Nipple discharge
Nipple discharge: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Nipple discharge can occur spontaneously or can be elicited by nipple stimulation. It’s characterized as intermittent or constant, unilateral or bilateral, and by color, consistency, and composition. Its incidence increases with age and parity. This sign rarely occurs (but is more likely to be pathologic) in men and in nulligravid, regularly menstruating women. It’s relatively common and typically normal in parous women. A thick, grayish discharge — benign epithelial debris from inactive ducts — can usually be elicited in middle-age parous women. Colostrum, a thin, yellowish or milky discharge, commonly occurs in the last weeks of pregnancy.
Nipple discharge can signal serious underlying disease, particularly when accompanied by other breast changes. Significant causes include endocrine disorders, cancer, certain drugs, and blocked lactiferous ducts.
History and physical examination
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last period. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
Medical causes
Breast abscess
Breast abscess, most common in breast-feeding women, may produce a thick, purulent discharge from a cracked nipple or infected duct. Associated findings include an abrupt onset of a high fever with chills; breast pain, tenderness, and erythema; a palpable soft nodule or generalized induration; and possibly, nipple retraction.
Breast cancer
Breast cancer may cause bloody, watery, or purulent discharge from a normal-appearing nipple. Characteristic findings include a hard, irregular, fixed lump; erythema; dimpling; peau d’orange; changes in contour; nipple deviation, flattening, or retraction; axillary lymphadenopathy; and, possibly, breast pain.
Choriocarcinoma
Galactorrhea (a white or grayish milky discharge) may result from this highly malignant neoplasm, which can follow pregnancy. Other characteristics include persistent uterine bleeding and bogginess after delivery or curettage and vaginal masses.
Intraductal papilloma
Intraductal papilloma is the primary cause of nipple discharge in the nonpregnant, non–breast-feeding woman. Unilateral serous, serosanguineous, or bloody nipple discharge — usually from only one duct — is its predominant sign. Discharge may be intermittent or profuse and constant and can usually be stimulated by gentle pressure around the areola. Subareolar nodules, breast pain, and tenderness may occur.
Mammary duct ectasia
A thick, sticky, grayish discharge from multiple ducts may be the first sign of mammary duct ectasia. The discharge may be bilateral and is usually spontaneous. Other findings include a rubbery, poorly delineated lump beneath the areola, with a blue-green discoloration of the overlying skin; nipple retraction; and redness, swelling, tenderness, and burning pain in the areola and nipple.
Paget’s disease
With Paget’s disease, serous or bloody discharge emits from denuded skin on the nipple, which is red, intensely itchy and, possibly, eroded or excoriated. The discharge is usually unilateral.
Prolactin-secreting pituitary tumor
Bilateral galactorrhea may occur with prolactin-secreting pituitary tumor. Other findings include amenorrhea, infertility, decreased libido and vaginal secretions, headaches, and blindness.
Proliferative (fibrocystic) breast disease
Proliferative breast disease is a benign disorder that occasionally causes a bilateral clear, milky, or straw-colored discharge, which is rarely purulent or bloody. Multiple round, soft, tender nodules are usually palpable in both breasts, although they may occur singly. Usually, nodules are mobile and are located in the upper outer quadrant. Nodule size, tenderness, and discharge increase during the luteal phase of the menstrual cycle. Symptoms then regress after menses.
Other causes
Drugs
Galactorrhea can be caused by psychotropic agents, particularly phenothiazines and tricyclic antidepressants; some antihypertensives (reserpine and methyldopa); hormonal contraceptives; cimetidine; metoclopramide; and verapamil.
Surgery
Chest wall surgery may stimulate the thoracic nerves, causing intermittent bilateral galactorrhea.
Special considerations
Although nipple discharge is usually insignificant, it can be frightening to the patient. Help relieve her anxiety by clearly explaining the nature and origin of her discharge. Apply a breast binder, which may reduce discharge by eliminating nipple stimulation.
Diagnostic tests may include tissue biopsy (if a breast lump is found), cytologic study of the discharge, mammography, ultrasonography, transillumination, and serum prolactin level.
Pediatric pointers
Nipple discharge in children and adolescents is rare. When it does occur, it’s almost always nonpathologic, as in the bloody discharge that sometimes accompanies the onset of menarche. Infants of both sexes may experience a milky breast discharge beginning 3 days after birth and lasting up to 2 weeks due to maternal hormonal influences.
Geriatric pointers
In postmenopausal women, breast changes are considered malignant until proven otherwise.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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- Nipple Discharge
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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