Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk. Aripiprazole can lower serum prolactin in a dose-related manner, and cases of poor milk supply and lactation cessation have been reported. Weight loss and poor weight gain have been reported in breastfed infants whose mothers were taking aripiprazole. Monitor the breastfed infant for dehydration and lack of appropriate weight gain. Cases of gynecomastia and galactorrhea have also been reported. Until more data become available, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.[1]

Prolactinomas as the most common type of functional pituitary adenoma and most will respond to dopamine agonist (DA) therapy with normalization of prolactin levels, restoration of gonadal function and/or reduction in tumor volume. A minority of prolactinomas are refractory to conventional doses of DA and present a clinical challenge. Characteristics associated with DA resistance include male sex, certain radiologic features (large size, cavernous sinus invasion, other characteristics), histopathologic evidence of high cell proliferation, and in a small number of cases, inherited pathologic germline variants of genes associated with pituitary tumors, such as MEN1 and AIP. Clinical management often requires a multimodal approach including titration of DA to higher than usual doses, surgical resection or debulking, and targeted radiotherapy. Robust evidence is lacking for non-approved adjunct therapies, such as aromatase inhibitors and estrogen receptor modulators, although the somatostatin receptor ligand pasireotide may have potential in select patients.

Premature ovarian insufficiency (POI) in a young unmarried woman was detected in association with hypothyroidism, chromosome 9 (Inv 9, p12q13) inversion, and cavernous angioma. A 27-year-old unmarried female presented with complaints of infrequent cycles only after undergoing withdrawal treatment for menstruation for the past 11 years. She was diagnosed with hypothyroidism and was subsequently prescribed thyroid replacement therapy. On examination, bilateral galactorrhoea was identified. Oestradiol and anti-Mullerian hormone values were low, whereas her follicle-stimulating hormone value was elevated. Her brain magnetic resonance imaging revealed a solitary cavernous angioma, and her karyotype indicated 46 XX and Inv(9) p12q13. POI in a young woman is a devastating condition affecting both physical and emotional well-being. Chromosomal aberrations should be ruled out in such cases. Life-long oestrogen replacement therapy and alternate options for infertility issues such as ovum donation or adoption can be considered.

Metoclopramide is a prokinetic and antiemetic agent widely used in primary care. Its mechanism of action explains both its therapeutic effects, as well as certain adverse reactions, including hyperprolactinemia and galactorrhea. Metoclopramide-induced galactorrhea may prompt concern and lead to unnecessary diagnostic testing. This case report is about a healthy 21-year-old woman taking a combined oral contraceptive who was prescribed metoclopramide for gastroenteritis with vomiting. Forty-eight hours after starting treatment, she developed spontaneous, bilateral, multiductal, painless galactorrhea without menstrual changes, headaches, neurological symptoms, or signs of pregnancy. Physical examination confirmed bilateral milk secretion without inflammatory signs or palpable masses, and the neurological exam was normal. Given the clear temporal relationship and absence of alternative causes, metoclopramide was discontinued. At follow-up, complete resolution of symptoms occurred, supporting the diagnosis of drug-induced galactorrhea. This case underscores an adverse reaction associated with a commonly used medication in Family Medicine. Clinicians should remain vigilant for the early identification of potential adverse drug reactions and avoid unnecessary diagnostic testing while maintaining a person-centered approach in routine Family Medicine practice.

A 70-year-old female with a past medical history of type 2 diabetes mellitus (treated with insulin), hypertension, and bipolar disorder was admitted to the Intensive Care Unit after suffering cardiac arrest post-seizure. During the initial workup, CT of the head was notable for marked, diffuse calvarial thickening (~17 mm), a large sella turcica, and no evidence of pituitary apoplexy. MRI of the head showed a 1.9 cm pituitary macroadenoma. The physical examination was notable for thick facial features such as macroglossia, acrochordon, and fleshy hands - consistent with acromegaly. Insulin-like growth factor-1 (IGF-1) was elevated at 570 ng/mL (Z score: 4; normal 34-245). IGF-binding protein 3 (IGFBP-3) was elevated at 9 µg/mL (normal 3-6). However, the patient had never previously been diagnosed with acromegaly. Throughout the course of her admission, the patient required multiple bronchoscopies due to thick secretions and mucus plugging. The etiology of her respiratory failure and sudden cardiac arrest remained undetermined after a comprehensive diagnostic workup. While acromegaly typically manifests with musculoskeletal changes and endocrine abnormalities - including diabetes mellitus, hypertension, and galactorrhea - it also carries a substantial risk of secondary respiratory and cardiac complications. This report highlights the importance of early diagnosis of acromegaly, specifically in identifying, being cognizant of, and preventing respiratory and cardiac complications.

Galactorrhea is most often associated with endocrine disorders or drug-induced hyperprolactinemia, particularly from antipsychotics. While commonly benign, persistent or unilateral galactorrhea with abnormal imaging findings warrants careful evaluation to exclude malignancy. We report the case of a 44-year-old woman receiving long-term antipsychotic therapy who developed unilateral (left-predominant) milky nipple discharge compatible with galactorrhea and breast tenderness. Mammography revealed diffusely distributed coarse heterogeneous calcifications, but two ultrasound-guided core needle biopsies (CNB) failed to identify malignancy, showing only papillomas with epithelial hyperplasia and atypia. Due to persistent radiologic suspicion, a tomosynthesis-guided vacuum-assisted biopsy (VAB) was performed and demonstrated low-grade ductal carcinoma in situ (DCIS). Mastectomy confirmed diffuse, multigrade DCIS (low-, intermediate-, and high-grade components), cribriform and comedo type, involving multiple breast quadrants. This case underscores the diagnostic challenges of attributing galactorrhea solely to medication side effects, highlights the limitations of core biopsy in diffuse calcifications, and emphasizes the importance of persistent diagnostic workup when imaging remains suspicious.

Bromocriptine is usually not used during breastfeeding because it suppresses lactation. The indication of lactation suppression has been withdrawn in the U.S. and discouraged in other countries because it increases the risk of maternal stroke, seizures, cardiovascular disorders, death and possibly psychosis.[1-4] A low dose of 2.5 mg once daily has been used for 3 days to decrease overproduction of milk.[5] The drug was undetectable in milk with this dosage and infants had no adverse reactions, but the safety of this use is not established. Case reports and series also exist of mothers treated with bromocriptine for amenorrhea-galactorrhea syndrome or prolactinoma during pregnancy and lactation who successfully breastfed their infants. Bromocriptine has been used to treat persistent galactorrhea following breast augmentation surgery.[6]