Transcript Galactorrhea in a 23 year old Male

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
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Milky discharge from the breast in the
absence of pregnancy, parturition, or
breast-feeding
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Synonyms:
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Nipple discharge
Disordered lactation
Inappropriate lactation
Witch's milk
Causes of Galactorrhea Differential
Patient Presentation &
Examination
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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
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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.
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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
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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, ectasy, vicodin, Ocycontin, and
mushrooms. He stated that he has been drug-free since his
incarceration in 2004.
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
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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:
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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
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The TSH level was normal at 2.550 uIu/mL (reference
range (0.27 – 4.2 uIu/mL) but his prolactin was
significantly elevated at 314.1 uIu/mL (reference range
for males is 4/04 – 15.20 uIu/mL).
The MRI defined a 1.7 X 1.5 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
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Change in medications – if taking medications which
can cause the condition
Medications which shrink the adenoma
 dopamine agonists
• Bromocriptine
• Cabergoline
• Pergolide
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Surgery
 Trans-sphenoidal approach
• Via nasal cavity
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Trans-cranial approach
• Larger tumors
Expected Outcomes
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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
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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
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Abrahamson, M and Snyder, P, Treatment of hyperprolactinemia
due to lactrotroph adenoma and other causes,
http://www.uptodate.com, 2007.
American Family Physician, Evaluation and Treatment of
Galactorrhea, Volume 63, Number 9, May 1, 2001.
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, 1997.
Endocrine and Metabolic Diseases Service, Prolactinoma,
http://www.endocine.niddk.nih.gov/pubs/prolact/prolact.htm, 2007.
EMedicine, Prolactinoma, Article last updated May 12, 2007.
Mayo Clinic, Galactorrhea, http://www.mayoclinic.com, 2007.