Impact of Prolactin and Estrogen on Nipple Secretions: Their Significant Functions Explored
Nipple discharge is a common experience among women of reproductive age, making it the third most common reason for women to visit a breast clinic. According to statistics, nearly 80% of women will experience nipple discharge at some point in their lives.
Every case of non-lactational nipple discharge deserves a full clinical evaluation, starting with history-taking and physical examination. Doctors will look for certain characteristics in a patient's history, such as whether the discharge is bloody or clear/milky, spontaneous or only with nipple manipulation, unilateral or bilateral, and from one duct or multiple ducts.
There are various types of nipple discharge. Lactation is a normal type of nipple discharge during pregnancy and the postpartum period. On the other hand, pathologic discharge is a type that raises red flags and is usually spontaneous, persistent, and from a single duct. Pathologic discharge can be caused by several factors, including papillomas, duct ectasia, breast cancer, infections, and periductal mastitis.
In cases of pathologic discharge, breast imaging (mammography or ultrasound) is essential to check for any abnormalities in the ducts or breast tissue. For women over 40, diagnostic mammography and breast ultrasound are recommended, while women between 30-39 should first have a mammogram followed by ultrasound if needed. Women under 30 should start with ultrasound and add mammography only if there's a suspicious finding or high-risk family history. Men with pathologic discharge should have both mammography and ultrasound.
One common cause of pathologic discharge is hyperprolactinemia, a condition characterised by elevated levels of prolactin, a hormone that stimulates milk production. Common medications known to cause physiological nipple discharge due to hyperprolactinemia primarily include drugs that increase prolactin secretion by blocking dopamine's inhibitory effects on the pituitary lactotroph cells.
These medications are typically dopamine antagonists or dopamine depleters, leading to elevated prolactin which can cause galactorrhea (pathological milk secretion or nipple discharge). The main drug classes and specific agents involved are typical and atypical antipsychotics (excluding aripiprazole), metoclopramide, domperidone, alpha-methyldopa, reserpine, and TRH.
In some cases, transient galactorrhea can occur even with normal hormone levels, usually in younger women. If no other issues are found, a doctor will reassure the patient and re-evaluate in a few months. If a medication is found to be causing galactorrhea, it may be adjusted or continued, depending on the case and its medical necessity.
Stress can trigger a small rise in prolactin levels, but it's important to ask about any recent breast trauma, medication history, and whether the patient is taking any anticoagulants, as they can increase discharge or make it bloody. In special cases where imaging is normal but symptoms persist, galactography or ductoscopy might be used to visualize the ducts directly.
Treatment for hormone-related nipple discharge depends on its cause. Benign conditions might be managed with microdochectomy or total duct excision, while duct papillomas typically require surgical removal of the affected duct. In cases of pathologic discharge, surgery may also be necessary, such as in the case of breast cancer, and may also involve chemotherapy or radiation, depending on how advanced the cancer is.
References: [1] Mayo Clinic. (2020). Galactorrhea. [online] Available at: https://www.mayoclinic.org/diseases-conditions/galactorrhea/symptoms-causes/syc-20353468 [2] NHS. (2021). Nipple discharge. [online] Available at: https://www.nhs.uk/conditions/nipple-discharge/
- The prevalence of nipple discharge is significant, making it a common topic in health and wellness discussions.
- Understanding the characteristics of nipple discharge is crucial for a proper medical-condition diagnosis.
- Lactation is a normal type of nipple discharge during pregnancy or breastfeeding, yet pathologic discharge requires attention.
- Pathologic discharge can signal underlying health-and-wellness concerns, including breast cancer and other conditions.
- A thorough history-taking and physical examination are the initial steps in investigating non-lactational nipple discharge.
- Breast imaging, such as mammography or ultrasound, may be needed to check for duct or breast tissue abnormalities.
- Women over 40 often require mammography and breast ultrasound, while younger women may start with ultrasound and add mammography if necessary.
- Hyperprolactinemia, characterized by elevated prolactin levels, is a common cause of pathologic discharge.
- Some medications can cause physiological nipple discharge due to hyperprolactinemia, including antipsychotics, metoclopramide, and domperidone.
- Stress and breast trauma can also trigger prolactin secretion and nipple discharge.
- Transient galactorrhea can occur even with normal hormone levels, particularly in younger women.
- In cases where imaging results are normal but symptoms persist, further diagnostic methods like galactography or ductoscopy may be used.
- Treatment for hormone-related nipple discharge depends on the cause and may involve surgery, microdochectomy, total duct excision, or drug adjustments.
- Surgical removal of affected ducts may be necessary in some cases, such as for breast cancer or persistent pathologic discharge.
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