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Nipple discharge

  • Nipple discharge is the efflux of fluid from the nipple
  • Accounts for about 5% of referrals to a breast clinic
  • Discharge can be elicited in approximately 20% of women by squeezing
  • Nipple discharge can be regarded as physiological in the following:
    • Neonatal period
    • Lactation
    • Pregnancy
    • Post lactation
    • Following mechanical stimulation
    • Hyperprolactinaemia
  • If can also represent duct pathology
    • Duct ectasia
    • Duct papilloma
    • Breast cancer

Description of nipple discharge

  • Unilateral or bilateral
  • Single or multiple ducts
  • Colour and nature
  • Blood-stained
  • Spontaneous or expressed

Galactorrhoea

  • Galactorrhoea is milk secretion unrelated to breast feeding
  • Bilateral, multi-duct, milky discharge
  • Often copious volumes and can occur spontaneously

Causes of Galactorrhoea

Physiological

  • Mechanical stimulation
  • Extremes of reproductive life
  • Post lactation
  • Stress

Drugs

  • Associated with hyperprolactinaemia
    • Dopamine receptor-blocking agents (e.g. phenothiazines, haloperidol)
    • Dopamine-depleting agents (e.g. Methyldopa)
  • Others
    • Oestrogens
    • Opiates

Pathological

  • Hypothalamic and pituitary stalk lesion
  • Pituitary tumours
  • Ectopic prolactin secretion
  • Hypothyroidism
  • Chronic renal failure

Coloured, opalescent discharge

  • Usually bilateral, multi-duct, creamy or green in colour
  • Usually occurs in late reproductive life
  • Symptoms may be intermittent
  • Commonest cause is duct ectasia

Blood-stained and serosanguinous discharge

  •  Serous or blood-stained discharges are more worrying
  • Often due to hyperplastic epithelial lesions
  • Risk of malignancy increases with age
  • 12% of breast cancers present with nipple discharge
  • 70% of cases of blood-stained discharge have either a duct papilloma or breast cancer

Blood-stained nipple discharge

Management

  • A detailed history will often indicate the underlying cause
  • Breast examination is often normal
  • Haemostix can be used to test for the presence of blood
  • Nipple smear cytology is rarely useful
  • Mammography should be performed in all women over 35 years
  • Ultrasound may identify retroareolar lesions
  • If a lump is present, investigation should be by triple assessment
  • If suggestion of galactorrhoea the serum prolactin should be measured
  • Other investigations that have been described include:
    • Galactography
    • Fibreoptic ductography
  • Most women with multi-duct, creamy discharge can be reassured after appropriate investigation
  • Surgery is only required if:
    • The discharge is profuse and embarrassing
    • Malignancy can not be excluded
  • In women with single-duct blood-stained discharge consider
    • Young women - microdochectomy
    • Older women - total duct excision

Bibliography

Falkenberry S S.  Nipple discharge.  Obstet Gynecol Clin North Am 2002;  29:  21-29.

King T A,  Carter K M,  Bolton J S,  Fuhrman G M.  A simple approach to nipple discharge.  Am Surg 2000;  66:  960-965.

Sakorafas G H.  Nipple discharge:  current diagnostic and therapeutic approaches.  Cancer Treat Rev 2001;  27:  275-282.

Simmons R,  Adamovich T,  Brennan M et al.  Nonsurgical evaluation of pathologic nipple discharge.  Ann Surg Oncol 2003;  10:  113-116.

Vargas H I,  Romero L,  Chlebowski R T.  Management of bloody nipple discharge.  Curr Treat Options Oncol 2002;  3:  157-161.

 

 
 

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