NIPPLE DISCHARGE
- Nipple discharge is when fluid leaks from the nipple. It is a common condition that can occur in women as part of physiological changes
- The causes of nipple discharge range from harmless to serious. If the discharge is spontaneous, occurs from a single opening/duct and if it is watery /blood stained it should be investigated
- Nipple discharge associated with other symptoms such as a lump, skin or nipple changes always require investigation, even if the discharge is not spontaneous or blood-stained
Intraductal papilloma
- A papilloma commonly presents as an abnormal nipple discharge, coming from a single duct and is usually bloody or watery. It can be single or multiple growths arising from the lining of the ducts. Papillomas do not usually present as a lump/swelling and are often missed on mammography and ultrasound. Treatment involves complete removal of the involved duct system for pathological evaluation and treatment
Duct ectasia
- Duct ectasia is caused by thickening of the walls of the milk duct. The milk ducts get blocked and widen. These findings are commonly observed on ultrasonography, especially in the elderly. They usually do not need surgery or other treatment. In few patients, especially diabetics and smokers, duct ectasia can cause repeated infections resulting in chronic periductal mastitis
The following features should be observed.
Nipple discharge can be:
- Spontaneous(fluid leaks from the nipple without any squeezing of the nipple) or on expression (fluid comes out of the nipple only when the nipple is squeezed)
- Unilateral(from one breast) or bilateral (from both the breasts)
- Single duct(from one opening on the nipple) or multiple ducts(from more than one opening on the nipple)
- Blood-stained, clear/watery, green, milkyor yellow in colour
Discharge of fluid from a normal breast is called “physiological discharge”. This type of discharge usually occurs on expression (rather than spontaneous), comes from multiple ducts and is yellow, milky or green in colour
Physiological discharge is normal and requires no treatment. It is important to stop expressing or squeezing the nipple, as this causes more fluid to be made. The discharge will usually stop naturally
Spontaneous nipple discharge, not related to pregnancy or breastfeeding is abnormal. Abnormal nipple discharge may be due to:
- Duct ectasia
- Duct papilloma
- Nipple eczema
- Paget’s disease of the nipple
- Breast cancer
Nipple discharge that is spontaneous, blood-stained and persistent requires clinical assessment by a breast specialist, imaging of the breasts with ultrasound and mammography and cytology of discharge fluid
Surgery for nipple discharge is required for:
- Intraductal papilloma, breast cancer
- Patients with blood-stained nipple discharge even if imaging shows no abnormality (as changes behind the nipple can be difficult to see on imaging)
- Few patients with duct ectasia where the discharge may be persistent and annoying
Few conditions like intraductal papillomas and ductal carcinoma in-situ are microscopic changes in the duct lining. They often do not manifest as a mass lesion or calcification, so mammography and ultrasonography may still be normal. Any abnormal discharge should always be thoroughly evaluated by a breast specialist even if imaging is normal
Milky discharge in a woman who is not pregnant or breast feeding is abnormal and is called galactorrhea. It is often caused by hormonal or endocrine problems. Common medicines which can cause galactorrhea include some antacids, antidepressants, antipsychotics, anti-hypertensive and estrogen containing drugs. Rarely galactorrhea may be caused by a tumor in the pituitary gland. Blood levels of Prolactin and Thyroid hormones should be assessed
Intraductal papilloma may be associated with atypia or ductal carcinoma in-situ and hence a complete removal of the involved duct with the papilloma is advised
