Introduction
Galactorrhea is the discharge of milk or colostrums from the mammary gland in the absence of nursing (Slovik, 2009, p.761). This condition is indicative of likelihood of hyperprolactinemia and the related risk for pituitary neoplasm, when abnormal menses or infertility accompanies it. When a patient indicates galactorrhea, it is crucial to inspect for rudimentary pituitary disease.
Pathophysiology and clinical indication
Ordinary milk production is a result of an interaction of prolactin and mammary glands prepared by progestin and estrogen. Slovik argues that in presence of pregnancy and lactation, the prolactin levels of the pituitary elevates 10 to 20 times (2009, p.761). This condition can occur in an elevated or normal serum prolactin level. The standard normal prolactin serum level in overall laboratories is 20 ng/ml. Thus, there are two contexts of galactorrhea, namely Normoprolactinemic and Hyperprolctinemic galactorrhea.
Medical scientists perceive Normoprolactimic galactorrhea as a product of local mammary stimulation or irritation in women having hormonally prepared mammary gland tissue (Giampietro, Ramacciotti, & Mogg, 1984, p.24). Stimulation of the mammary glands may trigger a mild, brief increase in prolactin secretion, although it is not maintained. Majority of cases can be linked to a distance pregnancy or the use of contraceptives. In this situation, the reproductive organs maintain their functions, with menstrual cycle and fertility remaining normal.
On the other hand, hyperprolactinemic galactorrhea arises due to excessive prolactin production, attributed to either the failure of hypothalamic inhibition of anterior pituitary lactotrophs or by the formation of an autonomously active pituitary adenoma (Eftekhari, Mirzaei, & Karimi, 2008, p.290). In seldom circumstances, hyperprolactinemia may develop from a reduced prolactin clearance attributed by renal failure. Importantly, even in the setting of elevated prolactin levels, galactorrhea does not develop without estrogen priming of the breast. Estrogen and progestin priming of the mammary glands is prerequisite for development of galactorrhea. Galactorrhea prevails by 80% in premenopausal women.
Differential diagnosis
Researchers organize galactorrhea differential diagnosis based on whether prolactin is raised and whether the elevation is due to a reduction in hypothalamic inhibition or over secretion due to a functional adenoma.
Normally, just 20% of galactorrhea cases indicate hyperprolactinemia. Prolactinoma is the major cause of hyperprolactinemia, amenorrhea, and galactorrhea. Clinician should make sure that there are no cases of pregnancy in women with hyperprolactinemia.
Other causes associated with the area of the pituitary are “parasellar sarcoidosis, pinealoma, craniopharyngioma, and empty-sella syndrome” Biller, 1999, p.76). Approximately one third of incidence of galactorrhea and amenorrhea is accounted for by Nonprolactinomic disease, within and about the pituitary (Riordan, 2005, p.34). Sustained galactorrhea after childbirth attributes for less than 10% of the incidence of galactorrhea. Drugs that are connected with galactorrhea are oral contraceptives and agents with central dopaminergic-blocking function, including “metoclopramide, haloperidol, and phenothiazines… drugs that partially induce galactorrhea include tricyclic antidepressants, isoniazid, methyldopa, and reserpine” (Torre, & Falorni, 2007, p. 944).
Normoprolactinemic Galactorrhea
- Local breast innervations caused by nursling, injury, or inflammation.
- Oral contraceptive use
- Recent pregnancy
- Idiopathic; that is, the slight increase in prolactin from innervations of the breasts.
Hyperprolactinemic galactorrhea
- Impairment of hypothalamic pituitary inhibition by:
- Drugs; tricyclic antidepressants, thioxanthenes, methyldopa, reesrpine, opiates, cocaine, heroin, cimetidine, metoclopramide, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and butyrophenones
- Laceration of the pituitary stalk (inactive seller tumors, infarction)
- Hypothalamic disease (infarction, infiltrative disease, craniopharyngioma)
- Overproduction by a pituitary adenoma
- Prolactinoma
- Hypothyroidism (imitate adenoma via thyrotropin releasing hormone simulation of lactrotope cells.
- Idiopathic
- Microadenoma undetectable using neuroimaging
- Breast stimulation, trauma, and stress
Laboratory test
Prolactin testing
The establishment of accurate prolactin assay and relationship of the galactorrhea with elevated prolactin levels and pituitary adenoma underscores the measurement of serum prolactin level as a significant component of diagnostic assessment. A single measurement is typically sufficient to indicate hyperprolactinemia. Nevertheless, the blood serum prolactin may be transiently elevated by breast stimulation, meals, time of day, or stress, although to a level not beyond 40 ng/ml. In such situations, consistent high levels are necessary to verify hyperprolactinemia. According to Benjamin (1994), prolactin levels ranging “between 20 and 200 ng/ml can characterize the condition” (p.890), regardless of the cause of hyperprolactinemia. Nevertheless, values beyond 200 ng/ml denote a prolactinoma.
A combination of galactorrhea and amenorrhea poses a risk for pituitary neoplasm; such that, it is pertinent that a clinician measures her prolactin levels the attributes for both conditions are obvious. As high as 10% of the patients with hyperprolactinemia, show an increase in macroprolactin levels. The macroprolcatin derives from “binding of prolactin to an antiprolactin autoantibody in the body” (Benjamin, 1994, p.897).
Additional testing and neuroimaging
Depending on the clinical setting, it may be important to rule out hyperthyroidism, renal failure, and pregnancy. For patient with a combination of galactorrhrrea and menstrual disturbances and a somehow unexplained increase in serum prolactin, neuroimaging of the sellar region is necessary to establish the cause. Magnetic Resonance imaging (MRI) is the preferred technique. However, computed tomography is the technique of choice in absence of MRI.
Treatment of galactorrhea
Treatment of galactorrhea is dependent on the causative agents. If the galactorrhea is caused by underlying thyroid disorder or meningitis, the health care practitioner will prescribe drugs that treat the underlying disorder (Pena, & Rosenfeld, 2001, p.1769). Galactorrhea disappears with the healing of the underlying disorder. If the disorder is a side effect of a drug, termination of the drug will definitely clear up galactorrhea. Nevertheless, terminating drugs is not always important. If the disease is due to a pituitary adenoma, surgery, radiation, or chemotherapy may be necessary. Some tumors eventually stop growing. Drug treatment involves bromocriptine to block production of prolactin by the anterior pituitary gland. If diagnostic analysis does not establish the cause, then treatment is not optional.
Conclusion
Mammary glands’ discharge in absence of lactation implies presence of galactorrhea. There are different causes of galactorrhea but it is important to establish the rudimentary problem in the pituitary glands before embarking on any corrective measure. Prolactin testing and neuro imaging are possible laboratory tests to ascertain presence galactorrhea; however, clinicians should be keen to preclude pregnancy cases or menstrual disturbances before concluding someone has galactorrhea.
Reference list
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Biller, M. (1999). Hyperprolactinemia. Int J Fertil Womens Med, 44(6), 74-7.
Eftekhari, N., Mirzaei, F., & Karimi, M. (2008).The prevalence of hyperprolactinemia and Galactorrhea in patients with abnormal uterine bleeding. Gynecol Endocrinol, 24(5):289-91.
Giampietro, O., Ramacciotti, C., & Moggi, G. (1984). Normoprolactinemic galactorrhea In a fertile woman with a copper intra-uterine device, (copper IUD). Acta Obstet Gynecol Scand, 63(1), 23-5.
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