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