Saturday, 25 April 2015

GALACTORRHEA: THE MILKY NIPPLES

Regular people with interesting stories.



        On a Monday morning, she was called in by the nurses for consultations. An innocent-looking young lady with bloodshot eyes and a look of uncertainty on her face. Judging by her appearance she could pass for a 24 year old. Smiling to put her at ease, we got to the business of the day.

        
Amanda is a 27 year old accountant with a busy accounting firm. She is also taking classes and preparing earnestly for her upcoming professional exams. She is ambitious, focused and the epitome of a well-bred young lady. Three months ago, she was involved in a near fatal accident and as a result of post traumatic stress disorder, she was placed on tranquilizers while also undergoing therapy sessions.
        Two days ago, as she was waiting for a bus at the bus stand, she noticed a group of young men pointing in her direction and smiling among themselves as they talked. She paid them no attention as her thoughts were on the coming week which was going to be quite hectic. Suprised, she turned as the middle aged woman standing beside her tapped her lightly on the shoulder saying "My daughter, it seems your child is hungry" at the same time pointing to her chest. Looking down in confusion, she saw the wet patches around both nipple areas of her shirt. Embarrassed,she clutched her handbag to her chest and thanked the woman. On alighting from the bus, she hurried into her house and quickly striped down still embarrassed. Standing before her mirror, she examined her breasts as she had being taught at a breast cancer awareness programme she had attended in the past. There were no unusual changes but to her amazement, milky fluid spurted from both nipples when she expressed them.
        Alarmed, she recalled that her menses had been irregular in the past two months but she had attributed it to the stress of juggling work with the demands of the preparations for her professional exams. But... Three months ago, about one week after her near fatal accident, she had attended the firm's gala night with Jeff, a colleague who had insisted she use the opportunity to unwind and get back in the flow with the living.
She had passed out on her second glass of an alcoholic cocktail and had woken up in her bed. On the assumption that her flat mate who was also a staff in the firm had seen to that, she had thanked her without bothering to ask for the details. In hindsight, she should have asked. Knowing that only pregnant women and breastfeeding mothers produced breastmilk she began to wonder as she had never been pregnant and was on an abstinence spree.
        "Had she been sexually assaulted while she was unconscious? But it was an open area. Could Jeff have touched her? No. Jeff was a christian and he was too decent for that". Her mind ran in circles. "How does one tell her family she was pregnant and had no idea who was responsible? To compound the issue, she had no memory of the act".After two sleepless nights spent pondering the unusualness of her situation, she presented to the clinic for medical evaluation.

         Galactorrhea is the spontaneous flow of milk from the breast in the absence of pregnancy, childbirth and lactation. It occurs in 5-32% of women and is caused by the direct physiologic effect of prolactin on the epithelial cells of the breasts. This condition is frequently benign and could affect one or both breasts. Milk could be seen on the nipples with or without manual stimulation. The quantity of milk produced is variable.
Affected persons may include young girls, non breastfeeding mothers and post menopausal women. Rarely, men are affected.
         Prolactin is a hormone produced by the lactotrophs of the anterior pituitary gland. It is released in a pulsatile manner and it's function is to enhance breast development during pregnancy and also to induce lactation. Overproduction of this hormone leads to decrease/cessation of menstrual periods and also infertility. It is reguated by dopamine and medications that interfere with this substance in the brain can cause elevated prolactin levels.
Physiologically, increase in this hormone occurs during sleep, stress, pregnancy, chest trauma and chest surgeries.
Galactorrhea could be caused by:
     Excessive nipple stimulation
     Hormonal disorders: Hyperprolactinaemia
                                               Hypothyroidism
     Medications: Side effect of drugs (Cimetidine)
                 Birth control pills(As a result of hormonal imbalance)
                 Marijuana, opiates
                 Tranquilizers ( Antipsychotic drugs- antagonises dopamine)
     Pituitary tumors (either by directly secreting prolactin or by compressing the infundibular stalk)
     Chest trauma and chest surgeries
     Seizures
     Liver cirrhosis
     Kidney disease
In 50% of cases, the cause of galactorrhea is unknown.
It is important to note that bloody nipple discharge is not galactorrhea and requires urgent medical attention. Also, galactorrhea involving one breast requires medical evaluation to rule out a malignancy.
Symptoms could include:
Milky nipple discharge
Headache
Blurred vision
Reduced to absent menses
Decreased interest in sex
Anovulation (due to suppression of gonadotrophins by prolactin)
Infertility
In males, erectile dysfunction, decreased libido, decreased hair growth and weakness could present.
Requested investgations could include:
     Pregnancy test
     Hormonal assay
     Liver function test
     Thyroid function test
     MRI or CT scan.
If the condition is due to medications, prolactin level will usually normalise within 3-4 days of withdrawal. Some cases stop spontaneously but wisdom entails a visit to your physician for proper medical evaluation and management.
In Amanda's case, what do you think might have been the cause of galactorrhea? Your comments and questions are welcome.
This article provides general medical information and in no way substitutes for a visit to your medical provider.
Do Stay Safe and Live Clean with Dr Ib Orabueze.