A 33-year-old woman, gravida 2 para 2, comes to the office for evaluation of nipple discharge. The nipples have intermittently leaked pale gray discharge for the past week. The patient had a progestin-releasing intrauterine device placed for contraception 3 years ago and has been amenorrheic for the past 2 years. Family history is significant for 2 maternal aunts with breast cancer in their 60s. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 36.7 C (98.1 F), blood pressure is 100/70 mm Hg, and pulse is 70/min. There are no palpable masses or nipple abnormalities. Brownish-gray discharge is expressed from both nipples and is guaiac negative. A urine pregnancy test is negative. Which of the following is the best next step in management of this patient?
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This patient's bilateral, gray nipple discharge is most consistent with galactorrhea, which is lactation in men or nonbreastfeeding women. Physiologic galactorrhea is usually bilateral and guaiac negative, as in this patient; the appearance is typically milky or clear but can also be yellow, brown, gray, or green.
Although galactorrhea is typically benign, a clinical breast examination is required to assess for underlying malignancy. Patients with bilateral, nonbloody nipple discharge and no findings concerning for malignancy (eg, no palpable breast mass, lymphadenopathy, or nipple or skin changes) can then undergo evaluation for medical causes of galactorrhea.
The most common cause of galactorrhea is hyperprolactinemia, which can occur with a pituitary prolactinoma, use of certain medications, hypothyroidism, pregnancy, or chest wall/nipple stimulation (eg, surgery, trauma). Therefore, evaluation with serum prolactin and TSH levels is required in patients with bilateral galactorrhea. Pituitary imaging (usually MRI) may be needed in those with elevated prolactin and/or symptoms of a pituitary mass (eg, vision disturbances, headaches). Patients with a normal evaluation can be managed with reassurance and routine follow-up (Choice D).
(Choice A) Cytologic evaluation of nipple discharge is not recommended because it has low sensitivity and specificity for malignancy and does not assess for medical causes of galactorrhea.
(Choices B and F) Mammography and breast ultrasonography are indicated in patients with findings concerning for malignancy (eg, unilateral or guaiac-positive discharge, palpable breast abnormalities, skin changes [eg, erythema, nipple retraction]), which are not present in this patient.
(Choice E) Medications that inhibit dopamine (eg, antipsychotics, antidepressants, opioids) or stimulate pituitary lactotrophs (eg, estrogen-containing contraceptives) can cause galactorrhea. However, progestin-releasing intrauterine devices, which act locally to thin the endometrium and block sperm entry, are not associated with galactorrhea. Therefore, removal is not indicated.
Educational objective:
Physiologic galactorrhea is usually bilateral, nonbloody, and clear or milky (most common), yellow, brown, gray, or green. Hyperprolactinemia is the most common cause. Therefore, patients with galactorrhea require pregnancy testing and measurement of serum prolactin and TSH.