- Most benign, especially if bilateral, multiductal, occurs with breast manipulation
- Consider malignancy if unilateral, uniductal, spontaneous, bloody, breast mass, >40yo
- 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
- 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)
- Visual fields
- Rule out bitemporal hemianopia (pituitary tumour)
- Breast exam
- 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
- Normal Prolactin
- No additional workup
- Consider dopamine agonist only if galactorrhea bothersome