Nipple discharge

Jump to: navigation, search
Nipple discharge
Nipple discharge.jpg
Abnormal nipple discharge may be described as any discharge not associated with lactation. The nature of the discharge may range in color, consistency and composition, and occur in one or both breasts.

WikiDoc Resources for Nipple discharge

Articles

Most recent articles on Nipple discharge

Most cited articles on Nipple discharge

Review articles on Nipple discharge

Articles on Nipple discharge in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Nipple discharge

Images of Nipple discharge

Photos of Nipple discharge

Podcasts & MP3s on Nipple discharge

Videos on Nipple discharge

Evidence Based Medicine

Cochrane Collaboration on Nipple discharge

Bandolier on Nipple discharge

TRIP on Nipple discharge

Clinical Trials

Ongoing Trials on Nipple discharge at Clinical Trials.gov

Trial results on Nipple discharge

Clinical Trials on Nipple discharge at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Nipple discharge

NICE Guidance on Nipple discharge

NHS PRODIGY Guidance

FDA on Nipple discharge

CDC on Nipple discharge

Books

Books on Nipple discharge

News

Nipple discharge in the news

Be alerted to news on Nipple discharge

News trends on Nipple discharge

Commentary

Blogs on Nipple discharge

Definitions

Definitions of Nipple discharge

Patient Resources / Community

Patient resources on Nipple discharge

Discussion groups on Nipple discharge

Patient Handouts on Nipple discharge

Directions to Hospitals Treating Nipple discharge

Risk calculators and risk factors for Nipple discharge

Healthcare Provider Resources

Symptoms of Nipple discharge

Causes & Risk Factors for Nipple discharge

Diagnostic studies for Nipple discharge

Treatment of Nipple discharge

Continuing Medical Education (CME)

CME Programs on Nipple discharge

International

Nipple discharge en Espanol

Nipple discharge en Francais

Business

Nipple discharge in the Marketplace

Patents on Nipple discharge

Experimental / Informatics

List of terms related to Nipple discharge

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Synonyms and Related keywords: Discharge from breasts; Milk secretions; Lactation - abnormal; Witches milk; Galactorrhea

Nipple discharge is the abnormal release of fluid from the nipples of the breasts. It is the third major reason, involving the breasts, for which women seek medical attention, after lumps and breast pain. The risk of nipple discharge increases with both age and number of pregnancies, but is also known to occur in adolescent boys and girls going through puberty. Discharge often is the result of stimulation of the breasts or by irritation through clothing.

Types of discharge

There are many different types of discharges. Some associations include:

Epidemiology and Demographics

  • Most often benign: overall incidence cancer ~ 3-5%
  • Risk of malignancy much increased if concurrent mass (~ 60%)
  • Reported in 10-15% of women with benign breast disease
  • Reported in 2.5-3% of women with breast cancer

Pathophysiology & Etiology

  • Physiologic
  • Discharge only with compression
  • Multiple duct involvement
  • Bilateral
  • Fluid may be clear, yellow, white or dark green
  • Pathologic
  • Spontaneous discharge
  • Bloody
  • Unilateral
  • Associated with a mass
  • Physiologic / Endocrinologic Discharge
  • Lactation
  • Milk produced in presence of postpartum exocrin, parathyrin, thyroxine, cortisol, growth hormone and placental lactogen
  • Milk secreted via stimulation of lobular and ductal epithelium by PRL
  • Milk ejected via stimulation of muscular walls of lactiferous ducts by oxytocin
  • Oxytocin and PRL secreted by pituitary in response to nipple stimulation
  • Galactorrhea:
  • Milk secretion unrelated to pregnancy/lactation
  • Usually due to hyperprolactin state, though can be idiopathic with normal prolactin (PRL)
  • Can occur via:
  • Chronic breast stimulation (nipple manipulation, rubbing on bra)
  • Oral Contraceptive Pills (OCPs) – E can stimulate PRL secretion
  • Drugs that inhibit dopamine (loss of tonic inhibition of PRL)
  • Hypothalamic/pituitary disease interfering with DA release
  • Prolactinoma
  • Hypothyroidism
  • Chronic renal failure
  • Chest wall injury – healing wound stimulates PRL release
  • Pathologic Discharge
  • Intraductal papilloma: monotonous proliferation of papillary cells growing into the lumen
  • Fluid typically straw-colored, transparent, sticky
  • Duct ectasia: distention of subareolar ducts
  • Fibrocystic disease: associated irritation within the duct
  • Papillomatosis: formation of multiple papillomas
  • Associated with small increase in breast cancer risk
  • Intraductal hyperplasia: increased number of epithelial cells lining the ducts
  • Cells appear benign but associated with small increase in breast cancer risk
  • Breast cancer: risk much increased if mass associated with abnormal discharge

History and Symptoms

  • Description of Discharge
  • Unilateral vs. bilateral (bilateral almost always due to endocrinologic cause)
  • Spontaneous vs. provoked
  • Bloody vs. non-bloody
  • Endocrine Symptoms
  • Irregular menses,
  • thyroid symptoms,
  • endo review of symptoms (& visual fields) if prolactinoma suspected
  • Medical Conditions
  • Renal failure,
  • thyroid disease
  • Medications
  • Potential causes of hyperprolactinemia

Physical Examination

  • Thorough breast exam to rule out palpable mass
  • Skin exam for superficial lesions that might produce discharge mimicking nipple discharge
  • (Eczema, Paget’s disease, local infections or irritation)
  • Expression of discharge: firm pressure applied at base of areola of each breast
  • Close observation to determine if discharge from > 1 nipple duct
  • Guaiac testing for blood
  • Cytology for bloody or G+ discharge:
  • Express fluid along surface of glass slide
  • Spray immediately with Pap smear fixative
  • Prepare 4-6 slides for evaluation
  • Low sensitivity, but high specificity for cancer

Other Imaging Findings

Mammogram

  • Mammogram in all patients with pathologic discharge
  • Mammogram in patients > 35 years old with physiologic or endocrinologic discharge:
  • If negative mammogram, exam and endocrine evaluation, avoidance of nipple stimulation will often lead to resolution of discharge

Risk Stratification and Prognosis

Referral

  • Unilateral, bloody or spontaneous discharge: all should be referred to breast surgeon
  • Terminal duct excision diagnostic; may also be therapeutic if benign lesion
  • Bilateral, non-bloody discharge with negative endocrine work-up: referral to breast surgeon if fails to resolve

See also

External links





Linked-in.jpg