Galactorrhoea

Synonym: Lactorrhoea

Galactorrhoea is milky secretion from the breasts. The term usually refers to milk secretion not due to breast-feeding. It is bilateral and from multiple ducts. The milk volume may be large or small, and milk may be secreted spontaneously or expressed.

Galactorrhoea is much more common in women than in men. In women it may be physiological but in men it is always pathological. Nipple discharge (of any type) accounts for 5% of referrals to a breast clinic, but should not be seen as synonymous with galactorrhoea.³

About a fifth of women with galactorrhoea have pituitary tumours but this rises to around a third if they have amenorrhoea too.⁴

Drugs that raise prolactin¹

The following list is not comprehensive and aims simply to list the more common drugs:

• Antihypertensives, including beta blockers, methyl dopa and verapamil.
• The traditional phenothiazine antipsychotics and haloperidol.
• The newer atypical neuroleptics may also be implicated. In one study, hyperprolactinaemia and related symptoms were common with risperidone, less common with olanzapine and did not occur with clozapine.⁹
• Antidepressants, especially the SSRIs.¹⁰
• H2 antagonists, especially cimetidine.
• Contraceptives, including combined oral contraceptives and depot contraceptives.
• Various others including opiates, danazol, sumatriptan, isoniazid and valproate.
• Illicit drugs including cannabis, opiates and amphetamines.
• Herbal remedies including anise, blessed thistle, fennel, fenugreek seed, marshmallow, nettle, red clover and red raspberry.

History

• Duration of symptoms, progression, nature, colour and amount of fluid.
• Unilateral or bilateral discharge (unilateral suggests local pathology, needs breast clinic referral).
• Is it spontaneous or does it have to be expressed?
• LMP? Suspect pregnancy until proved otherwise.
• Drugs: prescribed, OTC and illicit; herbal treatments and dietary supplements.
• Ask about acne, hirsutism, menstrual irregularity, reduced libido, infertility and erectile dysfunction (symptoms of hyperprolactinaemia).
• Thyroid and other endocrine symptoms.
• Ask about headaches, visual symptoms and cranial nerve symptoms (for pituitary tumours).

Examination

• Thyroid gland, signs of hypothyroidism, Cushing's disease or acromegaly.
• Neurological examination including visual fields (if intracranial or pituitary tumour suspected).
• Abdominal palpation for pregnancy.
• Examine the breasts:³
  • Can discharge be seen? Does it look milky or blood-stained?. If no discharge is apparent try gently massaging the breasts, or ask the patient to do so herself, to try to express some fluid. Is it bilateral and from multiple ducts?
  • Note any previous breast surgery or abnormality of surrounding skin.
  • Palpate for lumps and nodes.

Breast disease:¹¹

• Mammary duct ectasia can cause nipple secretions which may be milky or discoloured in appearance. The discharge can be bilateral and from multiple ducts.
• Duct papilloma typically causes serous or bloodstained discharge from a single duct. Underlying malignancy is rare but needs excluding.
• Persistent discharge through a fistula following an abscess.

Initial investigations:

• Prolactin levels (see article on Hyperprolactinaemia. Very high levels suggest prolactinoma.
• Thyroid function tests (it is important to exclude hypothyroidism).
• Renal and liver function.
• Pregnancy test if appropriate.

Further investigations may be needed:

• Formal testing of visual fields: defects suggest optic nerve compression and merit urgent referral.
• MRI or CT brain scan - needed e.g. if prolactin levels significantly raised and not explained by other cause, or if irregular menstruation
• Other endocrine assessments, e.g. for Cushing's or acromegaly, may be appropriate.
• If the nature of breast secretions is unclear, microscopy can show fat globules which are present in milk; haemostix can test for blood.³

See related article on Hyperprolactinaemia (link above).

1. Exclude serious pathology: investigations as above; exclude breast disease.
2. Identify and treat the cause, if possible:
   • Treat hypothyroidism.
   • Management of prolactinomas is described in the Hyperprolactinaemia article.
   • Review/change any contributing drugs.
3. If the cause cannot be addressed, consider:
   • Dopamine agonists such as bromocriptine (see Hyperprolactinaemia record for drug treatment details).
   • Hormone treatment: testosterone for men or oestrogens for women (e.g. the combined contraceptive pill). These help prevent osteoporosis and may improve symptoms.^12,13
4. When all else has been excluded, what remains is labelled as idiopathic. Female patients with galactorrhea but normal prolactin levels, normal thyroid function and regular periods can probably be observed.¹

These depends on the underlying cause. There is probably an increased risk of osteoporosis if hyperprolactinaemia is untreated.