Galactorrhea

1. Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
Email: elnashar53@hotmail.com
Aboubakr Elnashar

2. Define
Nonpuerperal watery or milky breast secretion that
contain neither pus nor blood.
Color Amount
Side Spontaneous or not
Incidence
Unk Recently increased
How to elicit?
Aboubakr Elnashar

3. Environment
Higher centers
Hypothalamus
Anterior pituitary
Prolactin
Breast
-
-
-
-
+
+
+
+
TSH = PRF
Endorphins
PIF = Dopamine
Aminobutyric ac
Aboubakr Elnashar

4. Causes
I. Inhibition of PIF
1. Stress . Prolonged suckling . Jug & run
2. Thoracotomy scars . Cervical spine lesions . Herpes zoster
3. Drugs 4. Chronic renal failure
5. CNS disease 6. Pituitary stalk lesions
II. Stimulation of PRF
Hypothyroidism
III.Increased prolactin production
1. Pituitary tumor 2. Non pituitary tumor
IV. Idiopathic
Aboubakr Elnashar

5. Drugs
The most common cause of galactorhea.
The commonest are metaclorpromide & phenothiazines
I. Estrogens & drugs that increase estrogen
1. OCP 2. Digitalis
3. Marijuana 4. Heroin
II. Dopamine receptor blockers
1.Phenothiazines 2.Haloperidol
3. Metaclorpromide 4. Isoniazide
III. CNS dopamine depleters
1. Psychoactive:Tricyclic antidepressant,phenothiazines,
Benzodiazepins
2. Antihypertensive: Reserpin, Methyl dopa, verapamil
3. Cimetidine
When galactorrhea disappear ?: 3-6 moAboubakr Elnashar

6. When to investigate ?
1. Nulliparous
2. 12 mo after last pregnancy or weaning
Aboubakr Elnashar

7. Galactorrhea without hyperprolactinamia:
50%
1. Episodic fluctuation & sleep increments
2. Bioactive PRL which is not detectable
3. An earlier episode of hyperprolactinaemia which
triggered persistent galactorrhea.
Aboubakr Elnashar

8. Hyperprolactinaemia without galactorrhea
66%
1. Inadequate detection
2. Hypoestrogenic state.
3. Inadequate estrogenic or progetational priming of the
breast
4. High PRL does not interact with the breast receptors
Aboubakr Elnashar

9. Diagnostic evaluation
History & Examination: Exclude: Recent pregnancy, breast stimulation
Drugs, Breast or chest lesion
Prolactin
>20 ng/ml <20 ng/ml
TSH
Normal High (hypothyroidism)
MRI (Normal or hyperplasia, Microadenoma or Macroadenoma)Aboubakr Elnashar

10. PRL
Basal conditions
Late morning
Fasting
after 60 min rest
not in late follicular phase
2nd blood sample if the first is raised
Level
> 100 ng/ml: 60% pituitary tumor.
> 300 ng/ml: 100% pituitary tumor
Modest elevation can be associated with pituitary tumor
Aboubakr Elnashar

11. MRI
superior to CT
Aboubakr Elnashar

12. Treatment
I. Idiopathic (normal PRL)
. Observation
. Dopamine agonist (anxiety, pregnancy). Stop during pregnancy
II. Hypothyroidism
. Eltroxin
III. Microadenoma
. Observation: annual PRL
. Dopamine agonist (anxiety, pregnancy). Stop after 2-3 yr.
. Surgery (rapid growth).
Transsphenoidal microsurgery is very safe, but recurrence is high (Sperof,1999)
IV. Macroadenoma
. Dopamine agonist: long term
. Surgery (No response, suprasellar extension, pregnancy).
Preoperative bromocriptine may result in fibrosis
Aboubakr Elnashar

13. I. Microadenoma:
usually do not enlarge significantly during pregnancy
II. Macroadenoma:
may grow rapidly & cause visual disturbance during
pregnancy.
Surgery before pregnancy should be considered.
An alternative method is continuation of dopamine
agonist during pregnancy: & visual field/ 3 mo: No
detrimental effects on the fetus, Nearly all delivered at
term without complications
Pregnancy, Breast feeding, COC s, ERT
not contraindicated Aboubakr Elnashar

14. Bromocriptine
(Parlodel, lactodel, Dopagon , 2.5 mg)
Dose:1 t bid
Side effects: n & v. , postural hypotension, headache,
nasal stiffness, constipation.
Can be minimized: give t at bed time, avoid large dose
increament, vaginal adminstration
Monitoring: mid normal values, titrate the dose
accoringly
Galactorhea stops after: 6 w & 11 w if there is adenoma
Vaginal: Absorption is almost complete & slow, the first
pass through the liver is avoided: 1 t /d & less side
effects. During menstruation: tampon at night.No effect
on sperms
Aboubakr Elnashar

15. Quinagolide
(Norplac, 75 ug)
Dose: 1 t/ d
It has higher affinity for dopamine receptors: tumors resistant to
bromocriptine have responded to this drug (Speroff,1999)
Aboubakr Elnashar

16. Cabergoline
(Dostinex, 0.5 mg)
Ergotline derivative, Long lasting
Dose: 1-2 t/ W
Side effects: less than bromocriptine
Aboubakr Elnashar

17. Thanks
Aboubakr Elnashar