BENIGN BREAST DISEASES

NIPPLE DISCHARGE

FOR GENERAL PRACTITIONERS

Physiological nipple discharge

‘Physiological nipple discharge’ is the discharge of fluid from a normal breast and is no cause for concern.  It arises from multiple ducts. It is usually yellow, milky, creamy or green in color.  It does not occur spontaneously.  Milky nipple discharge is physiological during pregnancy and lactation.  It may be prolonged for many months following lactation.  Nipple discharge can be seen arising from the nipples of 50–70% of asymptomatic women when massage or breast pumps are used or can sometimes be noted at the time of breast compression for mammography. 

What is abnormal nipple discharge?

Nipple discharge unrelated to pregnancy and lactation is abnormal.  In the majority of cases it has a benign cause.  Spontaneous, profuse blood stained or clear single duct discharge can be associated with an underlying pathology.

Which patients with nipple discharge can be managed at the GP practice?

All patients with physiological nipple discharge can be managed at the GP practice

Which patients with nipple discharge should be referred to hospital?

Patients with spontaneous unilateral blood stained/clear nipple discharge.

Which other nipple symptoms need referral?

Patients with unilateral eczematous skin or nipple change that does not respond to topical treatment. Paget’s disease always involves the nipple, and eczema affects the areola first and later spreads to the nipple.

Patients with nipple distortion of recent onset. 

 

What is the management of patients with nipple discharge?

A detailed history

• Is the discharge spontaneous or on expression?
• Colour, frequency, and duration of the discharge.

Physical examination

• To exclude any associated nipple ulceration, skin change, or breast lump.
• Express the nipple to reproduce the discharge to assess
• The colour of the fluid
• The number of ducts fluid is originating from

Physiological discharge requires no specific investigation.

When to check for prolactin levels?

When women present with persistent copious bilateral milky discharge not associated with pregnancy and breast feeding (galactorrhoea) then check for prolactin levels.

Treatment

Patients with physiological nipple discharge require no specific treatment.

• The patient can be reassured that it is not due to cancer.
• Patients should be advised to stop expressing as this causes more secretions.
• Should the discharge become spontaneous or bloodstained, they should be advised to return for further assessment

When physiological discharge is a nuisance surgery can be offered and hence can be referred to the breast center.

Abnormal nipple discharge (managed at the breast centre)

Clinical examination, Ultrasound, Mammography, Nipple smear are performed.

If any of the investigations are abnormal then further assessment is done.

If investigations are normal and discharge not suspicious or troublesome patients are reassured.

If investigations are normal, and discharge suspicious or troublesome then surgery is offered.

Surgery

• Microdochectomy.

• Subareolarduct excision.  Can be performed either surgically or with mammotome (handheld vacuum assisted device) excision under ultrasound guidance.