Nipple Discharge

General Overview

• Most benign, especially if bilateral, multiductal, occurs with breast manipulation
• Consider malignancy if unilateral, uniductal, spontaneous, bloody, breast mass, >40yo

DDx

• Galactorrhea
  • Hyperprolactinemia
    • Medications/drugs - eg. antipsychotics, antidepressants, antiemetics, antihypertensive, estrogen, verapamil, opioids, cocaine
    • Pathologic - pituitary adenoma, chronic renal failure, cirrhosis, hypothyroid, Cushing disease, acromegaly
    • Physiological - lactation, pregnancy, stress, stimulation, macroprolactin
      • Lactation (Pregnancy, postpartum 6mo after delivery or 6mo after cessation of breastfeeding)
• Serosanguineous
  • Papilloma, duct ectasia
  • Malignancy (DCIS)
    • 20% of lactating women may have benign bloody nipple discharge, but still warrants surgical evaluation to r/o malignancy

History

• Discharge
  • Unilateral vs Bilateral
  • Timing/Frequency/Spontaneity
  • Colour
    • Milky (likely galactorrhea) - Prolactin, TSH, b-hCG, Meds
    • Brown/green/blood - Cytology, Imaging, surgery referral
• Medication
• Hyperprolactinemia (amenorrhea, hot flashes, vaginal dryness)

Physical Exam

• Visual fields
  • Rule out bitemporal hemianopia (pituitary tumour)
• Breast exam
  • Nipple discharge

Investigations

• Rule out blood positive guaic
• All patients with spontaneous, or unilateral, or clear/serous/bloody nipple discharge should be referred for surgical evaluation
  • Terminal duct excision is diagnostic and therapeutic (even for benign cause)
• Consider ultrasound (and mammogram if ≥ 30yo) in all patients
• Galactorrhea (nonlactational milk production)
  • Lab work-up: b-hCG (r/o pregnancy), Prolactin, TSH, Creat/eGFR, ALT, Bilirubin, INR, platelets
    • Elevated Prolactin, investigate and correct underlying cause
      • Physiological - lactation, pregnancy, stress, stimulation, macroprolactin
        • Lactation (Pregnancy, postpartum 6mo after delivery or 6mo after cessation of breastfeeding)
      • Review medication/drugs : antipsychotics, antidepressants, antiemetics, antihypertensive, estrogen, verapamil, opioids, cocaine
        • Can increase prolactin up to 4XULN
      • Hyperestrogenemia (pregnancy, tumour, unclear if OCP can cause)
      • Chest wall lesions (surgery, trauma, burn, herpes zoster)
      • If prolactin elevated and work-up negative, r/o Pituitary adenoma
        • MRI pituitary
  • Normal Prolactin
    • No additional workup
    • Consider dopamine agonist only if galactorrhea bothersome