HNY Central Digital Repository - York

Characterised by a large amount of milky discharge from multiple ducts. Usually bilateral and usually due to raised prolactin levels.

• Breast lump
• Blood staining
• Single duct discharge (only one point of discharge on nipple)

• Ensure not pregnant or breast feeding.
• Identify any drugs – stop, reduce or obtain advice.
• History and examination to look for potential underlying endocrine cause eg Thyroid disorder, Pituitary tumour (visual field defects/ headaches), Prolactinoma.
• Check serum prolactin, TSH and any other relevant hormones.
• Raised prolactin levels are common (e.g. due to medication or stress).
• In prolactinoma a very high value (over 1000 and usually several 1000mU/L) is expected.

Causes of Hyperprolactinaemia

• Physiological – up to 2 years after stopping breastfeeding, times when hormones fluctuating (puberty, menopause)
• Idiopathic – up to 40% of cases
• Prolactinomas
• Other causes of hyperprolactinaemia – Addisons, Acromegaly, Cushings, tumours
• Drugs* see below
• Systemic disorders – CKD, Liver disease, Hypothyroidism
• Chest wall lesions – breast surgery, Herpes zoster
• Infiltration of pituitary stalk – MS, tumours, Trauma
   

Drugs that raise prolactin levels: (the following list is not comprehensive)

• Antipsychotics - the most common drugs to cause hyperprolactinaemia:
• Traditional phenothiazine antipsychotics (chlorpromazine, prochlorperazine, thioridazine, trifluoperazine) and haloperidol.
• Atypical neuroleptics may also be implicated, but less frequently. Risperidone is the most likely to cause a raised PRL, also amisulpride. Olanzapine is less likely to do so.
• Antidepressants - especially the selective serotonin reuptake inhibitors (SSRIs). Monoamine-oxidase inhibitors (MAOIs) and some tricyclic antidepressants (TCAs) less often.
• H2 antagonists - especially cimetidine, but also ranitidine.
• Antihypertensives - including beta-blockers, methyldopa and verapamil.
• Contraceptives - including combined oral contraceptives and depot contraceptives.
• Prokinetics - domperidone, metoclopramide.
• Illicit drugs - including cannabis, opiates and amphetamines.
• Others - including digoxin, spironolactone, opiates, danazol, sumatriptan, isoniazid and valproate.

None

Unless there are red flags – referral should be to Endocrinology for assessment of underlying issue.

References

Kernow Clinical Commissioning Group Reviewed 2019

Profession guidance on Patient.co.uk

Patient information

Westmead (Australia) Breast Cancer Information

Responsible Consultant: Miss Jenny Piper 

Responsible GP: Dr Ruth Guest

Responsible Pharmacist: Faisal Majothi