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:

cloudy white color -- most common, can be galactorrhea

clear or light white -- pregnancy

red -- contains blood -- most often due to breast infection or intraductal papillomas, but
can be breast cancer

whitish-yellow or yellow or even green -- pus due to infection

Abscess

Breast cancer

Breast infection

Ductal carcinoma in situ (DCIS)

Excessive breast stimulation

Fibroadenoma

Fibrocystic breasts

Galactorrhea

Hormone imbalance

Injury or trauma to the breast

Intraductal papilloma

Mammary duct ectasia

Medication use

Menstrual cycle hormone changes

Paget's disease of the breast

Pregnancy and breast-feeding

Prolactinoma

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, Pagets 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