  To the Editor:  A healthy 20- year- old woman presented with breast pain and bilateral purulent nipple discharge three weeks after having her nipples pierced.  She received a course of antibiotics ( cephalexin)
 and her infection resolved.  Two weeks later,  she returned because of bilateral spontaneous galactorrhea.  Evaluation at that time showed a prolactin level of 218 µ g per liter,  with a negative urine test for pregnancy and normal concentrations of serum thyrotropin (
0. 22 µ U per milliliter)  blood urea nitrogen ( 8 mg per deciliter [ 2.
9 mmol per liter]  and serum creatinine ( 0. 6 mg per deciliter [ 53 µ mol per liter]
 Three weeks later,  the patient noted a decrease in galactorrhea;  her prolactin level was 82. 7 µ g per liter.  Two months later,
 she became pregnant and had an uneventful termination of the pregnancy.  Her menses remained normal throughout this time,  except during the pregnancy.  Two months after the pregnancy,  she had the nipple rings removed,  and she has had no further galactorrhea.
 By a month after the removal of the rings,  her prolactin level had returned to normal,  at 11. 3 µ g per liter.  Since cephalexin therapy was completed,
 the patient has not received any medications.  Magnetic resonance imaging of the pituitary was normal.  This young woman had a dramatic increase in prolactin and associated galactorrhea that coincided with the placement of bilateral nipple rings.  Harrison's Principles of Internal Medicine1 notes that hyperprolactinemia in which the prolactin level is greater than 100 µ g per liter " almost invariably is indicative of a prolactin-
secreting pituitary adenoma.  Williams Textbook of Endocrinology2 comments that " a single prolactin measurement may be sufficient to diagnose a prolactinoma if the value is greater than 200 µ g [ per liter]  The online version of UpToDate3 notes that serum prolactin concentrations "
may increase slightly,  reaching the range of 21 to 40 µ g per liter,  with " intense breast stimulation"  and that serum prolactin values above 200 µ
g per liter " usually indicate the presence of a lactotroph adenoma.  In an older study, 4 nipple stimulation did not elevate serum prolactin levels in nonlactating women.  Other studies have shown lower levels of hyperprolactinemia ( less than four times the upper limit of normal)
 even with the intense stimulation of afferent pathways from severe chest burns or rib fracture or immediately after thoracotomy. 5 In the case we report,  marked hyperprolactinemia ( prolactin level,  > 200 µ
g per liter)  was associated with the intense stimulation of nipple rings ( probably with the added stimulation of the associated infections)  and the prolactin level returned to normal with removal of the rings.  Geoffrey A.  Modest,
 M. D.  Boston University School of Medicine Boston,  MA 02118 gmodest@ partners. org John J.
W.  Fangman,  M. D.  Harvard Medical School Boston,  MA 02115 
