Question

• Discuss common causes of galactorrhea and describe the pathophysiology, clinical manifestations, evaluation, and treatment of galactorrhea.

Answer 1

Galactorrhea is a milky nipple discharge unrelated to the normal milk production of breast feeding. Galactorrhea isn't a disease itself, but sometimes it is a symptom of underlying problem. It usually occurs in women, even those who have never had children or after their menopause. But sometimes it seems that galactorrhea can happen in men and even in infants.

Excessive breast stimulation, medication side effects or abnormal function of the pituitary gland all may lead to cause Galactorrhea. Often, galactorrhea results from increased level of prolactin in the body, the hormone that stimulates milk production.

Sometimes, the cause of galactorrhea can't be determined. The problem may resolve on its own.

Common or possible causes of galactorrhea :

Galactorrhea often results from having too much prolactin secretion when you have a baby. Prolactin is produced by a small bean shaped gland at the base of your brain, pituitary gland that sectrets and regulates several hormones.

1. Medications, such as certain sedatives, anti-depressants, and high blood pressure drugs,

2. Use of opioid,

3. Intake of Herbal supplements, such as anise, fennel seeds,

4. Birth control pills,

5. Stress or depressed mind,

6. Chronic kidney disease,

7. Spinal cord surgery, injury or tumours,

8. Disorder of pituitary gland or noncancerous pituitary tumor (prolactinoma),

9. Nerve damage to the chest wall from chest surgery, burns or other chest surgeries,

10. Excessive breast stimulation, which may be caused due to sexual activity, frequent breast self exams with nipple manipulation or prolonged clothing friction.

Pathophysiology of Galactorrhea :

Prolactin is produced in the cells called lactotrophs that constitute about 30% of the cells of the anterior pituitary. Non functioning pituitary mass lesions also can increase lrevels of prolactin by compressing the pituitary stalk and thus reducing the action of dopamine that is a inhibitor of prolactin.

Hyperprolactinemia and Galactorrhea also may be caused by ingestion of certain drugs, including phenothiazines and some other antipsychotics, antihypertensives (especially alpha-methyldopa), and opioids. Increase level of thyroid releasing hormone increase secretion of prolactin as well as thyroid stimulating hormone (TSH), Primary hypothyroidism can also cause Hyperprolactinemia and Galactorrhea. Hyperprolactinemia may be associated with hypogonadotrophism and hypogonadism through gonadotrophin releasing hormone(GnRH) release inhibition or action on the pituitary gonadotrophes.

Clinical menisfestations:

The milk is white, and fat globules can be seen when a sample is examined with a microscope. Women with galactorrhea commonly also have amenorrhea or oligomenorrhea and may have symptoms and signs of estrogen deficiency. Hyperprolactinemia may occur with other menstrual cycle disturbances besides amenorrhea, including infrequent ovulation and corpus leteum dysfunction.

Men with prolactin secreting pituitary tumors typically have headaches or visual difficulties.

Symptoms :

1. Nipple discharge involving multiple milk ducts,

2. Persistent or intermittent milky nipple discharge,

3. Absent or irregular menstrual periods,

4. Spontaneously leaked or manually expressed nipple discharge,

5. Headache or vision problems,

6. One or both breasts affected,

Diagnosis :

1. Prolactin levels,

2. Thyroxine (T4) and TSH levels,

3. CT or MRI.

Evaluation and treatment of Galactorrhea :

The evaluation of galactorrhea includes a thorough history and physical examination, selected laboratory tests and imaging studies.

1. History : the history should include the duration of galactorrhea, previous pregnancies and other symptoms of Hyperprolactinemia, such as infertility and menstrual abnormalities.

2. Physical examination : the physical examination includes an evaluation of the patient's visual fields, thyroid gland, breasts and skin. If the type of nipple discharge is in doubt, the physician may attempt to elicit the discharge and examine it under a microscope. If the physician is not certain that the discharge is milk, a sample may be sent to a laboratory for special staining and evaluation, including cytology.

3. Laboratory tests : laboratory tests may include serum pregnancy test, a prolactin level, renal function tests and a thyroid stimulating hormone levels. Because prolactin levels are influenced by stress and breast stimulation, blood should not be drawn immediately after a breast examination. Rather, it should be drawn at least one hour after the examination and when the patient is relaxed.

4. Imaging studies : imaging studies are also important in the evaluation of abnormal lactation. If the patient has symptoms galactorrhea with amenorrhea, or an elevated prolactin level, magnetic resonance imaging(MRI) of the brain is indicated to detect a pituitary tumor. If the patient has normal menses and normal prolactin level, the risk for pituitary adenoma is low, and imaging is not necessary.

Treatment

1. Stop taking medication, change dose or switch to another medication. Make medication changes only if your doctor says it's OK to do so.

2. Take a medication such as levothyroxine, to encounter insufficient hormone production by your thyroid gland.

3. In women, indications for treatment include desire for pregnancy, amenorrhea or significant oligomenorrhea, troublesome galactorrhea etc.

4. In men, galactorrhea itself is rarely troublesome enough to require treatment; indications for treatment include hypogonadism, erectile dysfunction, troublesome infertility.

5. self manipulation of the breast should be stopped.

6. Because of the inherent risks of surgery and the efficasy of dopamine agonists in treating patients with prolactinoma, surgical resection rarely is required. Surgery should be considered only if cases of resistance or intolerance to optical medical therapy, when there clearly are neurologic or other problems caused by direct expansion of the tumor.