What is the treatment for galactorrhea?

Treatment of Galactorrhea

Cabergoline is the preferred medication for treatment of hyperprolactinemia-induced galactorrhea due to its superior efficacy and tolerability compared to other dopamine agonists. 1

Diagnostic Approach

Before initiating treatment, a proper diagnostic workup is essential:

1. Laboratory evaluation:

   • Serum prolactin level (primary test)
   • Pregnancy test (for premenopausal women)
   • Thyroid-stimulating hormone (TSH)
   • Renal function tests

2. Medication review:

   • Identify and discontinue medications that can cause hyperprolactinemia (antipsychotics, metoclopramide, some antidepressants, opioids)

3. Imaging:

   • MRI of the pituitary gland if hyperprolactinemia is confirmed and no other cause is identified

Treatment Algorithm

For Hyperprolactinemic Galactorrhea:

1. First-line: Dopamine Agonist Therapy

   • Cabergoline: Preferred agent 1

     • Starting dose: 0.25 mg twice weekly
     • Can be titrated up to 1 mg twice weekly based on response
     • Advantages: Better tolerated, more effective, longer half-life allowing twice-weekly dosing 2

   • Bromocriptine: Alternative option

     • Typical dose: 2.5 mg 2-3 times daily
     • Less well-tolerated than cabergoline (more gastrointestinal side effects)
     • Preferred for women planning pregnancy due to more extensive safety data 3

2. Second-line: Surgical Intervention

   • Transsphenoidal surgery for:
     • Patients who fail to respond to maximum doses of dopamine agonists
     • Those who cannot tolerate dopamine agonist therapy
     • Patients with large macroadenomas causing visual field defects or other neurological symptoms 1

3. Third-line: Radiation Therapy

   • Reserved for cases resistant to both medical therapy and surgery

For Normoprolactinemic Galactorrhea:

1. If not bothersome: Reassurance only, no treatment needed 4

2. If bothersome: Short course of low-dose dopamine agonist (cabergoline or bromocriptine) 4

Special Considerations

Prolactinomas

• Microadenomas (<10 mm): Medical therapy with dopamine agonists is usually sufficient
• Macroadenomas (≥10 mm): Higher doses of dopamine agonists may be required; surgical intervention more likely

Pregnancy

• For women planning pregnancy:
  • Bromocriptine has more extensive safety data during pregnancy 3
  • Cabergoline should be discontinued one month before attempting conception 5
  • Close monitoring of prolactinomas during pregnancy is essential as they may enlarge

Medication-Induced Galactorrhea

• Discontinue or replace the offending medication if possible
• If medication cannot be discontinued, low-dose dopamine agonist therapy may be considered

Monitoring and Follow-up

1. Prolactin levels:

   • Check 1 month after initiating therapy
   • Then every 3-6 months until normalized
   • Annually thereafter

2. Imaging:

   • Repeat MRI 6-12 months after initiating therapy for prolactinomas
   • Then annually until stable

3. Side effect monitoring:

   • Nausea, dizziness, headache (common)
   • Cardiac valve abnormalities (rare, more associated with high-dose, long-term cabergoline)

Common Pitfalls to Avoid

1. Failure to identify medication-induced causes - Always perform a thorough medication review
2. Missing physiologic causes - Rule out pregnancy, recent breastfeeding, and chest wall stimulation
3. Inadequate dose titration - Some patients require gradual dose increases to achieve normalization of prolactin
4. Overlooking associated symptoms - Headaches and visual changes may indicate a macroadenoma requiring urgent attention

By following this treatment algorithm, most cases of galactorrhea can be effectively managed, with resolution of symptoms and normalization of prolactin levels in the majority of patients.