What is the evaluation and treatment approach for abnormal lactation (galactorrhea)?

Evaluation and Management of Abnormal Lactation (Galactorrhea)

Begin evaluation with serum prolactin measurement after ruling out pregnancy, then proceed with TSH and renal function tests; if hyperprolactinemia is confirmed without medication cause, obtain brain MRI to exclude pituitary adenoma. 1, 2, 3

Initial Diagnostic Approach

History and Physical Examination

• Focus specifically on: menstrual irregularity, infertility, weight changes, hirsutism, and complete medication review (particularly antipsychotics, metoclopramide, antidepressants) 1, 4
• Physical examination must assess: presence and character of galactorrhea (spontaneous vs. expressible, unilateral vs. bilateral), signs of hypothyroidism, hirsutism, and visual field defects 1, 4
• Critical distinction: Milky nipple discharge within one year of pregnancy cessation is usually physiologic and requires no further workup 3

Laboratory Evaluation Algorithm

1. First-line tests (obtain in all patients):

   • Pregnancy test (mandatory in premenopausal women) 2, 3
   • Serum prolactin level (single most important test) 1, 2
   • TSH (hypothyroidism is a treatable cause) 2, 3
   • Renal function tests (chronic renal failure causes hyperprolactinemia) 2, 3

2. Serial prolactin measurements may be necessary to exclude stress-related elevation, as prolactin increases with stress, sleep, sexual intercourse, and breast stimulation 1, 4

3. If amenorrhea is present: measure FSH and LH levels 1

Imaging

• Brain MRI is indicated when: hyperprolactinemia is confirmed and no medication cause or hypothyroidism is identified 2, 3
• Rationale: Prolactinomas account for 53% of pituitary adenomas in young people, and imaging is essential to detect sellar/suprasellar lesions 1, 2

Treatment Strategy Based on Etiology

Medication-Induced Galactorrhea

• Discontinue or switch the offending medication if clinically feasible, replacing with an agent from the same class with lower prolactin-elevating potential 2, 3
• Common culprits include antipsychotics, metoclopramide, SSRIs, and antihypertensives 4, 2

Prolactinomas (Most Common Pathologic Cause)

Dopamine agonists are the treatment of choice for hyperprolactinemic disorders 1, 5, 3

Medication Selection:

• Cabergoline is preferred over bromocriptine due to superior efficacy, better tolerability, and less frequent dosing 2, 5, 3
• Bromocriptine is preferred for fertility treatment when conception is desired, as it has longer safety data in pregnancy 5
• Cabergoline must be discontinued one month before attempting conception 5

Bromocriptine Specifics (FDA-Approved):

• Suppresses galactorrhea completely or almost completely in approximately 75% of cases 6
• Menses typically reinitiate within 6-8 weeks (range: days to 8 months) 6
• Galactorrhea reduction of at least 75% usually observed after 8-12 weeks 6

Surgical Indications:

• Surgery is rarely required and reserved for: patients failing high-dose cabergoline therapy, those intolerant to dopamine agonists, or tumors causing mass effect despite medical therapy 5, 3, 7
• Transsphenoidal surgery is the preferred surgical approach 3

Normoprolactinemic Galactorrhea

• If galactorrhea is not bothersome: reassurance alone is sufficient; no treatment needed 2, 3
• If galactorrhea is bothersome: short course of low-dose dopamine agonist usually effective 2

Hypothyroidism-Related

• Treat underlying hypothyroidism with thyroid hormone replacement; galactorrhea typically resolves with normalization of thyroid function 2, 3

Critical Safety Considerations

Pregnancy Management

• Withdraw bromocriptine when pregnancy is diagnosed in patients treated for hyperprolactinemia 6
• Careful observation is mandatory during pregnancy, as prolactin-secreting adenomas may expand and cause optic nerve compression requiring emergency pituitary surgery 6
• Most compression resolves following delivery; reinitiation of bromocriptine postpartum may improve visual fields if nerve compression occurred 6

Bromocriptine Warnings (FDA Label):

• Complete pituitary evaluation is mandatory before initiating treatment, as pituitary tumors are common 6
• Symptomatic hypotension occurs in almost 30% of patients, with supine systolic drops of 20+ mmHg; caution with driving/machinery during initiation 6
• Somnolence and sudden sleep onset have been reported; patients experiencing these must not drive or operate machinery 6
• Contraindicated for lactation suppression due to rare but serious adverse events including hypertension, MI, seizures, and stroke in postpartum women 6

Monitoring and Prognosis

• Regular monitoring should assess: menstrual function, fertility, weight, hirsutism, and galactorrhea 1
• Long-term consequences of untreated hyperprolactinemia: infertility, irregular menses, and osteoporosis risk 1, 5
• Prognosis is excellent: most prolactinomas remain stable or regress with medical therapy 4

Common Pitfalls to Avoid

• Do not delay imaging in patients with confirmed hyperprolactinemia of unclear etiology—missing a macroadenoma can lead to permanent visual loss 6, 2
• Do not attribute galactorrhea to stress alone without measuring prolactin; pathologic causes must be excluded 1, 2
• Do not continue bromocriptine for lactation suppression in postpartum women—this indication is contraindicated due to serious cardiovascular and neurologic risks 6
• Do not assume physiologic lactation beyond one year postpartum or in nulliparous women—these require full evaluation 3