Nipple discharge (유두 분비물)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
KEYWORDS: ..유즙분비는 일생동안 여성의 20-25%에서 경험하는 증상이며, 드물지만 남성 에서도 발생할 수 있다. Fig 1. Physiology of lactation ..Normal nonpregnant women prolactin level range from 1 to 20ng per mL and may increase to as high as 300ng per mL during pregnancy. Nipple discharge Hypothalamus Thyrotropin-releasing hormone ; stimulation Dopamin : inhibition Pituitary gland Protactin Breast tissue Lactation Stimulation : Estrogen Progesteron Growth hormone Insulin Thyroid hormone Glucocorticoids Inhibition : High levels of estrogen and progesterone - The precipitous drop in the levels of these hormones after delivery, in the presense of an elevated prolactin level, facilitates lactation Stimulation : Sucking Stress Dehydration, Exercise, Sexual intercourse, Sleep, Estrogen, Serotonin(?) 499 The Root of ambulatory care Hyperprolactinemia, Euprolactinemia Antidepressants & anxiolytics : Alprazolam, Buspirone, Monoamine oxidase inhibitors-Moclobemide, SSRI-Citalopram, Fluoxetine, Paroxetine, Sertraline, Tricyclic antidepressants Antihypertensives : Atenolol, Methyldopa, Reserpine, Verapamil Antipsychotics Histamine H2-receptor blockers : Cimetidine, Famotidine, Ranitidine Hormone : Conjugated estrogen and medroxyprogesterone, Medroxyprogesterone contraceptive injections, Oral contraceptive formulations Phenothiazines : Chlorpromazine, Prochlorperazine Other drugs : Amphetamines, Anesthetics, Arginine, Cannabis(대마), Cisapride, Cyclobenzaprine, Danazol, Dihydroergotamine, Domperidone, Isoniazid, Metoclopramide, Octerotide, Opiates, Rimantadine, Sumatriptan, Valporic acid Herbs : Anise, Blessed thistle(엉겅퀴), Fennel(회향풀), Fenugreek seed(호로파), Marshmallow(양아욱), Nettle(쐐기풀), Red clover(자주토끼풀), Red raspberry(붉은 나무딸기) Pituitary adenoma, Bronchogenic carcinoma, Renal adenocarcinoma, Lymphoma, Craniopharyngioma, Hydatidiform mole, Hypermephroma, Mixed growth hormonesecreting and prolactin-secreting tumors, Null-cell adenoma Pregnancy and postpartum state, Breast stimulation, “ Witch's milk”in neonates-results from the precipitous drop in maternal estrogen and progesterone levels after delivery Craniopharyngioma and other tumors, Infiltrative conditions-Sarcoidosis, Tuberculosis, Schistosomiasis, Pituitary stalk resection, Multiple sclerosis, Empty sella syndrome Hypothyroidism (TRH↑), Chronic renal failure (decreased clearance of prolactin by the kidneys), Cushing's disease, Acromegaly Irritating clothes or ill-fitting brassieres, Herpes zoster, Atopic dermatitis, Burns, Breast surgery, Spinal cord injury or surgery, Spinal cord tumor, Esophagitis, Esophageal reflux (stimulating the thoracic nerves via the cervical and thoracic ganglia) Idiopathic : 35% (Idiopathic galactorrhea associated with a reduced risk of breast cancer) Medications and herbs : 20% Neoplastic processes : 18% Physiologic conditions : 14% Hypothalamic-pituitary disorders : < 10% Systemic process : < 10% Chest wall irritation : < 10% Nipple discharge ..Galactorrhea occurs more often after discontinuation of oral contraceptive pills than during prolonged use. ..Pituitary prolactinoma clinical signs : headache, galactorrhea, amenorrhea, defects in peripheral vision, hirsutism, acne, hypogonadism (decreased libido, decreased fertility, decreased bone density) Nipple discharge Microscopy shows fat globules in discharge Galactorrhea Laboratory tests : Human chorionic gonadotropin level Prolactin level Thyroid-stimulationg hormone level BUN/Cr levels High thyroid-stimulating hormone level. Low thyroxine level Thyroid hormone replacement therapy MRI of the brain Nongalactorrheal discharge Reassurance Regular menses? Normal thyroid-stimulating hormone level. Normal prolaction level Normal thyroid-stimulating hormone level. Prolactin level higher than 20ng per mL Consider breast cancer : Intraductal papilloma Papillomatosis Mammary duct ectasia Fibrocystic breast disease Fig 2. Evaluation of nipple discharge No Yes 501 The Root of ambulatory care ..Prolactin level은 스트레스와 유방자극에 의해 영향을 받기 때문에 채혈은 Breast examination후 최소한 1시간 후 시행되어야 한다. ..Galactorrhea와 유방암과의 연관성은 희박하기에 mammography는 일반적 으로 추전되지 않는다. ..Osteoporosis & hyperprolactinemia - High prolactin level effect on gonadotropina and resulting low estrogen levels - Osteoporosis risk can be reduced with medical therapy : dopamine agonist like bromocriptine ..Discharge that is from multiple ducts or bilateral is rarely cancer. ..Bilateral discharge is usually normal or secondary to endocrine disorders or drugs. ..Bloody discharge and discharge in men is cancer until proved otherwise. 참고 문헌 Kristin S. Pena, M.D., Jo Ann Rosenfeld, M.D. : Evaluation and Treatment of Galactorrhea. A journal of the American Family Physicains 2001 ; 63 : 1763-1770, 1775 Elana Nudel Kripke : Nipple discharge, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 509-510 한지혜 : 유즙분비, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1300-1303