Gyno Abnormalities

"I have been having a milky breast discharge for a long time which I overlooked, but recently my menstrual period ceased which I believed was as a result of the discharge. Can it cause barrenness in future, whom do I meet for treatment?

I am 29 and single, with irregular menses. The first Doctor I saw prescribed Parlodel® which makes me sick each time I take it." Ifeoma

The milky breast nipple discharge is a symptom, not a cause of anything. Often it is the result of an elevated prolactin or milk hormone. Normally that hormone is only elevated in pregnancy. The rest of the time, the brain secretes a prolactin-inhibiting factor. Sometimes medications or stress or medical conditions can disturb this inhibiting factor and the result is an elevated prolactin level and then a milky nipple discharge begins. There does not need to be an elevated prolactin all of the time; sometimes local breast and nipple factors just stimulate the milk production.

Are irregular menstrual periods part of the milky nipple discharge syndrome?

Yes. The same hypothalamic brain stresses that block prolactin inhibiting factor can also block the release of FSH and LH which are needed for monthly egg ovulation. Anovulation, or lack of ovarian function in women can cause many problems. It can cause no menses (amenorrhea) and thus infertility. As you say, barrenness or infertility can be a result but not of the milky discharge, just of the anovulation. Skipping of menses can also cause subsequent prolonged bleeding episodes. Almost any abnormal uterine bleeding in the reproductive years may be associated with anovulation.

When doctors investigate for anovulation, they occasionally find an increase in the breast milk producing hormone prolactin. That hormone can also be elevated in women who have normal menses, but who have a milky discharge from the breast. Women who are breast feeding have a normally elevated prolactin level and usually no ovulations or menses. In that case increased prolactin causing milk from the breasts and anovulation is a desirable effect.

How do you see if prolactin elevation is causing the milky discharge?

When elevated prolactin causes menstrual delay or prolonged abnormal uterine bleeding, or even milky breast discharge, diagnosing the reason for the elevated prolactin is a goal in itself because there are medicines that can lower blood levels of prolactin. Normal blood level in most labs is less than 25 ng/ml. Prolactin levels can normally increase a small amount with eating, orgasm, sleep deprivation, and physical and emotional stress. Therefore any values above 25 ng/ml and below 50 ng/ml should be repeated in the fasting state.

Laboratory tests to order include a pregnancy test (HCG), "brain hormones" such as FSH, LH (ovulation), TSH (thyroid), (pituitary gland) and tests of renal function. Most importantly, a head xray study such as a CAT scan (computer-aided tomography) or an MRI (magnetic resonance imaging) is ordered to rule-out tumors or lesions of the head or brain. Approximately 30% of women with increased prolactin levels have a small tumor of the pituitary gland (prolactinoma). This usually can be treated medically. If any of the xrays show a tumor, an ACTH and growth hormone level should be drawn to see if the tumor secretes other hormones. If all of those studies are negative, a chest xray and a scan of the abdomen may be indicated to look for non-pituitary tumors such as in lung or kidney that may secrete prolactin. These studies are not done unless the prolactin level is quite high (over 100 ng/ml).

What diseases or conditions can cause an elevated prolactin (hyperprolactinemia)?

One educational article, Faber KA: A pragmatic approach to evaluating, managing hyperprolactinemia. Obg Management 1998; June 1998:66-79, has pointed out the work-up algorithm for elevated prolactin.

In a medical history, the doctor asks about any chest wall lesions, trauma, burns or breast surgery including breast implants. For some reason, any disturbance of the nerves of the chest wall can send a signal to the brain to increase prolactin production. Even an infection with herpes zoster (shingles) on the chest wall can produce this and even a spinal cord tumor or lesion. The second major factor a physician asks about is what medications a woman is taking. Several medications can cause prolactin elevation.

What medications commonly cause an elevated prolactin?

Although not a total list, medications known to cause elevated prolactin are:

amitriptyline (Elavil®)
androgens (testosterone)
anesthetics (usually post surgical)
chlorpromazine (Thorazine®)
cimetadine (Tagamet®)
estrogens
fluphenazine
haloperidol (Haldol®)
metoclopramide (Reglan®)
monoamine oxidase inhibitors (Nardil®, Parmate®)
opiates (codeine, pain pills, morphine)

What kind of treatments are available for the milky nipple discharge and irregular menses?

Keep in mind that women can have milky breast discharge or anovulation or irregular bleeding and not have prolactin elevations in their blood. When it is elevated, thorough diagnosis is important. The first treatment needs to be directed at any cause of the hypothalamic brain suppression. Increased stress, thyroid disease, or any anatomical brain tumors should be treated. Any medications that are suspect should be switched, if possible, to ones that are not known to delay mense or elevate prolactin hormone.

Sometimes the source of the milky discharge is a local breast irritation, frequent nipple stimulation during lovemaking or even the frequent squeezing of the nipples that a woman does just to keep checking to see if the milky discharge is still present. It is essential to stop stimulating or squeezing the nipple to check for discharge. Each time the nipple is stimulated, it sends a signal back to the brain to release more prolactin hormone and to produce breast milk. Thus any continued nipple stimulation just makes the problem last longer and not go away.

Parlodel® has been used in the past to treat galactorrhea or milky nipple discharge. Parlodel® is bromocriptine which functions as a prolactin inhibiting factor. It has not been shown to help infertility but it can successfully stop the galactorrhea. It is a member of a general class of drugs called dopamine agonists. Many of those drugs have the side effects you describe. Still, it may be worth asking your physician if you can try one of the other dopamine agonists that are primarily used to treat Parkinson's disease:

Dostinex®* (cabergoline)
Mirapex® (pramipexole)
Permax® (pergolide)
Requip® (ropinirole)
Symmetrel® (amantadine)