for Galactorrhea (versus other Nipple Discharge)
    1. Consider examining discharge under microscope
      1. Typically not performed, but consider if appearance is not definitive for milky discharge
      2. Sudan IV Stain will demonstrate fat globules in discharge consistent with Galactorrhea
    2. Amenorrhea present? (see history above)
      1. Galactorrhea with Amenorrhea is pathognomonic for Hyperprolactinemia
      2. Galactorrhea without Amenorrhea is associated with normal Serum Prolactin
  2. Interpretation
    1. Non-Galactorrhea
      1. Evaluate for Breast pathology
      2. See Nipple Discharge
    2. Galactorrhea
      1. Follow step 2 below

X. Evaluation: Step 2 - Galactorrhea

  1. Evaluate for physiologic Lactation
    1. Serum Prolactin rises 200 to 500 ng/ml in pregnancy
    2. Breast Feeding or delivery in the last year
    3. Obtain urine qualitative bHCG
  2. Interpretation
    1. Follow step 3 if non-physiologic Galactorrhea (negative urine bHCG and no Lactation in last year)

XI. Evaluation: Step 3 - Non-Physiologic Galactorrhea

  1. Obtain Serum Prolactin
    1. Delay measurement until at least 30 minutes or more after vigorous Exercise or Breast Exam or nipple stimulation
  2. Interpretation: Normal or decreased Serum Prolactin
    1. Idiopathic Galactorrhea
  3. Interpretation: Increased Prolactin (Hyperprolactinemia)
    1. Go to Step 4

XII. Evaluation: Step 4 - Hyperprolactinemia

  1. Tests
    1. Thyroid Stimulating Hormone (TSH) Level and Free Thyroxine
    2. Comprehensive Metabolic Panel (Electrolytes, Serum Creatinine, hepatic panel)
    3. Sex Hormones (if Hypogonadism suspected)
      1. Serum Estrogen
      2. Serum Testosterone
      3. Follicle Stimulating Hormone
      4. Luteinizing Hormone
  2. Interpretation
    1. Prolactin Level > 20 ng/ml in postmenopausal women (>30 ng/ml in premenopausal women, >18 ng/ml in men)
      1. See Hyperprolactinemia
      2. Consider MRI Pituitary (see imaging above)
    2. Hypothyroidism (TSH increased)
      1. Replace Thyroid Hormone
    3. Decreased Renal Function
      1. Evaluate for Chronic Kidney Disease
    4. Decreased liver function
      1. Evaluate for liver dysfunction
    5. Suspected Medication Causes of Hyperprolactinemia
      1. Trial medication change or discontinuation
      2. Repeat Serum Prolactin level at least 3 days after medication change
      3. If persistent Hyperprolactinemia, consider MRI Pituitary and Hyperprolactinemia evaluation
    6. Normal labs
      1. Regular Menses
        1. Observe
        2. Periodically recheck Serum Prolactin levels
      2. Amenorrhea or Oligomenorrhea
        1. Consider False NegativeProlactin seen with very large Prolactinomas (hook effect)
        2. Consider asking lab to re-run Serum Prolactin at 1:100 dilution
        3. Consider MRI Brain
        4. See Hyperprolactinemia

XIII. Management

  1. See Hyperprolactinemia
  2. Nursing pads
  3. Microadenoma with Amenorrhea and mild or manageable Galactorrhea
    1. See Hyperprolactinemia for management with Dopamine Agonists
    2. Low dose Oral Contraceptives may be considered as an alternative to Dopamine Agonists
      1. Continue Serum Prolactin level and symptom monitoring (at least yearly) and MRI pituitary as needed
  4. Microadenoma with normal Menstrual Cycles (or postmenopausal) and mild or manageable Galactorrhea
    1. Patient may choose no management (or Dopamine Agonist)
    2. Continue Serum Prolactin level and symptom monitoring (at least yearly) and MRI pituitary as needed

XIV. References

  1. Bruehlman (2022) Am Fam Physician 106(6): 695-700 [PubMed]
  2. Falkenberry (2002) Obstet Gynecol Clin North Am 29:21-9 [PubMed]
  3. Huang (2012) Am Fam Physician 85(11): 1073-80 [PubMed]
  4. Leung (2004) Am Fam Physician 70:543-54 [PubMed]
  5. Pena (2001) Am Fam Physician 63:1763-70 [PubMed]
  6. Yazigi (1997) Fertil Steril 67:215-25 [PubMed]

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Related Studies

Ontology: Galactorrhea not associated with childbirth (C0235660)

Concepts Disease or Syndrome (T047)
MSH C537072
ICD9 611.6
ICD10 N64.3
SnomedCT 78622004, 198115002
French GALACTORRHEE, Allaitement non puerpéral, Galactorrhée non liée à la naissance, Galactorrhée chez la femme, Lactation non puerpérale, LACTATION NON PUERPERALE, Galactorrhée
English Galactorrhea not associated with childbirth, GALACTORRHEA, GALACTORRHOEA, LACTATION NONPUERPERAL, Inappropriate milk production, nonpuerperal galactorrhea, nonpuerperal galactorrhea (diagnosis), Galactorrhea - non-obstetric, Galactorrhoea - non-obstetric, Galactorrhea female, Lactation non-puerperal, Lactation nonpuerperal, Galactorrhea-nonobstet, Nonpuerperal galactorrhea, Galactorrhoea female, Galactorrhea, Galactorrhoea, Inappropriate lactation, Inappropriate production of milk, Milk from non-pregnant breast, Galactorrhoea not associated with childbirth, Galactorrhea due to non-obstetric cause, Galactorrhoea due to non-obstetric cause, Galactorrhea due to non-obstetric cause (disorder), Galactorrhea not associated with childbirth (disorder), galactorrhea; not associated with childbirth, lactation; nonpuerperal, nonpuerperal; lactation, Galactorrhea, NOS
Portuguese GALACTORREIA, Lactação não puerperal, Galactorreia não associada a parto, Galactorreia na mulher, LACTACAO NAO PUERPERAL, Galactorreia
Spanish GALACTORREA, Lactación no puerperal, Lactancia no puerperal, Galactorrea no asociada al parto, Galactorrea femenina, SECRECION LACTEA NO PUERPERAL, galactorrea de causa no obstétrica (trastorno), galactorrea de causa no obstétrica, galactorrea no asociada con el nacimiento (trastorno), galactorrea no asociada con el nacimiento, galactorrea, Galactorrea
German GALAKTORRHOE, Galaktorrhoe, nicht assoziiert mit Geburt, Laktation, nicht puerperal, Laktation, puerperal, Galaktorrhoe, weiblich, Galaktorrhoe, nicht im Zusammenhang mit der Geburt, LAKTATION OHNE SCHWANGERSCHAFT, Galaktorrhoe
Italian Galattorrea, Galattorrea femminile, Lattazione non puerperale, Galattorrea non associata con il parto
Dutch galactorrhoea niet veroorzaakt door geboorte kind, galactorrhoea vrouw, niet-puerperale lactatie, galactorroe; niet samenhangend met bevalling, lactatie; niet-puerperaal, niet-puerperaal; lactatie, Galactorroe zonder verband met bevalling, galactorroe
Japanese 乳汁漏出症, 非産褥性乳汁分泌, ﾆｭｳｼﾞｭｳﾛｳｼｭﾂｼｮｳ, ﾋｻﾝｼﾞｮｸｾｲﾆｭｳｼﾞｭｳﾌﾞﾝﾋﾟ, ﾋｻﾝｼﾞｮｸｾｲﾆｭｳｼﾞｭｳﾌﾞﾝﾋﾟﾂ, ﾌﾞﾝﾍﾞﾝﾆﾄﾓﾅﾜﾅｲﾆｭｳｼﾞｭｳﾛｳｼｭﾂｼｮｳ, 分娩に伴わない乳汁漏出症, ｼﾞｮｾｲﾆｭｳｼﾞｭｳﾛｳｼｭﾂｼｮｳ, 女性乳汁漏出症
Czech Galaktorea u ženy, Galaktorea, Galaktorea nesouvisející s porodem, Laktace nepuerperální
Korean 출산과 관련되지 않은 젖흐름증
Hungarian Szüléshez nem kapcsolódó galactorrhoea, Nem gyermekágyi tejelválasztás, Galactorrhoea, Szüléstől független galactorrhoea, Női galactorrhoea
Derived from the NIH UMLS (Unified Medical Language System)

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