Galactorrhoea

Section: Breast Curriculum: Curriculum, page 9

Definition

• Secretion of milk not related to pregnancy / lactation

Causes

• Physiological
  • Mechanical stimulation (stimulates Prolactin)
  • Stress
  • Breast feeding
  • Pregnancy
• Pathological
  • Drugs that decrease dopamine activity
    • Leads to increased prolactin secretion from anterior pituitary
    • Dopamine from hypothalamus usually inhibit this
    • Mostly antipsychotics - Haloperidol / Chlorpromazine / Metoclopramide
  • Tumours
    • Prolactinomas
    • 1o Prolactin-secreting tumour or Bronchogenic cancer
  • Other
    • Hypothyroidism
      • increased TRH stimulates prolactin secretion
    • Idiopathic hyperprolactinemia
    • Chronic kidney disease (reduced prolactin clearance)
    • Liver disease (altered metabolism of hormones)

Workup

• History
  • Duration, frequency, and nature of discharge.
  • Relation to pregnancy, breastfeeding, or trauma.
  • Menstrual irregularities, headache, or vision changes.
  • Medication history (e.g., antipsychotics, SSRIs).
  • Systemic symptoms (e.g., thyroid dysfunction, renal or liver disease).
• Physical Examination
  • Breast Examination
    • Check for masses, tenderness, or asymmetry.
    • Evaluate nipple discharge (color, consistency, and expression without stimulation).
  • Thyroid Examination
    • Assess for goiter or signs of hypothyroidism.
  • Neurological Examination
    • Look for visual field defects or cranial nerve abnormalities.
• Laboratory Tests
  • Serum Prolactin Levels:
    • Elevated in hyperprolactinemia (>20–25 ng/mL in women, >15 ng/mL in men).
    • Check fasting levels for accuracy.
  • Thyroid Function Tests (TSH, free T4):
    • Elevated TSH suggests hypothyroidism.
  • Other Hormonal Tests:
    • Estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in women with menstrual irregularities.
    • Serum testosterone in men.
  • Renal and Liver Function Tests:
    • To rule out systemic causes.
• Imaging
  • Pituitary MRI:
    • Indicated for hyperprolactinemia or suspicion of pituitary adenoma.
  • Breast Imaging:
    • Mammogram or ultrasound if concerning breast findings are present.
  • CT Chest:
    • If chest wall pathology is suspected.

Management

Address Underlying Cause

• Physiological Causes:
  • Reassure; no specific treatment needed.
• Medication-Induced:
  • Discontinue or switch offending drugs, if feasible.
• Hypothyroidism:
  • Treat with levothyroxine to normalize TSH levels.
• Hyperprolactinemia:
  • Microadenomas (<10 mm):
    • Dopamine agonists (e.g., cabergoline or bromocriptine) are first-line treatments.
  • Macroadenomas (>10 mm):
    • Dopamine agonists.
    • Surgery (transsphenoidal resection) if refractory or causing mass effects (e.g., vision loss).
• Idiopathic:
  • Observe if symptoms are mild and prolactin levels are only slightly elevated.