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  1. 1. Prof. Aboubakr Elnashar Benha University Hospital, Egypt Email: Aboubakr Elnashar
  2. 2. Define Nonpuerperal watery or milky breast secretion that contain neither pus nor blood. Color Amount Side Spontaneous or not Incidence Unk Recently increased How to elicit? Aboubakr Elnashar
  3. 3. Environment Higher centers Hypothalamus Anterior pituitary Prolactin Breast - - - - + + + + TSH = PRF Endorphins PIF = Dopamine Aminobutyric ac Aboubakr Elnashar
  4. 4. Causes I. Inhibition of PIF 1. Stress . Prolonged suckling . Jug & run 2. Thoracotomy scars . Cervical spine lesions . Herpes zoster 3. Drugs 4. Chronic renal failure 5. CNS disease 6. Pituitary stalk lesions II. Stimulation of PRF Hypothyroidism III.Increased prolactin production 1. Pituitary tumor 2. Non pituitary tumor IV. Idiopathic Aboubakr Elnashar
  5. 5. Drugs The most common cause of galactorhea. The commonest are metaclorpromide & phenothiazines I. Estrogens & drugs that increase estrogen 1. OCP 2. Digitalis 3. Marijuana 4. Heroin II. Dopamine receptor blockers 1.Phenothiazines 2.Haloperidol 3. Metaclorpromide 4. Isoniazide III. CNS dopamine depleters 1. Psychoactive:Tricyclic antidepressant,phenothiazines, Benzodiazepins 2. Antihypertensive: Reserpin, Methyl dopa, verapamil 3. Cimetidine When galactorrhea disappear ?: 3-6 moAboubakr Elnashar
  6. 6. When to investigate ? 1. Nulliparous 2. 12 mo after last pregnancy or weaning Aboubakr Elnashar
  7. 7. Galactorrhea without hyperprolactinamia: 50% 1. Episodic fluctuation & sleep increments 2. Bioactive PRL which is not detectable 3. An earlier episode of hyperprolactinaemia which triggered persistent galactorrhea. Aboubakr Elnashar
  8. 8. Hyperprolactinaemia without galactorrhea 66% 1. Inadequate detection 2. Hypoestrogenic state. 3. Inadequate estrogenic or progetational priming of the breast 4. High PRL does not interact with the breast receptors Aboubakr Elnashar
  9. 9. Diagnostic evaluation History & Examination: Exclude: Recent pregnancy, breast stimulation Drugs, Breast or chest lesion Prolactin >20 ng/ml <20 ng/ml TSH Normal High (hypothyroidism) MRI (Normal or hyperplasia, Microadenoma or Macroadenoma)Aboubakr Elnashar
  10. 10. PRL Basal conditions Late morning Fasting after 60 min rest not in late follicular phase 2nd blood sample if the first is raised Level > 100 ng/ml: 60% pituitary tumor. > 300 ng/ml: 100% pituitary tumor Modest elevation can be associated with pituitary tumor Aboubakr Elnashar
  11. 11. MRI superior to CT Aboubakr Elnashar
  12. 12. Treatment I. Idiopathic (normal PRL) . Observation . Dopamine agonist (anxiety, pregnancy). Stop during pregnancy II. Hypothyroidism . Eltroxin III. Microadenoma . Observation: annual PRL . Dopamine agonist (anxiety, pregnancy). Stop after 2-3 yr. . Surgery (rapid growth). Transsphenoidal microsurgery is very safe, but recurrence is high (Sperof,1999) IV. Macroadenoma . Dopamine agonist: long term . Surgery (No response, suprasellar extension, pregnancy). Preoperative bromocriptine may result in fibrosis Aboubakr Elnashar
  13. 13. I. Microadenoma: usually do not enlarge significantly during pregnancy II. Macroadenoma: may grow rapidly & cause visual disturbance during pregnancy. Surgery before pregnancy should be considered. An alternative method is continuation of dopamine agonist during pregnancy: & visual field/ 3 mo: No detrimental effects on the fetus, Nearly all delivered at term without complications Pregnancy, Breast feeding, COC s, ERT not contraindicated Aboubakr Elnashar
  14. 14. Bromocriptine (Parlodel, lactodel, Dopagon , 2.5 mg) Dose:1 t bid Side effects: n & v. , postural hypotension, headache, nasal stiffness, constipation. Can be minimized: give t at bed time, avoid large dose increament, vaginal adminstration Monitoring: mid normal values, titrate the dose accoringly Galactorhea stops after: 6 w & 11 w if there is adenoma Vaginal: Absorption is almost complete & slow, the first pass through the liver is avoided: 1 t /d & less side effects. During menstruation: tampon at night.No effect on sperms Aboubakr Elnashar
  15. 15. Quinagolide (Norplac, 75 ug) Dose: 1 t/ d It has higher affinity for dopamine receptors: tumors resistant to bromocriptine have responded to this drug (Speroff,1999) Aboubakr Elnashar
  16. 16. Cabergoline (Dostinex, 0.5 mg) Ergotline derivative, Long lasting Dose: 1-2 t/ W Side effects: less than bromocriptine Aboubakr Elnashar
  17. 17. Thanks Aboubakr Elnashar