Nipple discharge

Last updated
Nipple discharge
Lactation.jpg
Milk coming from the nipple
Specialty Gynecology
TypesPhysiologic, pathologic [1]
Diagnostic method Normal: Late pregnancy, after childbirth, newborns [2] [3]
Abnormal: Intraductal papilloma, duct ectasia, blocked milk duct, infected breast, breast cancer, high prolactin [1] [4] [3]
TreatmentDepends on the cause [2]
FrequencyCommon [2]

Nipple discharge is fluid from the nipple, with or without squeezing the breast. [2] [5] The discharge can be milky, clear, green, purulent, bloody, or faintly yellow. [6] The consistency can be thick, thin, sticky, or watery. [5] [6]

Contents

Nipple discharge may be normal, such as milk in late pregnancy or after childbirth, and in newborns during the first weeks of life. [2] [3] It may also be normal following squeezing, in women during the reproductive years. [2] [5] It is likely abnormal if it occurs in men, contains blood, is from only one breast, or is associated with a breast lump, swelling, redness or overlying skin changes. [2] [3] Reasons for abnormal discharge include an intraductal papilloma, duct ectasia, blocked milk duct, infected breast (mastitis or breast abscess), breast cancer, certain medications, and conditions that raise prolactin. [1] [3] [4]

Milky discharge in a non-pregnant, non-breast feeding women is evaluated differently to other abnormal nipple discharge. [4] Often, the cause can be determined based on symptoms and examination. [5] Blood tests may be done to rule out low thyroid or high prolactin. [7] Other tests may include mammography, breast ultrasound, breast biopsy, or skin biopsy. [8]

Treatment depends on the underlying cause. [2] Duct ectasia may be treated with surgical removal of the ducts involved. [2] Infectious causes may require antibiotics or incision and drainage. [2] Nipple discharge is the third most common breast complaint by women, after breast pain and a breast lump. [4] About 3% of breast cancer cases are associated with discharge. [4] [9]

Signs and symptoms

Nipple discharge is fluid from the nipple, with or without squeezing the breast. [2] [5] The discharge can be milky, clear, green, purulent, bloody, or faintly yellow. [6] The consistency can be thick, thin, sticky, or watery. [5] [6]

Causes

Nipple discharge can arise from any one or more of the 15 to 20 milk ducts that each breast contains, and its causes can be divided into normal (physiological) and abnormal (pathological). [2] [5]

Normal

Milky liquid from nipples is normal during the last few weeks of pregnancy, after childbirth and during breastfeeding. [2] [5] Some newborn babies may leak a milky liquid which is usually normal and lasts a couple of weeks. [3]

Stimulation of breasts by massage, using a breast pump or after mammography, may induce yellow, milky, or green nipple discharge in many healthy women of reproductive age. [5]

Abnormal

Spontaneous nipple discharge unrelated to pregnancy or lactation is considered abnormal, but mostly have a non-serious cause. [5] Nipple discharge in men is not normal. [3] Discharge from nipples is also more likely to be abnormal (pathological) if it is crystal clear or blood-stained, is from only one breast, or is associated with a breast lump, swelling, redness or overlying skin changes. [2] [3] [4]

A blocked or enlarged milk duct can result in nipple discharge. [3]

Intraductal papillomas are non-cancerous lesions and commonest in women age 30 to 50. Divided into central and peripheral papillomas, nipple discharge is more frequently observed when they are central. [10] Up to half of women with intraductal papillomas may present with bloody nipple discharge, but it can also be straw-coloured. [4] They are usually too small to feel and have a rare association with breast cancer. [5] [10]

15-20% of people with nipple discharge are found to have duct ectasia. [4] This is usually in perimenopausal and menopausal women, who may have associated pain and retraction of the nipple. A lump may also be present. [11]

Ductal carcinoma in situ (DCIS) usually presents with abnormal findings on mammography, but can less frequently present with a lump or nipple discharge in women, [12] whereas in men with DCIS, nipple discharge is the common presentation. [13]

Infection in a breast, either mastitis or breast abscess may cause a discharge. [1] [3] Eczema of the nipple may result in a discharge with crusting of the nipple skin. [5]

Nipple discharge may be due to breast cancer, particularly if there is an accompanying breast lump. [4] A blood-stained discharge may appear in Paget's disease. [5]

Milky

Some condition that cause a raised prolactin can result in a milky liquid appearing from nipples. These include endocrine causes such as pituitary and thyroid disease, and some medications. [5] Such medications include: [1] [3] [14]

Some herbs including anise and fennel have also been implicated as causing leaking of fluid from nipples. [8]

Diagnosis

The evaluation of milky nipple discharge in a non-pregnant, not breast feeding women is different to the assessment of other abnormal nipple discharge. [4] Often, the cause can be ascertained without performing tests. [5]

When blood tests are requested, they usually include thyroid tests and prolactin to rule out hypothyroidism and hyperprolactinemia. [7] Other tests that may be considered include mammography, breast ultrasound, CT scan of the head to rule out a pituitary tumour, breast biopsy, x-ray imaging of breast ducts or skin biopsy. [8]

The absence of cancerous cells in samples of nipple discharge does not exclude cancer, hence cytology of the nipple discharge is not usually performed. [1] [9] However, guidance on investigations varies and tests are more likely performed if the discharge is bloody, from one breast, and the woman is age over 50. [4] If the test is performed and malignant cells are found, an underlying cancer is highly likely. [5] [15]

Treatment

Initially, an evaluation for cancer is indicated. Treatment will depend on the cause found, and may involve changing medication, having a lump removed, applying a cream to treat a skin condition or being given medication to treat the condition causing the discharge. Duct ectasia may be treated with surgical removal of the ducts involved. [2] [8] Infectious causes may require antibiotics and/or incision and drainage. [2] Sometimes, no treatment is required. [8]

If no abnormality is found, a surgical duct excision may resolve the symptoms. Treatment also depends on whether single-duct or multiple-duct discharge is present, and whether the symptoms of nipple discharge are distressing to the person. In some cases, there may be no need for any further intervention; in others, microdochectomy or a total duct excision may be appropriate. If the person wishes to conserve the ability to breastfeed and only single-duct discharge is present, then ductoscopy or galactography should be considered in view of performing a localised duct excision. [2] [16]

Epidemiology

Nipple discharge is the third most common breast complaint by women, after breast pain and a breast lump. 10% of women can notice a nipple discharge when squeezing their breast and more than 50% of women can experience this using a breast pump. [4]

Most abnormal nipple discharge is not associated with breast cancer, but 1-5% of breast cancers present with nipple discharge. [4] [9]

Related Research Articles

<span class="mw-page-title-main">Nipple</span> Part of the breast

The nipple is a raised region of tissue on the surface of the breast from which, in females, milk leaves the breast through the lactiferous ducts to feed an infant. The milk can flow through the nipple passively or it can be ejected by smooth muscle contractions that occur along with the ductal system. Male mammals also have nipples but without the same level of function, and often surrounded by body hair.

<span class="mw-page-title-main">Mastitis</span> Medical condition

Mastitis is inflammation of the breast or udder, usually associated with breastfeeding. Symptoms typically include local pain and redness. There is often an associated fever and general soreness. Onset is typically fairly rapid and usually occurs within the first few months of delivery. Complications can include abscess formation.

<span class="mw-page-title-main">Paget's disease of the breast</span> Medical condition

Paget's disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. The condition is an uncommon disease accounting for 1 to 4.3% of all breast cancers and was first described by Sir James Paget in 1874.

Inflammatory breast cancer (IBC) is one of the most aggressive types of breast cancer. It can occur in women of any age. It is referred to as "inflammatory" due to its frequent presentation with symptoms resembling a skin inflammation, such as erysipelas.

Witch's milk or neonatal milk is milk secreted from the breasts of some newborn human infants of either sex. Neonatal milk secretion is considered a normal physiological occurrence and no treatment or testing is necessary. It is thought to be caused by a combination of the effects of maternal hormones before birth, prolactin, and growth hormone passed through breastfeeding and the postnatal pituitary and thyroid hormone surge in the infant.

Breast pain is the symptom of discomfort in either one or both breasts. Pain in both breasts is often described as breast tenderness, is usually associated with the menstrual period and is not serious. Pain that involves only one part of a breast is more concerning, particularly if a hard mass or nipple discharge is also present.

<span class="mw-page-title-main">Lactiferous duct</span>

Lactiferous ducts are ducts that converge and form a branched system connecting the nipple to the lobules of the mammary gland. When lactogenesis occurs, under the influence of hormones, the milk is moved to the nipple by the action of smooth muscle contractions along the ductal system to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts or milk ducts.

<span class="mw-page-title-main">Ductal carcinoma in situ</span> Medical condition

Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. DCIS is classified as Stage 0. It rarely produces symptoms or a breast lump one can feel, typically being detected through screening mammography. It has been diagnosed in a significant percentage of men.

<span class="mw-page-title-main">Fibrocystic breast changes</span> Medical condition

Fibrocystic breast changes is a condition of the breasts where there may be pain, breast cysts, and breast masses. The breasts may be described as "lumpy" or "doughy". Symptoms may worsen during certain parts of the menstrual cycle due to hormonal stimulation. These are normal breast changes, not associated with cancer.

Breast diseases make up a number of conditions. The most common symptoms are a breast mass, breast pain, and nipple discharge.

<span class="mw-page-title-main">Breast cyst</span> Medical condition

A breast cyst is a cyst, a fluid-filled sac, within the breast. One breast can have one or more cysts. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm.

<span class="mw-page-title-main">Duct ectasia of breast</span> Medical condition

Duct ectasia of the breast, mammary duct ectasia or plasma cell mastitis is a condition that occurs when a milk duct beneath the nipple widens, the duct walls thicken, and the duct fills with fluid. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

The term nonpuerperal mastitis describes inflammatory lesions of the breast (mastitis) that occur unrelated to pregnancy and breastfeeding.

Granulomatous mastitis can be divided into idiopathic granulomatous mastitis and granulomatous mastitis occurring as a rare secondary complication of a great variety of other conditions such as tuberculosis and other infections, sarcoidosis and granulomatosis with polyangiitis. Special forms of granulomatous mastitis occur as complication of diabetes. Some cases are due to silicone injection or other foreign body reactions.

<span class="mw-page-title-main">Intraductal papilloma</span> Medical condition

Intraductal papillomas of the breast are benign lesions with an incidence of approximately 2-3% in humans. They result from abnormal proliferation of the epithelial cells lining the breast ducts.

<span class="mw-page-title-main">Breast mass</span> Localized swellings that feel different from the surrounding tissue

A breast mass, also known as a breast lump, is a localized swelling that feels different from the surrounding tissue. Breast pain, nipple discharge, or skin changes may be present. Concerning findings include masses that are hard, do not move easily, are of an irregular shape, or are firmly attached to surrounding tissue.

<span class="mw-page-title-main">Nipple adenoma</span> Medical condition

A nipple adenoma is a rare benign tumour of the breast.

<span class="mw-page-title-main">Gynecomastia</span> Endocrine system disorder of human male breast

Gynecomastia is the abnormal non-cancerous enlargement of one or both breasts in males due to the growth of breast tissue as a result of a hormone imbalance between estrogens and androgens. Gynecomastia can cause significant psychological distress or unease.

Galactography or ductography is a medical diagnostic procedure for viewing the milk ducts. The procedure involves the radiography of the ducts after injection of a radiopaque substance into the duct system through the nipple. The procedure is used for investigating the pathology of nipple discharge.

<span class="mw-page-title-main">Breast imaging</span>

In medicine, breast imaging is a sub-speciality of diagnostic radiology that involves imaging of the breasts for screening or diagnostic purposes. There are various methods of breast imaging using a variety of technologies as described in detail below. Traditional screening and diagnostic mammography uses x-ray technology and has been the mainstay of breast imaging for many decades. Breast tomosynthesis is a relatively new digital x-ray mammography technique that produces multiple image slices of the breast similar to, but distinct from, computed tomography (CT). Xeromammography and galactography are somewhat outdated technologies that also use x-ray technology and are now used infrequently in the detection of breast cancer. Breast ultrasound is another technology employed in diagnosis and screening that can help differentiate between fluid filled and solid lesions, an important factor to determine if a lesion may be cancerous. Breast MRI is a technology typically reserved for high-risk patients and patients recently diagnosed with breast cancer. Lastly, scintimammography is used in a subgroup of patients who have abnormal mammograms or whose screening is not reliable on the basis of using traditional mammography or ultrasound.

References

  1. 1 2 3 4 5 6 7 8 Salzman, B; Fleegle, S; Tully, AS (15 August 2012). "Common breast problems". American Family Physician. 86 (4): 343–9. PMID   22963023.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Saj2020, Karima R.; Sugumar, Kavin; Adigun, Rotimi (2020), "Breast Nipple Discharge", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   28613688 , retrieved 2 November 2020
  3. 1 2 3 4 5 6 7 8 9 10 11 "Nipple discharge". nhs.uk. 19 October 2017. Archived from the original on 30 October 2020. Retrieved 30 October 2020.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Danielle Mazza (2011). "11. Nipple discharge". Women's Health in General Practice. Churchill Livingstone Elsevier. p. 189. ISBN   9780729538718.
  5. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Brennan, Meagan; Houssami, Nehmat; French, James (May 2005). "Management of benign breast conditions. Part 3 – other breast problems" (PDF). Australian Family Physician. 34 (5): 353–355. PMID   15887938.
  6. 1 2 3 4 Barry, Michele (1990), Walker, H. Kenneth; Hall, W. Dallas; Hurst, J. Willis (eds.), "Nipple Discharge", Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.), Boston: Butterworths, ISBN   978-0-409-90077-4, PMID   21250127 , retrieved 2020-10-30
  7. 1 2 Arthur, Rhonda (2014). "13. Gynaecologic guidelines". In Jill C., Cash; Glass, Cheryl A. (eds.). Family Practice Guidelines, Third Edition. Springer Publishing Company. p. 450. ISBN   978-0-8261-9782-5.
  8. 1 2 3 4 5 DeMuro, Jonas (30 October 2018). "Nipple discharge: MedlinePlus Medical Encyclopedia". medlineplus.gov. Archived from the original on 3 November 2020. Retrieved 3 November 2020.
  9. 1 2 3 Saad, Reda S.; Silverman, Jan F. (2008). "25. Breast". In Marluce Bibbo (ed.). Comprehensive Cytopathology. David Wilbur (Third ed.). Saunders Elsevier. pp. 760–761. ISBN   978-1-4160-4208-2.
  10. 1 2 Stuart J. Schnitt; Laura C. Collins (2009). "8. Papillary lesions". Biopsy Interpretation of the Breast. Lippincott Williams & Wilkins. p. 205-206. ISBN   978-0-7817-9146-5.
  11. ↑ Stuart J. Schnitt; Laura C. Collins (2009). Biopsy Interpretation of the Breast. Lippincott Williams & Wilkins. p. 35-36. ISBN   978-0-7817-9146-5.
  12. 1 2 Stuart J. Schnitt; Laura C. Collins (2009). Biopsy Interpretation of the Breast. Lippincott Williams & Wilkins. p. 69. ISBN   978-0-7817-9146-5.
  13. ↑ Stuart J. Schnitt; Laura C. Collins (2009). Biopsy Interpretation of the Breast. Lippincott Williams & Wilkins. p. 403. ISBN   978-0-7817-9146-5.
  14. ↑ Hall, Mellisa; Cash, Jill C. (2014). "19. Endocrine guidelines". In Jill C., Cash; Glass, Cheryl A. (eds.). Family Practice Guidelines, Third Edition. Springer Publishing Company. p. 644. ISBN   978-0-8261-9782-5.
  15. ↑ "Nipple discharge cytology | Eurocytology". www.eurocytology.eu. Retrieved 7 December 2020.
  16. ↑ J Michael Dixon (22 June 2013). Breast Surgery: Companion to Specialist Surgical Practice. Elsevier Health Sciences. p. 274. ISBN   978-0-7020-4967-5.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.