Galactorrhea

Galactorrhea is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Milky nipple discharge not associated with gestation or present >1 year after weaning. Galactorrhea does not include serous, purulent, or bloody nipple discharge.
  • System(s) affected: endocrine/metabolic, nervous, reproductive
Pregnancy Considerations
  • Most cases of galactorrhea during pregnancy are physiologic.
  • Pregnancy stimulates lactotroph cells, so pituitary prolactin-secreting macroadenomas may increase by 21% (1)[A].

Epidemiology

  • Predominant age: 15 to 50 years (reproductive age)
  • Predominant sex: female > male (rare, e.g., in patients with multiple endocrine neoplasia type 1 [MEN1], the most common anterior pituitary tumors are prolactinomas)

Prevalence
6.8% of women referred to physicians with a breast complaint have nipple discharge.

Etiology and Pathophysiology

  • Lactation is stimulated by prolactin, which is secreted in pulses by the anterior pituitary, inhibited by dopamine produced in the hypothalamus.
  • Galactorrhea results either from prolactin overproduction or loss of inhibitory regulation by dopamine.
    • Afferent neural stimulation
      • Chest wall trauma
      • Chiari-Frommel, del Castillo, and Forbes-Albright syndromes
      • Herpes zoster
      • Nipple stimulation
      • Spinal cord injury
    • Organic hyperprolactinemia
      • Craniopharyngiomas
      • Irradiation
      • Meningiomas or other tumors
      • Multiple sclerosis (MS) (with hypothalamic lesion)
      • Pituitary stalk compression
      • Post-breast augmentation surgery (1%)
      • Prolactinoma
      • Sarcoid
      • Traumatic injury
      • Vascular malformations (aneurysms)
    • Functional hyperprolactinemia
      • Adrenal insufficiency
      • Breast tissue with increased sensitivity to prolactin and/or increased prolactin receptors
      • Chronic kidney disease
      • Cirrhosis
      • Hypothyroidism
      • Lung cancer
      • Renal cell cancer
    • Medications/substances:
      • Cardiology
        • α-Methyldopa
        • Reserpine
        • Verapamil
      • GI
        • Domperidone
        • H2 blockers
        • Metoclopramide
        • Proton pump inhibitors (2)[C]
      • Herbal
        • Anise
        • Barley
        • Blessed thistle
        • Fenugreek seed
        • Fennel
      • Illicit
        • Cocaine
        • Marijuana (3)[C]
      • Infectious disease
        • Isoniazid
        • Protease inhibitors
        • Typical and atypical antipsychotics
      • Pain
        • Opioids
      • Psych/neuro
        • Neuroleptics
        • Stimulants
        • SSRIs (prolactin not always elevated)
        • Tricyclic antidepressants
      • Reproductive
        • Estrogens
        • Copper IUD
    • Postoperative condition, especially oophorectomy
    • Idiopathic
      • Normal prolactin levels

General Prevention

  • Frequent nipple stimulation can cause galactorrhea.
  • Avoid medications that can suppress dopamine.

Commonly Associated Conditions

See “Etiology and Pathophysiology.”

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