Galactorrhoea and Mastalgia Flashcards
What is galactorrhoea?
- Copious, bilateral, multiductal milky discharge from nipples
- Not associated with pregnancy or lactation
- Mostly in females but rarely seen in male infants secondary to maternal oestrogen
- If postpartum, includes milk production 6-12 months after pregnancy and cessation of breast feeding
Lactation - physiology
- Lactation regulated by hormone prolactin (secreted by anterior pituitary)
- Prolactin inhibited by dopamine release (from hypothalamus)
- TRH and oestrogen stimulate prolactin release
Most common causes of hyperprolactinaemia - most common cause of galactorrhoea
- Idiopathic
- Pituitary adenoma - prolactinoma
- Drug induced - SSRIs, antipsychotics, H2 antagonists
- Neurological - neurogenic pathways activated to inhibit dopamine eg varicella zoster infection or spinal cord injury
- Hypothyroidism - high TRH
- Renal failure or liver failure
- Damage to pituitary stalk - reduced dopamine inhibition eg surgery, MS, sarcoidosis, TB
Causes of normoprolactinaemic galactorrhoea
- Less common
- Usually idiopathic
True galactorrhoea vs other disease
For true needs to be:
* Multiductal
* Milky white nipple discharge
* Typically bilateral
* Can do Sudan IV stain for fat droplets in discharge to confirm but rarely use this now
Other symptoms to ask about when presenting with galactorrhoea
- Breast lumps
- Mastalgia
- Last menstrual period
- Endocrine disease features - eg hypothyroidism
- Neurological symptoms eg headaches/visual disturbance
- Drug history
Examination findings
- None usually on breast exam
- Check for visual changes and hypothyroidism signs
Investigations - bedside and bloods for galactorrhoea
- Pregnancy test - all women reproductive age
- Serum prolactin
- TFTs
- LFTs
- U&Es
- Endocrine tests eg ACTH or IGF-1 may be needed if history suggests
Imaging for galactorrhoea presentation
- If suspect pituitary tumour - MRI head with contrast
- Breast imaging if lumps or palpable lymph nodes
What level of prolactin suggests prolactinoma?
> 1000mU/L in absence of any drug cause
Management galactorrhoea
- Depends on cause
- If pituitary adenoma - dopamine agonist eg Cabergoline and Bromocriptine
- Then referral to neurosurgery for potential trans-sphenoidal surgery
- If normal prolactin, usually resolves spontaenously but can use low dose dopamine agonist
What to do if intolerant to medication and galatorrhoea persists with non-tumour causes?
- May need bilateral total duct excision
Classification of mastalgia
- Cyclical
- Non-cyclical
- Extra mammary - chest wall or shoulder pain
Cyclical breast pain
- Pain associated with menstrual cycle - most common
- Typically both breasts
- Beginning few days before menstruating and subsiding at the end
- Caused by hormonal changes
- Most patients which present are still menstruating or are on HRT
Non-cyclical breast pain
- Unrelated to menstrual cycle
- Can be caused by medication eg hormonal contraceptives, antidepressants eg sertraline or antipsychotic drugs eg haloperidol
