Galactorrhea is a pathological secretion of milk from the mammary glands, which is not associated with the process of feeding a child. It occurs in men and women of different ages and is more often associated with hyperprolactinemia. The causes of galactorrhea may be systemic diseases, pathology of the hypothalamic-pituitary system or side effects of certain medications. When diagnosing, hormone levels are determined, ultrasound of the pelvic organs, MRI of the brain are performed. Treatment depends on the cause of galactorrhea. Medications that block the production of prolactin are used, and surgical and radiation therapy is used for tumors.
ICD 10
N64.3 Galactorrhea not related to childbirth
General information
Galactorrhea is more common in women than in men, observed both at reproductive age and on the threshold of menopause. During the newborn period, it is diagnosed with the same frequency in girls and boys, but in this case it is a manifestation of physiological adaptation and passes without treatment. In 67% of cases with galactorrhea, the level of prolactin is increased, but there is no direct dependence of the appearance of milk on the degree of increase in the hormone. Most women with galactorrhea have a menstrual cycle, and 70% have infertility.
Causes of galactorrhea
Galactorrhea is a pathological symptom, it appears without connection with the lactation process after childbirth, it can occur in unborn women. Hormone releases occur during sexual intercourse, during physical exertion, stress and during sleep, but they do not lead to the occurrence of galactorrhea. The reasons for the pathological increase in hormone levels and the appearance of milk are:
- Lesions of the hypothalamus. Hyperprolactinemia and galactorrhea on its background develops with tumors of the hypothalamus. The cause may be a traumatic brain injury, brain surgery, encephalitis. In rare cases, galactorrhea is a consequence of radiation damage to the hypothalamus.
- Endocrine syndromes. Galactorrhea, which is accompanied by hyperprolactinemia, occurs with polycystic ovary syndrome. Milk secretion can begin in patients with hypothyroidism, Cushing’s syndrome and acromegaly.
- Pathology of the adrenal glands or kidneys. Tumors of the adrenal glands, in which the production of estrogens increases, cause an increase in prolactin, which entails galactorrhea. With renal insufficiency, prolactin excretion is disrupted, it remains circulating in the blood and causes galactorrhea.
- Iatrogenic factors. Galactorrhea develops against the background of taking drugs that affect the secretion and metabolism of dopamine, reduce its reserves in the central nervous system or stimulate the serotonin-energy system. Anticonvulsants, antidepressants, antipsychotics, amphetamines, opiates, including cocaine, heroin have such effects.
- Malignant tumors. Prolactin can be secreted not only in the brain. Its synthesis occurs in some malignant tumors. This is most often observed in bronchogenic carcinoma, hypernephroma.
Pathogenesis
In humans, prolactin secretion is controlled by a complex neuroendocrine mechanism, involving the central and peripheral nervous system. Dopamine, somatostatin, gamma-aminobutyric acid, gastrin and some other peptides inhibit prolactin emissions. Stimulating factors are oxytocin, TSH, GnRH, melanocyte stimulating hormone, serotonin, opiates, insulin, estrogens and androgens.
The main suppressive factor is dopamine. With a decrease in its effect, there is an increase in the release of prolactin into the blood. Due to prolonged stimulation of lactotrophic cells in the pituitary gland, they first hyperplasize, and then micro- and macroadenomas arise. Under its influence, the synthesis of gonadotropin-releasing hormone is disrupted, the release of FSH and LH decreases. A woman with galactorrhea changes her menstrual cycle according to the type of amenorrhea, infertility develops.
The extragenital effect of prolactin leads to a violation of carbohydrate metabolism, promotes the conversion of glucose into fats and the development of obesity. Many people develop insulin resistance. The production of dihydroandrostenedione is stimulated, hyperandrogenism with its characteristic symptoms is formed in women. Endocrine disorders lead to the development of osteopenia.
Classification of galactorrhea
For the occurrence of galactorrhea, it is necessary that an increase in the level of the hormone occurs with a simultaneous decrease in estrogens. The appearance of breast milk sometimes appears several years earlier than menstrual disorders, in half of the patients these symptoms develop simultaneously. The degrees of galactorrhea are determined depending on the amount of milk secreted:
- 1 degree. A woman has single drops of a liquid resembling milk, with strong pressure on the nipple.
- 2nd degree. With slight pressure, large drops or a stream of milk flow out.
- 3rd degree. Milk is released spontaneously without external influence.
Symptoms of galactorrhea
The main sign of galactorrhea is the appearance of milk from the mammary glands. The volume of discharge depends on the severity of the disease. The menstrual cycle is disrupted. Menstruation becomes rare, short-lived, blood loss decreases. Amenorrhea is gradually developing. Attempts to get pregnant for a year and no longer bring results. Many women note symptoms of estrogen deficiency in the form of vaginal dryness, decreased libido.
With galactorrhea, headaches are often bothered, with the presence of pituitary macroadenoma, visual disorders occur. There are also cerebellar-vestibular, oculomotor, pyramidal, chiasmal disorders. They are the first signs of neurological pathologies. Many patients with galactorrhea have a tendency to depression, depressed mood, memory decreases, and fatigue worries.
Women develop obesity, it is impossible to reduce body weight with the help of diets or physical activity. Insulin resistance may eventually turn into type 2 diabetes mellitus. Hyperandrogenism leads to hirsutism, increased greasiness of the skin and hair, the appearance of acne. There is also an acceleration of bone resorption, which is manifested by pain in the legs, osteoporosis develops.
Complications
In the absence of treatment, galactorrhea can cause persistent infertility. The danger is the effect of hyperprolactinemia on metabolic processes. Obesity over time leads to an increased risk of developing cardiovascular diseases, brain catastrophes. Osteoporosis in advanced form is the main cause of pathological bone fractures that are poorly treatable.
The effect of increased prolactin on the risk of hyperplastic processes of the reproductive organs is also noted. Studies show that with chronic galactorrhea, the likelihood of breast cancer increases. But there is evidence that proves the opposite, that prolactin blocks genes that are responsible for cancer aggression.
Diagnostics of galactorrhea
Examination in galactorrhea is aimed at excluding organic changes in the structure of the brain. A gynecologist takes part in the diagnosis. Consultation of an endocrinologist is mandatory, and for differential diagnosis with hypothalamic tumors, a profile examination and examination is carried out by a neurosurgeon. The following diagnostic methods are used:
- Gynecological examination. In women, a gynecologist’s examination is required to exclude pregnancy. With galactorrhea, the external genitalia are not changed, the uterus and appendages are palpationally of the usual size. When the nipple is squeezed, milk appears.
- Laboratory tests. For hyperprolactinemia, a single detection of the hormone level above 500 mEd/ l is sufficient. Levels of FSH, LH and estradiol in galactorrhea are minimally acceptable or reduced below normal. TSH, T4, ACTH, 17-OPG, IGF-1 are being investigated for the differential diagnosis of the causes of galactorrhea.
- Gynecological ultrasound. With galactorrhea, the size of the uterus and ovaries may correspond to the norm. In women with polycystic ovaries, they are enlarged in size, there is a large number of follicles, with hyperprolactinemia, the size of the ovaries is not changed, but the number of follicles may increase.
- MRI of the brain. It is necessary for visualization of the pituitary gland area. With a macroadenoma, a tumor formation is diagnosed, which can squeeze other brain structures and give appropriate symptoms.
- Laparoscopy. It is used when polycystic ovaries are suspected to clarify the disease. Surgical treatment can be performed simultaneously. Polycystic ovaries are characterized by a large number of follicles under a dense white capsule.
Treatment of galactorrhea
The goal of galactorrhea treatment is to normalize hormone levels, restore fertility. Treatment methods are diverse and depend on the causes of the disease. In case of tumor processes, preference is given to surgical methods of therapy. With galactorrhea, which has arisen a second time against the background of other diseases, treatment of the main cause of hyperprolactinemia is necessary.
Conservative therapy
Drug treatment of galactorrhea is aimed at suppressing the synthesis of prolactin, restoring the normal level of sex hormones. Women are observed at the gynecologist of the antenatal clinic, hospitalization in the department of gynecology or endocrinology is necessary only for invasive diagnosis. The following groups of drugs are used:
- Dopamine agonists. They act on dopamine receptors in the brain, inhibit the synthesis and release of prolactin. Preference is given to cabergoline, bromocriptine does not act selectively, therefore it has a large number of side effects.
- Thyroid hormones. Levothyroxine sodium is prescribed for diagnosed hypothyroidism. In cases of preservation of elevated prolactin and galactorrhea during treatment, dopamine agonists are additionally used.
- Antiandrogens. They are used for polycystic fibrosis, which caused galactorrhea. Prescribe combined oral contraceptives with a pronounced antiandrogenic effect. They should include ciproterone, chlormadinone, dienogest or drosperinone.
- Ovulation stimulators. After reducing the hormone to normal levels and stopping galactorrhea, the cycle should recover, menstruation begins. If ovulation does not occur, clomiphene citrate or letrozole is used to stimulate it.
Surgical treatment
Surgical treatment is carried out in the Department of neurosurgery. It is indicated with the ineffectiveness of drug therapy or its intolerance, increased intracranial pressure, signs of compression of the chiasm. Removal of the tumor is required with its progressive growth, the appearance of liquorrhea. Dopamine agonists should not be used in patients with mental disorders, this causes an exacerbation of the underlying disease. The pituitary macroadenoma is not operated on.
Radiation therapy
With pituitary adenoma, radiation therapy is used in cases where surgical treatment is impossible. If the patients do not have positive dynamics during drug therapy, only radiation exposure remains. It is associated with the risk of damage to other cells of the pituitary and hypothalamus system. Many patients develop hypopituitarism after a few years.
Prognosis and prevention
With galacotrea, the prognosis is favorable for general health and the realization of reproductive function. With timely treatment, the menstrual cycle is normalized, ovulation is restored, and pregnancy can be planned. Prevention of galactorrhea consists in timely access to a doctor for any endocrine disorders, prevention of traumatic brain injuries, infectious diseases. Stress and nervous disorders can lead to galactorrhea, so it is recommended to prevent the appearance of these conditions.
