Nipple discharge (유두 분비물)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
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