Galactorrhea
Galactorrhea is the production of breast milk in men or in women who are not breastfeeding.
In both sexes, the most common cause of galactorrhea is a prolactin-secreting tumor (prolactinoma) in the pituitary gland. Prolactinomas usually are very small when first diagnosed; however, they tend to be larger in men than in women, probably because they come to attention later. Overproduction of prolactin and the development of galactorrhea may also be induced by drugs, including phenothiazines, certain drugs given for high blood pressure (especially methyldopa), opioids, and even licorice. There are other causes of galactorrhea that do not involve high levels of prolactin, such as an underactive thyroid gland (hypothyroidism).
Symptoms
Although breast milk production may be the only symptom of a prolactinoma, many women also stop menstruating (amenorrhea) or have less frequent menstrual periods. Women with prolactinomas often develop hot flashes and vaginal dryness, which causes discomfort with sexual intercourse, because of low estrogen levels. About two thirds of men with prolactinomas lose interest in sex (reduced libido) and have erectile dysfunction (impotence). A high prolactin level can cause infertility in both men and women.
When a prolactinoma is large, it may press on the nerves of the brain that are located just above the pituitary gland, causing the person to have headaches or to become blind in specific visual fields (see Section 20, Chapter 235).
Diagnosis
The diagnosis is usually suspected in women when menstrual periods are reduced or absent or when breast milk is unexpectedly produced. It is also suspected in men with reduced libido and decreased levels of testosterone in the blood who are producing breast milk. It is confirmed by finding a high level of prolactin in the blood. Computed tomography (CT) or magnetic resonance imaging (MRI) scans are performed to search for a prolactinoma. If no tumor is seen in the pituitary and there is no other apparent cause of the high prolactin level (such as a drug), it is still most likely, particularly in women, that the cause is a pituitary tumor, but one too small to be seen on the scan.
If a prolactinoma is large on imaging studies, an ophthalmologist tests the person's visual fields for possible effects on vision.
Treatment
Drugs can be given to stimulate dopamine, the chemical in the brain that blocks prolactin production. They include bromocriptine and cabergoline. These drugs are taken by mouth and are effective only as long as they are used; they seldom result in cure of the tumor. In most people, they lower prolactin levels enough to restore menstrual periods (in women), stop galactorrhea, and increase estrogen levels in women and testosterone levels in men, and they are often able to restore fertility. They also usually shrink the tumor and improve any vision problems. Surgery is also effective for treating small prolactinomas but is not usually used first because drug treatment is safe, effective, and easy to use.
When a person's prolactin levels are not extraordinarily high and a CT or MRI scan shows only a small prolactinoma or none at all, a doctor may not recommend treatment. This is probably appropriate in women who are not having problems getting pregnant as a result of the high prolactin level, whose menstrual periods remain regular, and who are not troubled by galactorrhea, and in men whose testosterone level is not low. Low estrogen levels usually accompany amenorrhea and increase the risk of osteoporosis in women; low testosterone levels increase the risk of osteoporosis in men.
To overcome the effects of low estrogen levels caused by a prolactinoma, estrogen or oral contraceptives that contain estrogen may be given to women with small prolactinomas who do not want to become pregnant. Although estrogen treatment has not been shown to stimulate the growth of small prolactinomas, most experts recommend a CT or MRI scan every year for at least 2 years to be sure the tumor is not enlarging substantially.
Doctors generally treat people who have larger tumors with dopamine agonist drugs (for example, bromocriptine or pergolide) or surgery. If dopamine agonists reduce the prolactin levels and symptoms disappear, surgery may not be necessary. Even when surgery is necessary, dopamine agonists may be prescribed to help shrink the tumor before the operation. They are often given after surgery, because a large prolactin-secreting tumor is unlikely to be cured with surgery.
Radiation therapy is sometimes needed, as for other pituitary tumors, when the tumor does not respond to medical or surgical treatment.
| 
