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Galactorrhea

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Galactorrhea

  • Definition
  1. Non-Lactational milk production and discharge from the Breast
    1. Men and children
    2. Women (non-lactating, >12 months postpartum)
  • Differential Diagnosis
  • 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, 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
    2. Decreased libido
    3. Recent pregnancies, Miscarriages or abortions
  4. Past medical history
    1. Chest surgery or injury
    2. Hypothyroidism
    3. Chronic Kidney Disease
  5. Family History
    1. Multiple endocrine neoplasia (esp. Type I)
    2. Thyroid disease
  6. Social history
    1. Recent emotional stress
  7. 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
  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. ThyroidGoiter
      2. Myxedema
      3. Coarse hair or Dry Skin
  • Imaging
  • Brain (if indicated)
  • Evaluation
  • Step 1
  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
  2. Interpretation
    1. Non-Galactorrhea
      1. Evaluate for Breast pathology
      2. See Nipple Discharge
    2. Galactorrhea
      1. Follow step 2 below
  • Evaluation
  • Step 2
  1. 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)
      1. Serum Estrogen
      2. Serum Testosterone
      3. Follicle Stimulating Hormone
      4. Luteinizing hormone
  2. 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 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
  • Management