Galactorrhea is the spontaneous, nonobstetric production of bilateral white or clear nipple discharge. It is estimated to occur in 20-25% of women at some time in their life. Physiologic production of breast milk after pregnancy, or lactation, occurs after the breast has fully developed and been primed by numerous hormones including estrogen, progesterone, and thyroid hormone. The hormone prolactin is produced in the pituitary gland and promotes milk secretion. At the time of labor and delivery, there is a sharp drop in estrogen and progesterone levels, which in conjunction with a high prolactin level causes milk production (lactation). Prolactin is secreted continuously in nonpregnant women with normal blood levels of 1-20 ng/ml; levels increase to as high as 300 mg/ml during pregnancy and lactation.
The most common cause of galactorrhea is “idiopathic,” in which the prolactin level is normal and there are no other identifiable causes of spontaneous nipple discharge. This accounts for nearly 35% of galactorrhea.
Prescription medications, herbal supplements, and illicit drugs account for 20% of all episodes of galactorrhea. The most common prescription medications that cause galactorrhea are antipsychotic medications and the selective serotonin-reuptake inhibitor antidepressant medications such as citalpram, fluoxetine, paroxetine, and sertraline. Antihypertensive medications including methyldopa, atenolol, and verapamil can also stimulate this condition. Any prescription hormones (i.e., oral contraceptive pills or hormone replacement therapy) or herbal estrogen or progesterone agent can contribute to this problem, which often develops after abruptly stopping the medication. The most common herbal supplements to cause galactorrhea are anise, fennel, red clover, and red raspberry. Marijuana, amphetamines, and opiates can also cause nonobstetric galactorrhea.
Eighteen percent of patients who present with galactorrhea are diagnosed with a tumor such as a prolactinoma or, rarely, lung or kidney tumors or a lymphoma. Prolactinomas, by far the most common tumors to cause galactorrhea, are nonmalignant growths of the anterior pituitary gland. They secrete high levels of prolactin, thus causing galactorrhea. Other symptoms of a prolactinoma include absence of menstruation and visual changes. Prognosis for these benign tumors is excellent. Breast cancer is generally not associated with galactorrhea.
In 13% of cases, systemic diseases including hypothyroidism, acromegaly (a disease characterized by excessive production of growth hormone), kidney failure, or Cushing’s disease (a disease characterized by excessive steroid production) can cause galactorrhea. Other possible causes include chest wall irritation from skin conditions such as herpes zoster (“shingles”) or eczema.
Diagnosis of the cause of galactorrhea includes careful questioning regarding symptoms and medications. Laboratory studies may include a pregnancy test, thyroid studies, and prolactin level. If the prolactin level is high, then the physician may order an imaging study of the brain such as a magnetic resonance imaging (MRI) to evaluate for pituitary gland abnormalities.
Treatment of galactorrhea is directed to its underlying cause. If medications are the culprit, then it may be beneficial to substitute another drug, if available. If a primary disease such as hypothyroidism is discovered, then initiation of appropriate treatment often eliminates galactorrhea. Patients discovered to have a prolactinoma may be offered surgical removal of the benign tumor, or medication to decrease prolactin production and tumor size. These include medications such as bromocriptine and pergolide.
SEE ALSO: Complementary medicine, Thyroid diseases
- Harris, G. D., White, R. D., Carlson, B., et al. (2000, December). Common breast problems (Monograph, Edition No. 259, Home Study Self-Assessment Program). Lea wood, KS: American Academy of Family Physicians.
- Pena, K. S., & Rosenfeld, J. A. (2001). Evaluation and treatment of galactorrhea. American Family Physician, 63, 1763—1770, 1775.
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