Breast, Nipple Discharge


Article Author:
Karima Sajadi-Ernazarova
Kavin Sugumar


Article Editor:
Rotimi Adigun


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/7/2019 5:55:19 PM

Introduction

The fluid that leaks from one or both nipples of a non-pregnant and non-breastfeeding breast is called a nipple discharge. Nipple discharge is a complex diagnostic challenge for the clinician partly because of it could be the manifestation of a wide variety of diseases and clinical conditions.

Each human breast has 15 to 20 milk ducts. A discharge can come from one or more of these milk ducts.

The most important consideration in a patient with nipple discharge for both the patient and the physician is the possible association of this condition with an underlying breast cancer. With the increased public awareness of breast cancer, an increasing number of women are asking their health care providers about nipple discharge. Thus, a clinician must be aware and knowledgeable in evaluating nipple discharge.

Nipple discharge is not an uncommon complaint in the emergency department and can be benign (physiologic discharge) or a sign of a pathologic process.[1]

Nipple discharge is normal during last weeks of pregnancy, after the childbirth and during the breastfeeding period. It can also be normal in women who are not pregnant and are not breastfeeding, especially during reproductive years. Certain manipulations of the breasts, such as fondling, sucking, or massaging can stimulate milk ducts to secrete fluid. Stress also has been shown to cause nipple discharge.[1]

All postmenopausal nipple discharge, however, is significant and requires further evaluation. Nipple discharge in men is always abnormal and also must prompt an evaluation.[2][3]

Etiology

The majority of all nipple discharges are benign in etiology (97%).[1][2][4][3]

Causes of physiologic nipple discharge:

  1. Pregnancy
  2. Lactation
  3. Postpartum galactorrhea which may last up to two years after delivery
  4. After spontaneous or intentional termination of pregnancy
  5. Fibrocystic changes of breast
  6. Hormonal fluctuations associated with menstrual cycle
  7. Duct ectasia
  8. Intraductal papilloma

Causes of pathologic nipple discharge:

  1. Infection (periductal mastitis)
  2. Breast abscess
  3. Neoplastic process of the breasts (e.g., intraductal carcinoma, Paget's disease of breast)
  4. Pituitary tumor/prolactinoma
  5. Thoracic/breast trauma
  6. Systemic disease/endocrinopathies that elevate prolactin level (e.g., hypothyroidism, disorders of the pituitary gland or hypothalamus, chronic kidney or liver disorders)
  7. A side effect of medications that inhibit dopamine secretion (e.g., opioids, oral contraceptives, antihypertensives (methyldopa, reserpine, verapamil), antidepressants and antipsychotics)

Epidemiology

Nipple discharge is the third most common breast complaint after breast pain and breast mass. Fifty percent to 80% of women in their reproductive years had a nipple discharge, and 6.8% of these were referred to a breast surgeon. Most nipple discharge is benign in origin (97%).[5]

History and Physical

The clinical history is most helpful in distinguishing benign from suspicious or pathologic nipple discharge. Patient's age is very important, as women older than 40 years old are at higher risk of having pathologic causes of the nipple discharge. Post-menopausal women with nipple discharge rarely have a benign cause of their symptom.

History of present illness should include the onset of discharge, association with the menstrual cycle, persistence, and the character and color of the discharge.

A patient's reproductive history is important (e.g., the age at menarche, age at menopause, and a history of pregnancies including age at first full-term pregnancy).

Obtain a history of any breast problems, including breast biopsies.

Obtain a surgical history (e.g., hysterectomy and whether ovaries were removed). In premenopausal women, obtain the pregnancies/births history, history of breastfeeding, use of oral contraception or hormonal replacement therapy (HRT).

Family history should contain information about cancers, especially of breast/ovaries, and menopausal status of close relatives.

Medications history is of paramount importance, as many medications can cause nipple discharge as a side effect.

In the review of systems, a physician should ask for the presence of fever (mastitis or breast abscess), symptoms of hypothyroidism (weight gain, cold intolerance, constipation, etc.amenorhea), symptoms of liver disease (ascites, jaundice), symptoms of pituitary tumor (visual amenorrhea, headache).

On physical examination, the physician should examine the patient for the presence of any breast masses, asymmetries, and skin changes. After the inspection, palpation should include all four quadrants of each breast and bilateral axillae, supra- and infraclavicular areas to look for masses, swelling, tenderness, lymphadenopathy. If no spontaneous discharge is visible, the examiner should attempt to extract the discharge by applying even pressure from the periphery toward the nipples (so-called, pressure point exam).

Physiologic discharge is usually bilateral, require manual extraction, fluid is clear, cloudy, white, yellow, green, or brown, involves multiple ducts, and is non-sticky. Pathologic discharge is usually unilateral, spontaneous, varies in appearance, and depending on the cause, involves a single duct. Abnormal discharge is frequently associated with other abnormalities, such as a mass, swelling, redness, dimpled skin, or retracted nipple.[2][4]

Evaluation

The primary goal of evaluation of the nipple discharge in a general outpatient setting or the emergency department is to distinguish patients with benign discharge from those with underlying breast cancer, infection/abscess, or those patients who are at high risk of developing pathologic processes. Those patients, whose age, history and physical examination suggest the benign cause of their discharge, may be reassured and discharged with outpatient follow-up at their primary care provider's office. However, in patients at high risk for a pathologic process as a cause of their discharge or with worrisome history and physical examination, urgent follow-up with a breast surgeon must be sought.[2][4]

The exception is a suspected or obvious breast abscess when emergent ultrasound of the breast and a general surgery consultation are needed in the emergency department. Depending on the results of the breast ultrasound and evaluation of the general surgery consultants, the patient may or may not be taken to the operating room for incision and drainage of an abscess. Incision and drainage of a breast abscess in the emergency department are discouraged due to the high pain sensitivity and aesthetic significance of the area, especially when abscess involves areola/nipple area. Therefore, appropriate anesthesia is needed, possibly in the operating room, to minimize pain and suffering in a patient, as well, as aesthetic considerations.

Treatment / Management

It is important to recognize that an emergency physician has a significant yet particular role in evaluating nipple discharge. An emergency department physician must recognize his or her limitations in detailed evaluation of suspected breast cancer and must emphasize to a patient the absolute need for seeking an appropriate breast specialist for further evaluation, diagnostic testing, and/or treatment. There is no role for an emergency department physician in the treatment of the pathologic nipple discharge, as this is beyond his or her scope of practice.[6][2][7]

Enhancing Healthcare Team Outcomes

Nipple discharge is best managed by a multidisciplinaryy team including nurse practitioners. However, it is important to be aware that not all nipple discharge is benign. In some cases a mass may be present and further workup to rule out a malignancy is recommended. Most nipple discharge is due to an intraductal papilloma and these patients have an excellent outcome when the lesion is excised.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Breast, Nipple Discharge - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is not true about nipple discharge?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 66-year-old female patient comes to the breast clinic with breast discharge. She has had this symptom for 3 weeks on and off accompanied with weight loss of 10 lb over 6 months. She was previously diagnosed with uterine fibroids at age 25 for which she underwent myomectomy. She has also been diagnosed with benign ovarian cysts for which she undergoes regular follow up. Her vitals include pulse rate: 85/minute, blood pressure: 105/80 mm Hg, and temperature: 98.6 degrees Fahrenheit. Which of the following characteristics of nipple discharge would suggest basement membrane invasion of breast ductal/lobular cells?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Approximately what percentages of women with benign breast disease complain of nipple discharge?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What percentages of women with breast malignancies have a nipple discharge?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most worrisome nipple discharge?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 29-year-old woman comes to the clinic for breast discharge. It started 2 weeks ago and is bilateral, spontaneous, and serous in inconsistency. She does not have any history of swelling in the breast, no pain or tenderness, and no similar symptoms in the past. She has no history of weight loss or reduced appetite. Her mother has a history of breast cancer for which mastectomy was done along with postoperative chemotherapy. She is on oral contraceptives for the past 3 months and takes vitamin supplements regularly. Her vitals include pulse rate: 78/minute, blood pressure: 110/80 mm Hg, and temperature: 98.7 degrees Fahrenheit. Which of the following is the next best step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 30-year-old male comes to the clinic with episodes of bloody nipple discharge. It started 4 months ago and is not associated with any trauma. Patient denies any pain, swelling, or tenderness around the nipples. He also denies any complaints of loss of weight or appetite. Moreover, he does not have any history of malignancy in his family. His father died 5 years back due to a stroke. At presentation, his vitals include pulse rate: 72/minute, blood pressure: 110/90 mm Hg, and temperature: 98.5 degrees Fahrenheit. What would be ideally advised for such a patient with the above symptoms?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 45-year-old female presents with a history of bloody or serosanguinous discoloration on her inner bra. A mammogram is performed and is normal. What is the next best step for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 51-year-old female patient comes to the clinic with symptoms of breast discharge and dull-aching pain around both the breasts. She was asymptomatic 2 months back when she started developing spontaneous greenish-brown discharge from her nipples. There was no history of trauma. There is no loss of weight or appetite. There is no history of breast malignancy in the family. Her vitals include heart rate: 80/minute, blood pressure: 110/70 mm Hg, and temperature: 98.6 degrees Fahrenheit. On examination, there is nipple retraction bilaterally. Which of the following is the most likely underlying pathology behind the symptoms in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Breast, Nipple Discharge - References

References

[Management of breast nipple discharge: Recommendations]., Ouldamer L,Kellal I,Legendre G,Ngô C,Chopier J,Body G,, Journal de gynecologie, obstetrique et biologie de la reproduction, 2015 Dec     [PubMed]
Frequency of diagnosis of cancer or high-risk lesion at operation for pathologic nipple discharge., Dupont SC,Boughey JC,Jimenez RE,Hoskin TL,Hieken TJ,, Surgery, 2015 Oct     [PubMed]
Benign Breast Disease in Women, Santen RJ,,, 2000     [PubMed]
Nipple discharge: current diagnostic and therapeutic approaches., Sakorafas GH,, Cancer treatment reviews, 2001 Oct     [PubMed]
A simple approach to nipple discharge., King TA,Carter KM,Bolton JS,Fuhrman GM,, The American surgeon, 2000 Oct     [PubMed]
Management of nipple discharge., Gülay H,Bora S,Kìlìçturgay S,Hamaloğlu E,Göksel HA,, Journal of the American College of Surgeons, 1994 May     [PubMed]
Klassen CL,Hines SL,Ghosh K, Common benign breast concerns for the primary care physician. Cleveland Clinic journal of medicine. 2019 Jan;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.