- 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
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
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
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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
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