Galactorrhea in a 23 year old Male Desire A. Mingear, PA-S Lock Haven University August 2007

Overview Definition of galactorrhea Differential Case presentation Treatment Expected outcomes

Definition of galactorrhea Milky discharge from the breast in the absence of pregnancy, parturition, or breast-feeding Synonyms: Nipple discharge Disordered lactation Inappropriate lactation Witch's milk

Causes of Galactorrhea - Differential

Patient Presentation & Examination A 23 year old Caucasian male presents to the clinic with bilateral nipple discharge for the last 2 months. taking psych medications (Lithium 300 mg PO Q 7 AM and 11 AM, 600 mg PO Q HS and Celexa 20 mg PO Q 11 AM) and the psychiatrist felt that his medications may be contributory so had discontinued them about one and a half months ago. The listed side affects of antipsychotic drugs do include an elevation of prolactin levels. He reported to clinic when the symptoms did not resolve. He was in no acute distress and actually found the idea that he was “lactating” to be of interest. Breast exam showed no nipple or breast masses, dimpling, or inversion of the nipples. While he did demonstrate some gynecomastia, he had no engorgement that would be seen with true lactation. He was able to express a few dribbles of “milk” from the right breast and was able to literally express milk that shot across the room from the left breast. There was little doubt that this was true galactorrhea. He also reported some visual field changes with a pattern that was not consistent between his left and right eyes.

PMH, SH, FH His past medical history included treatment of Bipolar Disorder, ADS, PSD, ASPD, and Dyslipidemia. Vitals taken included a pulse of 88 beats per minute, blood pressure 122/80, height of 5’11”, weight of 312 pounds, and a BMI greater than 46. His calculated ideal body weight was 180 pounds, placing him in the morbidly obese category. The patient is also a smoker who smokes roughly 1 pack a day. The only medication that he currently takes is Benadryl 5 mg Q HS. He stated that he was doing fine without his Depakote and Celexa, even though he has been on Depakote for over ten years. His social history is significant in that he has abused alcohol, marijuana, methadone, ecstasy, vicodin, Oxcycontin, and mushrooms. He stated that he has been drug-free since his incarceration in His current occupation is as the head block laundry worker at Rockview Penitentiary. Family history seems non-contributory as all members of his immediate family are alive and healthy with no long-term health issues other than his maternal grandfather who passed away from throat cancer. He was also a smoker.

What to do?

Screening He was immediately referred for a visual examination and for bloodwork. His complete blood count was drawn along with a TSH and prolactin level. The HCG and BUB/Creatinine was deferred by the physician. He was also scheduled for an MRI of the brain. Follow-up: The eye exam showed that he did indeed have visual field changes that were different in each eye. The diagram indicates the areas where his visual acuity is lost. (The white coloration indicates normal vision. Anything darker indicates changes or loss of visual fields.)

Results The TSH level was normal at uIu/mL (reference range (0.27 – 4.2 uIu/mL) but his prolactin was significantly elevated at uIu/mL (reference range for males is 4.04 – uIu/mL). The MRI defined a 1.7 X 1.5 cm mass arising form the sella expanding the sella and extending superiorly out of the sella and slightly displacing the optic chiasm. It was determined that it was probably a pituitary macroadenoma that was secreting prolactin. There were no changes visible to the ventricular system and no evidence of hydrocephalus, mass effect, or shift.

Diagram of pituitary adenoma

Pituitary adenoma

Treatment Change in medications – if taking medications which can cause the condition Medications which shrink the adenoma dopamine agonists Bromocriptine Cabergoline Pergolide Surgery Trans-sphenoidal approach Via nasal cavity Trans-cranial approach Larger tumors

Expected Outcomes Dopamine agonists serve to decrease both the size of the tumor and its secretions. The reduction in prolactin diminishes and hopefully eliminates the mammary secretions while the shrinking of the tumor potentially restores visual fields to normal. While restoration of vision tends to occur almost immediately, treatment often continues for over a year, dependent upon the size of the tumor. Bromocriptine is the drug of choice. Prognosis in these patients is excellent with up to 95% of tumors remaining “reduced” after a 4-6 year follow-up period

Patient Outcome At the time of my clinical rotation, the patient had been taking a dopamine agonist, Cabergoline, twice a week. This medication was chosen for it’s ease in administration as well as it’s relative lack of side effects. The patient had not yet begun to respond as he had only taken 2 doses of the medication. It is expected that he will need to follow protocol and remain on this medication for over a year in order to achieve an appreciable and permanent reduction in tumor size. He also has an appointment with a neurosurgeon to discuss surgical interventions, should it become necessary.

References Abrahamson, M and Snyder, P, Treatment of hyperprolactinemia due to lactrotroph adenoma and other causes, American Family Physician, Evaluation and Treatment of Galactorrhea, Volume 63, Number 9, May 1, Delgrange, Etienne and Trouillas, Jacqueline, Maiter, Dominique, Donnekier, Julian, Tourniare, Jacques, Sex-Related Differences in the Growth of Prolactinomas : A Clinical and Proliferation Marker Study, The Journal of Clinical Endocrinology and Metabolism, Volume 82, Number 7, Endocrine and Metabolic Diseases Service, Prolactinoma, EMedicine, Prolactinoma, Article last updated May 12, Mayo Clinic, Galactorrhea,