My partner and I have been together 5 years. I am 29 and he is 37. We each have a child from previous relationships, and would now love to have one together. We have not been using contraception for the past two years, but haven't actively been trying until now. My periods are as regular as clockwork every 28 days, but I just have a niggling doubt that I can't conceive.
I am also worried because I have very little discharge every month, and I also have white flaky stuff around my nipples. What is this stuff? Thanks for listening.
There is a chance you have something called galactorrhea, which may be caused by hyperprolactinemia. I'd suggest you talk to your gynecology provider to be sure. I have pasted some information below:
Definition: Galactorrhea is the secretion of breast milk in men, or in women who are not breastfeeding an infant.
Description: Lactation, or the production of breast milk, is a normal condition occurring in women after delivery of a baby. Many women who have had children may even be able to express a small amount of breast milk from the nipple up to two years after childbirth. Galactorrhea, or hyperlactation, however, is a rare condition that can occur in both men and women, where a white or grayish fluid is secreted by the nipples of both breasts. While this condition is not serious in itself, galactorrhea can indicate more serious conditions, including hormone imbalances or the presence of tumors.
Causes: Galactorrhea is associated with a number of conditions. The normal production of breast milk is controlled by a hormone called prolactin, which is secreted by the pituitary gland in the brain. Any condition that upsets the balance of hormones in the blood or the production of hormones by the pituitary gland or sexual organs can stimulate the production of prolactin.Often, a patient with galactorrhea will have a high level of prolactin in the blood. A tumor in the pituitary gland can cause this overproduction of prolactin. At least 30% of women with galactorrhea, menstrual abnormalities, and high prolactin levels have a pituitary gland tumor. Other types of brain tumors, head injuries, or encephalitis (an infection of the brain) can also cause galactorrhea.
Tumors or growths in the ovaries or other reproductive organs in women, or in the testicles or related sexual organs of men, can also stimulate the production of prolactin. Any discharge of fluid from the breast after a woman has passed menopause may indicate breast cancer. However, most often the discharge associated with breast cancer will be from one breast only. In galactorrhea both breasts are usually involved. The presence of blood in the fluid discharged from the breast could indicate a benign growth in the breast tissue itself. In approximately 10.15% of patients with blood in the fluid, carcinoma of the breast tissue is present.
A number of medications and drugs can also cause galactorrhea as a side-effect. Hormonal therapies (like oral contraceptives), drugs for treatment of depression or other psychiatric conditions, tranquilizers, morphine, heroin, and some medications for high blood pressure can cause galactorrhea.
Several normal physiologic situations can cause production of breast milk. Nipple stimulation in men or women during sexual intercourse may induce lactation, for women particularly during or just after pregnancy.Even after extensive testing, no specific cause can be determined for some patients with galactorrhea.
Symptoms: The primary symptom of galactorrhea is the discharge of milky fluid from both breasts. In women, galactorrhea may be associated with infertility, menstrual cycle irregularities, hot flushes, or amenorrhea--a condition where menstruation stops completely. Men may experience loss of sexual interest and impotence. Headaches and visual disturbances have also been associated with some cases of galactorrhea.
Diagnosis: Galactorrhea is generally considered a symptom which may indicate a more serious problem. Collection of a thorough medical history, including pregnancies, surgeries, and consumption of drugs and medications is a first step in diagnosing the cause of galactorrhea. A physical examination, along with a breast examination, will usually be conducted. Blood and urine samples may be taken to determine levels of various hormones in the body, including prolactin and compounds related to thyroid function.A mammogram (an x ray of the breast) or an ultrasound scan (using high frequency sound waves) might be used to determine if there are any tumors or cysts present in the breasts themselves. If a tumor of the pituitary gland is suspected, a series of computer assisted x rays called a magnetic resonance imaging (MRI) scan to locate tumors or abnormalities in tissues.
Treatment: Treatment for galactorrhea will depend on the cause of the condition and the symptoms. The drug bromocriptine is often prescribed first to reduce the secretion of prolactin and to decrease the size of pituitary tumors. This drug will control galactorrhea symptoms and in many cases may be the only therapy necessary. Oral estrogen and progestins (hormone pills, like birth control pills) may control symptoms of galactorrhea for some women. Surgery to remove a tumor may be required for patients who have more serious symptoms of headache and vision loss, or if the tumor shows signs of enlargement despite drug treatment. Radiation therapy has also been used to reduce tumor size when surgery is not possible or not totally successful. A combination of drug, surgery, and radiation treatment can also be used.
Galactorrhea is more of a nuisance than a real threat to health. While it is important to find the cause of the condition, even if a tumor is discovered in the pituitary gland, it may not require treatment. With very small, slow-growing tumors, some physicians may suggest a "wait and see" approach.
Prognosis: Treatment with bromocriptine is usually effective in stopping milk secretion, however, symptoms may recur if drug therapy is discontinued. Surgical removal or radiation treatment may correct the problem permanently if it is related to a tumor. Frequent monitoring of hormone status and tumor size may be recommended.
Prevention: There is no way to prevent galactorrhea. If the condition is caused by the use of a particular drug, a patient may be able to switch to a different drug that does not have the side-effect of galactorrhea.
Resources:"Galactorrhea." In Cecil Textbook of Medicine. 20th ed. Philadelphia, PA: W.B. Saunders Company, 1996, pp. 1318-1319."Galactorrhea." In Current Medical Diagnosis & Treatment 1998, 37th ed. Stamford, CT: Appleton & Lange, 1998, p. 1033.
"Galactorrhea (Hyperprolactinemia)." In Professional Guide to Diseases, 5th ed. Springhouse, PA: Springhouse Corporation, 1995, pp. 974-975.
"Galactorrhea." In The Merck Manual of Diagnosis and Therapy. Edited by Robert Berkow, et al. Rahway, NJ: Merck Research Laboratories, 1992, pp. 1065-1067.
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
This health encyclopedia is made possible by the Dr. Joseph F. Smith Trust Fund. Dr. Smith was a surgeon who resided in Wausau from 1908 to 1952. In addition to his surgical practice, Dr. Smith possessed a strong commitment to community service and medical education. The agreement which created the Dr. Joseph F. Smith Medical library was signed in July of 1948.
Background: Hyperprolactinemia is a condition of elevated serum prolactin. Prolactin is a 198 amino acid protein (23-kD) produced in the lactotroph cells of the anterior pituitary gland. Its primary function is to enhance breast development during pregnancy and to induce lactation. However, prolactin also binds to specific receptors in the gonads, lymphoid cells, and liver. Secretion is pulsatile; it increases with sleep, stress, pregnancy, and chest wall stimulation or trauma, and therefore must be drawn after fasting. Normal fasting values generally are less than 30 ng/mL depending on the individual laboratory.
Pathophysiology: The primary action of prolactin is to stimulate breast epithelial cell proliferation and induce milk production. Estrogen stimulates the proliferation of pituitary lactotroph cells, resulting in an increased quantity of these cells in premenopausal women, especially during pregnancy. However, lactation is inhibited by the high levels of estrogen and progesterone during pregnancy. The rapid decline of estrogen and progesterone in the postpartum period allows lactation to occur. During lactation and breastfeeding, ovulation may be suppressed due to the suppression of gonadotropins by prolactin.
Dopamine has the dominant influence over prolactin secretion. Secretion of prolactin is under tonic inhibitory control by dopamine, which acts via D2-type receptors located on lactotrophs. Prolactin production can be stimulated by the hypothalamic peptides, thyrotropin-releasing hormone (TRH) and vasoactive intestinal peptide (VIP). Thus, primary hypothyroidism (a high TRH state) can cause hyperprolactinemia. VIP increases prolactin in response to suckling, probably because of its action on receptors that increase adenosine 3',5'-cyclic phosphate (cAMP).
Frequency: In the US: This condition occurs in less than 1% of the general population and in 10-40% of patients presenting with secondary amenorrhea. Approximately 75% of patients presenting with galactorrhea and amenorrhea have hyperprolactinemia. Of these patients, approximately 30% have prolactin-secreting tumors.
Mortality/Morbidity: Mortality is unlikely; however, in cases where the condition is due to a large prolactin-secreting tumor, local mass effect can lead to significant morbidity. The condition causes systemic complaints that often resolve when the prolactin level returns to normal or once the tumor shrinks.
Sex: Clinical presentation in women is more obvious and occurs earlier than in men. They typically present with oligomenorrhea, amenorrhea, galactorrhea, or infertility. Galactorrhea is less common in postmenopausal women due to lack of estrogen. If a pituitary tumor is present, it is a microadenoma (<10 mm) approximately 90% of the time.
Prolactinoma is less common in men than in women, typically presenting as an incidental finding on a brain CT scan or MRI, or with symptoms of tumor mass effect. This is most evident as a complaint of visual disturbances or headache. By the time of diagnosis in men, approximately 60% have macroprolactinomas.
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography
- Women typically present with a history of oligomenorrhea, amenorrhea, or infertility, which generally result from prolactin suppression of gonadotropin-releasing hormone (GnRH). Galactorrhea is due to the direct physiologic effect of prolactin on breast epithelial cells.
- Men typically present with complaints of sexual dysfunction, visual problems, or headache and are subsequently diagnosed with hyperprolactinemia in the evaluation process. Prolactin suppresses GnRH, causing a decrease in luteinizing hormone and follicle-stimulating hormone, ultimately leading to decreased serum testosterone levels and hypogonadism. Prolactinoma in men also may cause neurological symptoms, particularly visual-field defects.
- In both sexes, the presence of a pituitary tumor may cause visual-field defects or headache. Most patients with a prolactinoma (the most common type of pituitary adenoma) are women.
Physical: Physical findings most commonly encountered in patients with hyperprolactinemia are galactorrhea and, occasionally, visual-field defects. Typically, the diagnosis is made via the aid of laboratory studies.
Causes: The diagnosis of hyperprolactinemia should be included in the differential for female patients presenting with oligomenorrhea, amenorrhea, galactorrhea, or infertility or for male patients presenting with sexual dysfunction. The condition is discovered in the course of evaluating the patient's problem. Once discovered, hyperprolactinemia has a broad differential that includes many normal physiologic conditions.
- Pregnancy always should be excluded unless the patient is postmenopausal or has had a hysterectomy. In addition, hyperprolactinemia is a normal finding in the postpartum period.
- Other common conditions to exclude include a nonfasting sample, excessive exercise, a history of chest wall surgery or trauma, renal failure, and cirrhosis. Postictal patients also develop hyperprolactinemia within 1-2 hours after a seizure. These conditions usually produce a prolactin level of less than 50 ng/mL.
- Hypothyroidism, an easily treated disorder, also may produce a similar prolactin level.
- Detailed drug history should be obtained because many common medications cause hyperprolactinemia, usually with prolactin levels of less than 100 ng/mL. Drugs that may cause the condition include the following:
- Dopamine receptor antagonists (eg, phenothiazines, butyrophenones, thioxanthenes, risperidone, metoclopramide, sulpiride, pimozide)
- Dopamine-depleting agents (eg, methyldopa, reserpine)
- Others (eg, isoniazid, danazol, tricyclic antidepressants, monoamine antihypertensives, verapamil, estrogens, antiandrogens, cyproheptadine, opiates, H2-blockers [cimetidine], cocaine)
- If no obvious cause is identified or if a tumor is suspected, MRI should be performed.
- Although no single test can help determine the etiology of hyperprolactinemia, a prolactinoma is likely if the prolactin level is greater than 250 ng/mL and less likely if the level is less than 100 ng/mL.
- Prolactin-secreting adenomas are divided into 2 groups: (1) microadenomas (more common in premenopausal women), which are smaller than 10 mm and (2) macroadenomas (more common in men and postmenopausal women), which are 10 mm or larger.
- If the prolactin level is greater than 100 ng/mL or less than 250 ng/mL, the evaluating physician must decide whether a radiographic study is indicated. In many cases, with the availability of MRI scanners, imaging is performed earlier and at lower prolactin levels to rule out a non.prolactin-producing tumor.
- When the underlying cause (physiologic, medical, pharmacologic) cannot be determined and an MRI does not identify an adenoma, idiopathic hyperprolactinemia is diagnosed.
I hope this information helps,
-- Cynthia, CNM