Galactorrhoea

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Example Management | References

Definition

Galactorrhoea is the inappropriate or excessive production of milk from the breasts, not associated with childbirth or nursing. It can occur in both men and women, although it is more common in women.

Aetiology

The causes of galactorrhoea can include:

• Hormonal imbalances: Hyperprolactinaemia due to pituitary adenomas (prolactinomas), hypothyroidism, or other endocrine disorders.
• Medications: Antipsychotics, antidepressants, antihypertensives, and oral contraceptives.
• Physical stimulation: Frequent breast stimulation, such as excessive self-examination or sexual activity.
• Systemic diseases: Chronic renal failure, liver cirrhosis.
• Idiopathic: No identifiable cause in some cases.

Pathophysiology

Galactorrhoea is usually due to elevated levels of prolactin (hyperprolactinaemia), which stimulates milk production. Elevated prolactin can result from:

• Increased production: Pituitary adenomas or hypothyroidism.
• Reduced clearance: Chronic kidney disease.
• Increased stimulation: Medications that affect dopamine, which normally inhibits prolactin secretion.

Risk Factors

• Female gender
• Age (most common in reproductive-aged women)
• Use of certain medications (e.g., antipsychotics, antidepressants)
• Endocrine disorders (e.g., hypothyroidism, pituitary adenomas)
• Chronic renal or liver disease

Signs and Symptoms

Common signs and symptoms of galactorrhoea include:

• Milky nipple discharge from one or both breasts
• Absence of menstruation (amenorrhoea) in women
• Decreased libido
• Headaches or visual disturbances (if caused by a pituitary tumour)
• Breast tenderness or enlargement

Investigations

• Clinical history and physical examination
• Serum prolactin levels: To assess for hyperprolactinaemia
• Thyroid function tests: To check for hypothyroidism
• Renal function tests: To assess for chronic kidney disease
• Liver function tests: To evaluate for liver disease
• Pregnancy test: To rule out pregnancy in women of reproductive age
• Magnetic resonance imaging (MRI) of the brain: To identify pituitary adenomas
• Mammography or breast ultrasound: To evaluate breast tissue, especially if there is a concern for breast cancer

Management

Primary Care Management

• Observation: In cases of idiopathic galactorrhoea where no underlying cause is identified and the patient is asymptomatic.
• Medication review: Identifying and discontinuing any medications that may be causing the condition, in consultation with the prescribing physician.
• Thyroid hormone replacement: For patients with hypothyroidism to normalise thyroid function and reduce prolactin levels.
• Referral: To an endocrinologist for further evaluation and management if an underlying endocrine disorder is suspected.

Specialist Management

• Dopamine agonists: Medications such as bromocriptine or cabergoline to lower prolactin levels in cases of hyperprolactinaemia.
• Surgery: Transsphenoidal surgery to remove pituitary adenomas if they are causing significant symptoms or do not respond to medical therapy.
• Radiotherapy: For patients with pituitary tumours that are not amenable to surgery.
• Treatment of underlying conditions: Addressing any primary conditions such as chronic kidney disease or liver cirrhosis.

Example Management for Galactorrhoea

A woman presenting with bilateral milky nipple discharge and amenorrhoea is found to have elevated serum prolactin levels. Further investigation with an MRI reveals a small pituitary adenoma. Initial management involves starting the patient on a dopamine agonist, such as cabergoline, to reduce prolactin levels. The patient is advised to avoid any medications that may exacerbate the condition and to monitor for any changes in symptoms. Regular follow-up appointments are scheduled to assess the response to treatment and adjust the medication dosage as needed.

References

1. NICE. (2024). Hyperprolactinaemia: Assessment and Management. Retrieved from NICE
2. NHS. (2023). Galactorrhoea. Retrieved from NHS
3. British Medical Journal (BMJ). (2022). Galactorrhoea: Diagnosis and Management. Retrieved from BMJ
4. Endocrine Society. (2021). Clinical Practice Guidelines for the Diagnosis and Treatment of Hyperprolactinaemia. Retrieved from Endocrine Society

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