Lactation problems – various disorders of the secretory and excretory functions of the mammary glands, manifested by states of galactorrhea, hypogalactia, agalactia, lactostasis, etc. In nursing women after childbirth, hypogalactia is most common – insufficient milk production, as a rule, corrected by the correct technique and feeding regime. Pathological milk excretion from the mammary glands, unrelated to childbirth – galactorrhea, is often caused by prolactisecreting tumors of the pituitary gland, etc. organs and requires surgical intervention.
Pathogenesis
The physiological process of lactation – the formation and excretion of milk by the mammary glands in women begins in the postpartum period and is supported by complex neuroendocrine regulation. Stimulation and maintenance of lactation is carried out by lactogenic hormones: placental lactogen, prolactin and oxytocin. The secretion of placental lactogen by the baby’s place (placenta) begins in the late stages of pregnancy, preparing a woman’s mammary glands for the formation of milk. Shortly after giving birth, lactogen disappears from the mother’s blood.
In the postpartum period, the hormones prolactin and oxytocin are involved in maintaining lactation. Prolactin– a peptide hormone synthesized by the pituitary gland, has a leading effect on both physiological and pathological lactation. In late pregnancy and lactation, the content of prolactin-secreting cells in the pituitary gland reaches 60-80%. The milk secreted under the influence of prolactin accumulates in the alveoli of the mammary glands, and then is excreted through the tubules, milk ducts and milky sinuses.
Oxytocin is responsible for the process of milk excretion, the secretion of which is reflexively stimulated during breast sucking. Normally, the lactation period is from 5 to 24 months, and the daily amount of secreted milk is about 1 liter. Stagnation of milk in the alveoli and milk ducts leads to depression and spontaneous disappearance of lactation after 1-2 weeks.
Lactation disorders are considered to be the following conditions:
- Galactorrhea – inadequate (pathological) milk production not related to childbirth;
- Hypogalactia – insufficient milk excretion by the mammary glands during postpartum lactation.
Galactorrhea
Causes of galactorrhea
The severity of galactorrhea can be of varying degrees: from periodically released drops to constant and abundant discharge of colostrum, milk-like secretions or milk from the mammary glands. Galactorrhea can be one- and two-sided, it occurs not only in women, but also in men. The incidence of galactorrhea among women is 1-4%.
While endocrinology, as a science, continues to study the causes of galactorrhea. In 50% of cases, the causes remain unidentified. In such cases, galactorrhea is called idiopathic. Among the known reasons for galactorrhea are:
- diseases of the central nervous system that prevent the entry of prolactin-inhibiting factors into the pituitary gland (encephalitis, hydrocephalus, meningitis, sarcoidosis, hypothalamus tumors, craniopharyngioma, etc.);
- non-pituitary tumors and pituitary tumors that cause increased prolactin secretion. Prolactin-secreting tumors of the pituitary gland include: pure prolactinomas; somatotropinomas producing somatotropin and prolactin (cause acromegaly and accompanying galactorrhea); chromophobic adenomas. Tumors of non–pituitary localization secreting prolactin are trophoblastic neoplasia (cystic drift, choriocarcinoma), bronchogenic cancer, etc.
- tumors and injuries of the hypothalamus;
- long-term use of certain medications (chlorpromazine, morphine, methyldofa, metoclopramide oral contraceptives);
- thyroid diseases (hypothyroidism and hyperthyroidism);
- diseases of the adrenal glands (estrogen-producing tumors of the adrenal glands, Addison’s disease);
- liver and kidney failure;
- polycystic ovary syndrome;
- stimulation of the nipples of the mammary glands, causing reflex galactorrhea with a slight increase in prolactin levels.
Symptoms of galactorrhea
Galactorrhea can develop against the background of the normal rhythm of menstruation, however, in almost 80% of patients it is combined with amenorrhea or oligomenorrhea. While maintaining normal menstrual function and minor galactorrhea, discharge from the mammary glands may not bother a woman. In other cases, galactorrhea may be accompanied by swelling, heaviness and dull pains in the mammary glands, frequent headaches and visual impairment, intense hair growth on the chin or chest, acne, decreased sexual activity. Copious discharge of secretions from the mammary glands can cause skin maceration and eczema.
If the breast discharge is milky white and contains lactose and casein, then it is true milk. The brown or greenish discharge, which does not contain milk components, is usually observed in endocrinopathies. The hemorrhagic nature of the discharge indicates malignant neoplasms of the mammary glands.
Galactorrhea in men is rarely observed, even with a minimal increase in the level of prolactin in the blood and is accompanied by signs of feminization.
Diagnosis of galactorrhea
Preliminary diagnosis begins with an examination by an endocrinologist and clarification of the patient’s complaints (menstrual cycle disorders, infertility, etc.). Milk is released from the mammary glands during palpation. When examining the secret under a microscope, droplets of fat are detected. The level of prolactin in galactorrhea exceeds 200 mcg / l (or 200 ng / ml).
At the next stage, the cause of galactorrhea is found out. Tumor lesion of the pituitary gland is excluded by radiography of the Turkish saddle in 2 projections (direct and lateral), MRI or CT of the brain, consultation of an ophthalmologist.
Breast ultrasound and mammography methods confirm or exclude the tumor. Collecting a medical history allows you to identify galactorrhea caused by taking medications. Abdominal ultrasound, liver, ovaries, kidneys, thyroid gland, regional lymphatic ducts is performed to exclude possible causes of galactorrhea.
Treatment of galactorrhea
To stop galactorrhea, it is necessary to eliminate the cause of hyperprolactinemia. Medication, surgical or radiation treatment of prolactin-secreting tumors, withdrawal of medications, treatment of hypothyroidism is carried out. Patients with mild idiopathic galactorrhea are recommended to bandage the mammary glands to exclude nipple irritation that supports lactation.
To suppress prolactin hypersecretion in patients with galactorrhea, bromocriptine is prescribed. The use of bromocriptine allows not only to suppress lactation, but also to restore the menstrual cycle when galactorrhea is combined with amenorrhea. Before the disappearance of the phenomena of galactorrhea, it is recommended to avoid stimulation and self-examination of the mammary glands (more often than once a month).
Prevention
With early detection of hyperprolactinemia, the prognosis is good for health. After the treatment of pituitary prolactinoma, a dispensary observation is carried out to prevent relapses of the disease: CT of the brain, determination of prolactin in the blood, consultation of an optometrist. The difficulties of preventing galactorrhea are associated with the variety of causes that cause it.
Hypogalactia
Causes of hypogalactia
Postpartum hypogalactia can be primary (develop immediately after childbirth) or secondary (develop after a period of sufficient lactation). Primary postpartum hypogalactia develops in 2.8-8% of women, usually primiparous, with neurohormonal disorders that cause underdevelopment of the mammary glands, a decrease in their motor and secretory function, failure of lactation. Functional failure of the mammary glands develops with infantilism, developmental abnormalities, due to severe toxicosis in late pregnancy, traumatic childbirth, postpartum bleeding and infections.
Secondary hypogalactia is more often observed, in which, for some reason, lactation decreases or its insufficient level is noted (not satisfying the needs of the child in breast milk). The development of secondary hypogalactia can lead to cracked nipples, mastitis, infectious diseases of the mother (sore throat, flu, tuberculosis), nervous shocks, fatigue, poor nutrition, improper regime (lack of sleep, insufficient walks). In addition, taking certain medications that inhibit lactopoiesis (milk formation) can lead to hypogalactia: camphor, androgens and progestogens, diuretics, parlodel, ergot preparations, etc.
Late, secondary hypogalactia is more often caused by violations of the feeding regime: irregular application of the baby to the breast, long breaks between feedings, leading to a decrease in milk formation and a decrease in the sucking activity of the child. Sluggish or premature babies due to insufficient irritation of the mammary glands during feeding also contribute to the suppression of lactation. Agalactia is extremely rare — a complete absence of lactation, usually caused by congenital underdevelopment of the mammary glands.
Symptoms of hypogalactia
Primary hypogalactia is characterized by early (in the first 10 days after childbirth) development. Hypogalactia, which developed later, is considered secondary. With hypogalactia, there is no swelling of the mammary glands in maternity women, when pressing on them, milk is released poorly, there is an insufficient amount of milk. When palpating the breast, undeveloped glandular tissue is often determined.
Due to the lack of milk, the baby does not eat enough during feeding, cries when weaning, does not gain enough weight or does not add at all. In most women during breastfeeding, hypogalactic crises are noted – periodic, recurring at intervals of 26-30 days and lasting several days, a decrease in milk secretion. The development of crises is explained by the cyclical processes of hormonal activity occurring in the female body.
Diagnosis of hypogalactia
The amount of milk produced per day is calculated by summing the amount of milk sucked by the child (set by control weighing of the child before each feeding and after), and the volume of expressed milk. The daily amount of milk required for a child of the first month of life is calculated according to the formula proposed by Finkelstein:
- V daily. = 70 x n (if the birth weight is less than 3200 g) or
- V daily. = 80 x n (if the birth weight is more than 3200 g), where n is the number of days of the newborn’s life.
In the future , the required daily volume of milk is determined according to the following scheme:
- from 4 to 6 weeks – 1/5 of body weight;
- from 1.5 to 4 months – 1/6 of body weight;
- from 4 to 6 months — 1/7 of body weight.
There are four degrees of hypogalactia:
- I – lack of milk (in comparison with the need of the child) does not exceed 25%;
- II – the lack of milk is from 25% to 50%;
- III – milk deficiency ranges from 50% to 75%;
- IV – milk deficiency exceeds 75%.
With early hypogalactia, the ratio of the concentration of estrogens and prolactin in the blood is determined. Cytological analysis of milk in hypogalactia shows reduced somatic cells in size. Ultrasound scanning of the mammary glands determines the type of their structure: glandular, fatty and mixed. Hypogalactia is most often observed with a fatty and mixed type of structure.
Thermography is used to determine the vascularization of the mammary gland, indicating the degree of its functional activity. There are three types of vascular pattern in the mammary glands: fine-mesh, coarse-mesh and trunk. The risk of developing hypogalactia is higher with the main type of vascular arrangement.
Treatment of hypogalactia
With secondary hypogalactia, it is necessary first of all to normalize the feeding technique: apply the baby alternately to each breast, strictly observe the feeding intervals, consume liquid in sufficient volumes.
In cases of primary hypogalactia, medicinal lactogenic agents (lyophilizate of the anterior pituitary lobe, deaminooxytocin) and restorative therapy are prescribed, with the development of secondary, a high-calorie diet, UFO, massage, a course of electrophoresis procedures with nicotinic acid on the mammary glands, psychotherapy are indicated. Bee products, herbal teas (from thyme, nettle, lemon balm, oregano, dill, fennel, cumin, etc.), homeopathy products also belong to the means of stimulating lactation.
Prevention
For the prevention of hypogalactia, the physiological course of pregnancy and childbirth is important, if possible, the refusal of stimulation and anesthesia during childbirth.
The most important measures for the prevention of hypogalactia are early (6-8 hours after delivery) putting the baby to the breast, observing the intervals and duration of feeding. A nursing woman should observe the daily routine, eat a full meal, and consume liquid in sufficient volumes. With hypogalactia, self-massage of the mammary glands is useful, with flat and retracted nipples, a woman can independently pull them through gauze several times a day.