What is the management and treatment of galactorrhea?

Management and Treatment of Galactorrhea

Initial Diagnostic Evaluation

All patients with galactorrhea require serum prolactin measurement, regardless of other symptoms, as this is the cornerstone of evaluation. 1

Essential Laboratory Tests

• Serum prolactin level is mandatory for all patients presenting with galactorrhea 1, 2
• Pregnancy test must be obtained in all premenopausal women before further workup 3
• Thyroid-stimulating hormone (TSH) to exclude hypothyroidism, which can cause hyperprolactinemia 1, 2
• Renal function tests to assess for chronic renal failure as a secondary cause 2, 3
• FSH and LH should be measured if amenorrhea is present 1

Critical Pitfalls to Avoid

• Never assume normal prolactin based on clinical presentation alone—even patients with galactorrhea may have normal prolactin levels 4
• Request serial dilutions when measuring prolactin in patients with large pituitary lesions to avoid falsely low results from the "hook effect" 1, 5
• Assess for macroprolactin if prolactin is elevated but clinical features are inconsistent, as 10-40% of hyperprolactinemia cases may be due to biologically inactive macroprolactin 5

When to Obtain Serial Prolactin Measurements

For mildly elevated prolactin levels, collect samples at 20-60 minute intervals using an indwelling cannula to exclude stress-related hyperprolactinemia 1, 6

---

Imaging Guidelines

High-resolution pituitary MRI with and without IV contrast is the gold standard when imaging is indicated. 1, 6

Indications for MRI

• Significantly elevated prolactin levels (>4,000 mU/L or 188 μg/L) 6
• Visual symptoms or signs of mass effect, regardless of prolactin level 6
• Unexplained hyperprolactinemia after excluding medication effects, hypothyroidism, and renal impairment 1

---

Treatment Algorithm

Step 1: Address Secondary Causes First

Discontinue or replace medications causing hyperprolactinemia whenever possible. 2, 3

Common offending medications include:

• Antipsychotics (dopamine antagonists)
• Antiemetics (metoclopramide, domperidone) 4
• Antidepressants
• Antihypertensives

Treat underlying conditions:

• Hypothyroidism with thyroid hormone replacement 2, 7
• Chronic renal failure management 2

Step 2: Determine Need for Pharmacologic Treatment

Treatment decisions depend on prolactin level, symptom severity, and fertility desires. 7

Patients Who Do NOT Require Treatment:

• Normal prolactin levels with idiopathic, non-bothersome galactorrhea—reassurance is sufficient 2
• Milky nipple discharge within one year of pregnancy cessation is usually physiologic 3

Patients Who Require Treatment:

• Hyperprolactinemia with bothersome galactorrhea 2
• Associated amenorrhea or infertility 2, 7
• Prolactinomas (microadenomas or macroadenomas) 7, 8

Step 3: Pharmacologic Management

Cabergoline is the preferred first-line dopamine agonist for treating hyperprolactinemia due to superior efficacy and tolerability. 9, 3

Cabergoline Dosing and Efficacy:

• Initial dose: Up to 2 mg/week for mild hyperprolactinemia 5
• Efficacy: Normalizes prolactin in 60-70% of patients and is superior to bromocriptine with fewer adverse events 5
• Clinical studies: 77% of patients achieved prolactin normalization at 0.5 mg twice weekly, with 77% restoration of menses and 73% resolution of galactorrhea 9
• Discontinuation before conception: Must stop one month before attempting pregnancy 7

Bromocriptine as Alternative:

• Preferred for fertility treatment when conception is desired, as it does not require discontinuation before pregnancy 7
• Dosing: 2.5 mg twice daily 9
• Efficacy: 59% prolactin normalization, 70% menses restoration, 56% galactorrhea resolution 9
• Less well-tolerated than cabergoline but more cost-effective 7

For Normoprolactinemic Patients with Bothersome Galactorrhea:

Short course of low-dose dopamine agonist usually provides symptom relief 2

Step 4: Monitoring During Treatment

Prolactin levels should be measured 1-3 months after initiating treatment, then every 3-6 months until stabilized. 5

Echocardiographic surveillance every 5 years for patients on standard cabergoline doses (≤2 mg/week) to monitor for cardiac valvulopathy 5

Monitor for side effects:

• Gastrointestinal intolerance 5
• Postural hypotension 5
• Psychological effects 5

---

Surgical and Radiation Therapy

Transsphenoidal surgery is reserved for specific situations and rarely required. 7, 3

Indications for Surgery:

• Failure to respond to high-dose cabergoline with persistent symptoms 3
• Intolerance to dopamine agonist therapy 3
• Large macroadenomas with mass effect not responding to medical therapy 8

Radiation therapy is rarely needed and reserved for refractory cases 8

---

Special Considerations

Pregnancy and Prolactinomas:

Prolactinomas must be monitored closely during pregnancy as lesions may significantly increase in size 8

Prognosis:

Most prolactinomas remain stable or regress with treatment, providing a favorable long-term prognosis 8