Galactorrhea

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

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
Medications
1. Oral Contraceptives are most common cause
2. See Medication Causes of Hyperprolactinemia
Gynecologic history
1. Amenorrhea or oligomenorrha or other altered Menstrual Cycle
2. Decreased libido
3. Recent pregnancies, Miscarriages or abortions
History in males
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
  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

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
Interpretation
1. Follow step 3 if non-physiologic Galactorrhea (negative urine bHCG and no Lactation in last year)

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

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)
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 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

See Hyperprolactinemia
Nursing pads
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
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