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Galactorrhea

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Galactorrhea

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Definition

Non-Lactational milk production and discharge from the Breast
1. Men and children
2. Women (non-lactating, >12 months postpartum)

Causes

See Causes of Hyperprolactinemia
See Medication Causes of Hyperprolactinemia

Differential Diagnosis

See Nipple Discharge

History

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, bilateral and multi-ductal
  2. Coloration can vary (yellow to brown, or even green)
  3. Precipitated by Breast stimulation
Medications
1. Oral Contraceptives are most common cause
2. See Medication Causes of Hyperprolactinemia
Gynecologic history
1. Amenorrhea or oligomenorrha
2. Decreased libido
3. Recent pregnancies, Miscarriages or abortions
Past medical history
1. Chest surgery or injury
2. Hypothyroidism
3. Chronic Kidney Disease
Family History
1. Multiple endocrine neoplasia (esp. Type I)
2. Thyroid disease
Social history
1. Recent emotional stress
Associated symptoms for common pathologic causes
1. Prolactinoma
  1. Age 20 to 35 years
  2. Headache or Vision change
  3. Seizure Disorder
  4. Polyuria or Polydypsia
2. Hyperprolactinemia
  1. Amenorrhea
  2. Decreased libido
  3. Infertility
3. Hypothyroidism
  1. Fatigue
  2. Cold Intolerance
  3. Constipation

Examination

Assess growth: Height and weight
1. Decreased growth
2. Increased growth (Acromegaly)
  1. Pituitary tumor
Assess Vital Signs
1. Bradycardia: Hypothyroidism
2. Tachycardia: Thyrotoxicosis
Chest exam
1. Observe for local injury or infection
2. Breast Exam (see Nipple Discharge)
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

Imaging
Brain (if indicated)

See Hyperprolactinemia

Evaluation
Step 1

Evaluate for Galactorrhea
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
Interpretation
1. Non-Galactorrhea
  1. Evaluate for Breast pathology
  2. See Nipple Discharge
2. Galactorrhea
  1. Follow step 2 below

Evaluation
Step 2

Tests
1. Quantitative Serum Beta hCG (Urine Pregnancy Test)
2. Serum Prolactin Level
  1. Delay measurement until at least 30 minutes or more after vigorous Exercise or Breast Exam or stimulation
3. Thyroid Stimulating Hormone (TSH) Level
4. Serum Creatinine
5. Sex Hormones (if Hypogonadism suspected)
Interpretation
1. Hypothyroidism
  1. Replace Thyroid Hormone
2. Prolactin Level > 20 ng/ml
  1. See Hyperprolactinemia
  2. Consider MRI Brain (see imaging above)
3. Normal labs
  1. Regular Menses
    1. Observe
    2. Periodically recheck Serum Prolactin levels
  2. Amenorrhea or Oligomenorrhea
    1. Consider False Negative Prolactin 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

Management

See Hyperprolactinemia

References