BENIGN BREAST DISEASES

NIPPLE DISCHARGE

If you have unusual nipple discharge, make an appointment with your doctor to have it evaluated. A visit to your doctor is especially important if you also notice breast changes, such as a new lump or skin changes. This will help your doctor identify the cause of the problem. 

What is nipple discharge?

Your nipples have many tiny openings through which fluid can pass. Any fluid that come out of your nipple is referred to as nipple discharge.   

What is 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. Nipple discharge can occur in one or both nipples. It is usually yellow, milky, creamy or green in colour.  It can vary in consistency from watery thin to thick and sticky.  It does not occur spontaneously.

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.  Milky nipple discharge is physiological during pregnancy and lactation. It may be prolonged for many months following lactation.

Bloody nipple discharge in pregnancy

Nipple discharge with frank blood or occult blood visible under the microscope during pregnancy or lactation is common. It is due to increased blood supply to the breast tissue.  This condition is benign (non cancerous and requires no special treatment.

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.

 

What should you do if you have an abnormal nipple discharge?

If you have unusual nipple discharge, make an appointment with your doctor to have it evaluated. It is especially important if you also notice breast changes, such as a new lump or skin changes.

Be prepared

Your doctor will ask you some questions which will help him/her to identify the cause for the problem

• What color is the discharge?

• Does it occur in one or both breasts?
• Does it occur in one duct (opening) or multiple ducts (openings)?
• How much discharge is there?
• Does the discharge occur spontaneously, or does it happen only when you squeeze your nipple?
• Is there any lump, ulceration or skin change associated with the discharge?
• For what length of time have you had the discharge? 
• Was there any redness, pain or fever associated with the discharge

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 profuse unilateral blood stained discharge from a single duct

·     Profuse single duct clear nipple discharge.  

Which other nipple symptoms need referral?

Patients with unilateral (one sided) 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? 

Physical examination is done by your doctor

·    To exclude any associated nipple ulceration, skin change, or breast lump.

·    Express the nipple to reproduce the discharge to assess

·    To determine the colour of the fluid

·    To determine the number of ducts fluid is originating from.

When to check for prolactin levels?

If you present with persistent copious bilateral milky discharge not associated with pregnancy and breast feeding (galactorrhoea) then you should be checked for prolactin levels. Causes of galactorrhoea are

·        Hormonal imbalance

·        Under active thyroid gland

·        A tumour of the pituitary gland

Treatment

If you have physiological nipple discharge you require no specific treatment.

• You can be reassured that it is not due to cancer. 

• You should be advised to stop expressing as this causes more secretions.

• Should the discharge become spontaneous or bloodstained, you will be advised to return for further assessment. 

Abnormal nipple discharge (managed at the breast centre)  

Clinical examination, Ultrasound, Mammography are performed.  Your doctor might collect a sample of the fluid from the nipple. Nipple smears are performed and sent to a lab for analysis. However, even after lab analysis, further evaluation may be necessary. Based on the information you provide and the results of a clinical examination, you might need to undergo additional testing such as a special type of X-ray (ductogram) or magnetic resonance imaging (MRI) to help identify the underlying cause. 

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

If investigations are normal and discharge not suspicious or troublesome you will be reassured and discharged. 

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

Surgery

Single duct excision (removal) known as microdochectomy

Excision of all the ducts beneath the nipple (Subareolar duct excision) can be performed either by an operation or with mammotome (handheld vacuum assisted device) removal of ducts under ultrasound guidance.

The operation is usually performed under local anaesthetic, but can be performed under general anaesthetic as a day case procedure.

The operation

The surgeon will make an incision around the edge of the pigmented skin surrounding the nipple (areola) and will either remove a single duct or most or all the milk ducts from beneath the nipple. Tissue removed at the time of surgery will be sent for testing.  The wound will be closed using an absorbable suture, covered with a waterproof dressing.   The sutures need not be removed.  Results of the analysis will be given to you in the following visit or you should make arrangements to get your results.

What are the risks/complications of surgery?

·  Altered or loss of nipple sensation.

·  Unable to breast feed.

·  Wound infection – you will be given appropriate antibiotics if indicated.

·  Wound haematoma – rarely bleeding under the skin may occur which produces a firm collection of blood (haematoma) this will normally dissipate gradually or leak out through the wound.

·   In rare cases nipple loss.

What are the causes of abnormal nipple discharge?

Mammary duct ectasia (dilatation of the ducts)

Intraductal papilloma Small benign growth (non cancerous) discharge is from a single duct and is blood stained.

Breast abscess can sometimes cause nipple discharge. 
Breast cancer: Nipple discharge rarely is a sign of breast cancer, but it's possible that discharge may indicate cancer is present within a duct (intraductal breast cancer) or outside the duct (invasive breast cancer).  

For more information contact: sasi@mybreastcare.org

This information sheet is aimed at women who have been examined by a breast specialist and found to have a nipple discharge. It is not a substitute for the advice of a qualified doctor. It is intended to provide information for better understanding and reassurance.