What is the evaluation and treatment for galactorrhea?

Evaluation and Treatment of Galactorrhea

The evaluation of galactorrhea should include serum prolactin measurement, thyroid function tests, renal function assessment, and pituitary imaging when hyperprolactinemia is confirmed without other obvious causes. Treatment with dopamine agonists, preferably cabergoline, is recommended for symptomatic hyperprolactinemia. 1, 2

Diagnostic Evaluation

Initial Assessment

• Obtain a thorough history focusing on menstrual irregularity, infertility, weight changes, hirsutism, and medication use 1
• Perform physical examination to assess for galactorrhea (crusting on nipples or expression of breast milk in non-lactating women), signs of hypothyroidism, and hirsutism 1
• Rule out physiologic causes, including recent pregnancy/breastfeeding (within one year) 2

Laboratory Testing

• Pregnancy test for all premenopausal women presenting with galactorrhea 2
• Serum prolactin measurement (single blood sample collected at any time of day) 1
  • Consider serial measurements for modestly elevated levels to exclude stress effects 1
• Thyroid-stimulating hormone (TSH) to rule out hypothyroidism 2
• Renal function tests to exclude chronic renal failure 2
• Consider follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if amenorrhea is present 1

Imaging

• Magnetic resonance imaging (MRI) of the pituitary gland is indicated when:
  • Hyperprolactinemia is confirmed without other obvious causes 2
  • Clinical features (galactorrhea) or laboratory results (hyperprolactinemia) suggest hypothalamic-pituitary axis abnormality 1
  • Note: Small pituitary adenomas may be beyond the resolution of MRI 1

Etiology

Common Causes

• Medications (most common non-physiologic cause) 3
  • Antipsychotics, antidepressants, antihypertensives, and hormonal contraceptives
• Pituitary adenomas (most common pathologic cause) 3
  • Prolactinomas account for 53% of pituitary adenomas in children/young people 1
• Hypothyroidism 3
• Chronic renal failure 3
• Physiologic causes (pregnancy, breastfeeding, nipple stimulation) 3

Less Common Causes

• Hypothalamic and pituitary stalk lesions 3
• Neurogenic stimulation 3
• Cirrhosis 2
• Idiopathic hyperprolactinemia 4

Treatment Approach

General Principles

• Treatment decision is based on:
  • Serum prolactin level
  • Severity of galactorrhea
  • Patient's fertility desires 3
• Discontinue or replace medications causing hyperprolactinemia when possible 4
• Normoprolactinemic patients with non-bothersome galactorrhea can be reassured without treatment 4

Pharmacologic Treatment

• Dopamine agonists are the treatment of choice for hyperprolactinemic disorders 3
  • Cabergoline is preferred due to better efficacy and tolerability 2
    • Initial dose: 0.25-0.5 mg twice weekly
    • Mechanism: Direct inhibitory effect on prolactin secretion through D2 receptor agonism 5
    • Advantages: Higher efficacy in normalizing prolactin levels (77% vs 59% for bromocriptine) and reducing galactorrhea (73% vs 56%) 5
  • Bromocriptine is an alternative option
    • Preferred for hyperprolactin-induced anovulatory infertility 3
    • Must be discontinued if pregnancy occurs 6
    • More side effects including hypotension, nausea, and dizziness 6

Special Considerations

• For prolactinomas:
  • Small asymptomatic microadenomas may be observed without treatment 7
  • Macroadenomas typically require treatment with dopamine agonists 3
  • Surgical resection (transsphenoidal approach) is rarely required and reserved for:
    • Patients who don't respond to or cannot tolerate dopamine agonists 2
    • Large tumors causing significant mass effect 3
• For pregnant women with prolactinomas:
  • Close observation is essential as lesions may increase in size during pregnancy 8
  • Cabergoline should be discontinued one month before attempting conception 3

Monitoring and Follow-up

• Regular monitoring of reproductive function is recommended, including questioning about:
  • Menstrual disorders
  • Fertility
  • Weight changes
  • Hirsutism
  • Galactorrhea 1
• Particular attention should be paid to patients on valproate and obese patients 1
• For patients with prolactinomas on dopamine agonist therapy:
  • Monitor prolactin levels to assess treatment response
  • Follow tumor size with periodic MRI if initially macroscopic 3

Prognosis

• Most prolactinomas remain stable or regress over time 8
• Hyperprolactinemia generally has a benign clinical course in most women 7
• Long-term consequences of untreated hyperprolactinemia may include:
  • Infertility
  • Irregular menses
  • Osteopenia or osteoporosis 3