Galactorrhea

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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

Pediatric Considerations
Can occur in male infants secondary to maternal estrogen exposure

Pregnancy Considerations
Pregnancy stimulates lactotroph cells, so pituitary prolactin-secreting macroadenomas may increase by 21% (1)[A].

Epidemiology

Predominant age: 15 to 50 years (reproductive age)

Incidence
Prolactinomas, as a cause of galactorrhea, have a 44.4 persons per 100,000 incidence in adults (2).

Prevalence
Third most common breast complaint in women. 20–25% of women experience galactorrhea in their lifetime (3)[C].

Etiology and Pathophysiology

  • Oxytocin stimulates prolactin secretion, which induces lactation. Prolactin is secreted by the anterior pituitary, and inhibited by dopamine produced in the hypothalamus.
  • Galactorrhea results either from prolactin overproduction or loss of inhibitory regulation by dopamine.
    • Physiologic galactorrhea
      • Nipple stimulation
      • Pregnancy
    • Pathophysiologic galactorrhea
      • Hyperprolactinemia
        • Craniopharyngiomas
        • Irradiation
        • Meningiomas or other tumors
        • Pituitary stalk compression
        • Post-breast augmentation surgery (1%)
        • Prolactinoma (sellar tumor, somatotroph adenoma, pituitary macroadenoma)
        • Traumatic brain injury
        • Vascular malformations (aneurysms)
      • Hyperprolactinemia in systemic disease
        • Adrenal insufficiency
        • Breast tissue with increased sensitivity to prolactin and/or increased prolactin receptors
        • Chronic kidney disease
        • Cirrhosis
        • Graves thyrotoxicosis
        • Hypothyroidism
        • Leukemias (rare)
        • Lung cancer
        • Multiple sclerosis (MS) (with hypothalamic lesion)
        • Renal cell cancer
        • Sarcoidosis/histocytosis
      • Nonhyperprolactinemia
        • Chest wall trauma
        • Chiari-Frommel, del Castillo, and Forbes-Albright syndromes
        • Herpes zoster
        • Spinal cord injury
  • Medications/substances:
    • Cardiovascular
      • α-Methyldopa
      • Reserpine
      • Verapamil
      • Spironolactone
    • GI
      • Domperidone
      • H2 blockers
      • Metoclopramide
      • Proton pump inhibitors (4)[C]
    • Herbal
      • Anise (liquorice)
      • 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/antipsychotics
      • Stimulants
      • SSRIs, SNRIs (prolactin not always elevated)
      • Tricyclic antidepressants
    • Reproductive
      • Estrogens
      • Copper IUD
  • Idiopathic
    • Normal prolactin levels (if patient has galactorrhea plus amenorrhea, likely can have microprolactinoma)

Genetics
No known genetic component

Risk Factors

Certain medications and supplements as above.

General Prevention

  • Avoid frequent nipple stimulation.
  • Avoid medications that can suppress dopamine.

Commonly Associated Conditions

See “Etiology and Pathophysiology.”

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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

Pediatric Considerations
Can occur in male infants secondary to maternal estrogen exposure

Pregnancy Considerations
Pregnancy stimulates lactotroph cells, so pituitary prolactin-secreting macroadenomas may increase by 21% (1)[A].

Epidemiology

Predominant age: 15 to 50 years (reproductive age)

Incidence
Prolactinomas, as a cause of galactorrhea, have a 44.4 persons per 100,000 incidence in adults (2).

Prevalence
Third most common breast complaint in women. 20–25% of women experience galactorrhea in their lifetime (3)[C].

Etiology and Pathophysiology

  • Oxytocin stimulates prolactin secretion, which induces lactation. Prolactin is secreted by the anterior pituitary, and inhibited by dopamine produced in the hypothalamus.
  • Galactorrhea results either from prolactin overproduction or loss of inhibitory regulation by dopamine.
    • Physiologic galactorrhea
      • Nipple stimulation
      • Pregnancy
    • Pathophysiologic galactorrhea
      • Hyperprolactinemia
        • Craniopharyngiomas
        • Irradiation
        • Meningiomas or other tumors
        • Pituitary stalk compression
        • Post-breast augmentation surgery (1%)
        • Prolactinoma (sellar tumor, somatotroph adenoma, pituitary macroadenoma)
        • Traumatic brain injury
        • Vascular malformations (aneurysms)
      • Hyperprolactinemia in systemic disease
        • Adrenal insufficiency
        • Breast tissue with increased sensitivity to prolactin and/or increased prolactin receptors
        • Chronic kidney disease
        • Cirrhosis
        • Graves thyrotoxicosis
        • Hypothyroidism
        • Leukemias (rare)
        • Lung cancer
        • Multiple sclerosis (MS) (with hypothalamic lesion)
        • Renal cell cancer
        • Sarcoidosis/histocytosis
      • Nonhyperprolactinemia
        • Chest wall trauma
        • Chiari-Frommel, del Castillo, and Forbes-Albright syndromes
        • Herpes zoster
        • Spinal cord injury
  • Medications/substances:
    • Cardiovascular
      • α-Methyldopa
      • Reserpine
      • Verapamil
      • Spironolactone
    • GI
      • Domperidone
      • H2 blockers
      • Metoclopramide
      • Proton pump inhibitors (4)[C]
    • Herbal
      • Anise (liquorice)
      • 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/antipsychotics
      • Stimulants
      • SSRIs, SNRIs (prolactin not always elevated)
      • Tricyclic antidepressants
    • Reproductive
      • Estrogens
      • Copper IUD
  • Idiopathic
    • Normal prolactin levels (if patient has galactorrhea plus amenorrhea, likely can have microprolactinoma)

Genetics
No known genetic component

Risk Factors

Certain medications and supplements as above.

General Prevention

  • Avoid frequent nipple stimulation.
  • Avoid medications that can suppress dopamine.

Commonly Associated Conditions

See “Etiology and Pathophysiology.”

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