patient is stimulating his or her nipple to examine for discharge
regular self-examination for discharge can produce ongoing, even spontaneous, discharge.
Regular self-examination or other forms of breast stimulation can repress the secretion of hypothalamic prolactin inhibitory factor,
Physiological nipple discharge
Fluid can be obtained from the nipples of 50–70% of asymptomatic women when massage or breast pumps are used.
This discharge of fluid from a normal breast is referred to as ‘physiological discharge’.
It is usually yellow, milky, or green in appearance
does not occur spontaneously
can be seen originating from multiple ducts.
can be noted after breast compression for mammography.
Milky nipple discharge (either spontaneous or on expression) is also physiological during pregnancy and lactation, and may be prolonged following lactation.
Abnormal nipple discharge
Nipple discharge that is spontaneous and unrelated to pregnancy or lactation is considered abnormal.
In the majority of cases it has a benign cause.
Spontaneous discharge caused by significant pathology is more likely to be unilateral, localised to a single duct, and crystal clear or blood stained in appearance
Causes
Duct ectasia – a benign condition with dilatation and inflammation of the ducts under the nipple, usually causes a bilateral yellow, green, or brown discharge from multiple ducts
Duct papilloma – typically causes a clear or bloodstained discharge. Papillomas are usually benign but may rarely be associated with breast cancer and therefore are always surgically removed
Nipple eczema – eczema or dermatitis affecting the skin of the nipple, particularly if infected, can cause a weeping, crusty, nipple discharge
Breast cancer – breast cancer is an uncommon cause of nipple discharge. Only about 3% of women with breast cancer have nipple discharge, and most of these have other symptoms such as a lump or newly inverted nipple in addition to the discharge. Cancer that causes nipple discharge is more likely to be in situ than invasive cancer
Paget disease – a particular clinical presentation of breast cancer causing a blood stained nipple discharge with ulceration and erosion of the nipple
Hyperprolactinaemia – high prolactin levels may cause galactorrhoea. Aetiology includes endocrine causes, eg. pituitary and thyroid disease; and drug causes, eg. Oral contraceptives, hormone therapy, antiemetics, antipsychotics, cocaine, and stimulants
Investigations
serum prolactin levels
is normal in nearly half of women who present with galactorrhea
Galactorrhea in the absence of hyperprolactinemia is usually not the result of any ongoing disease process.
cytological assessment of nipple fluid or nipple scrapings
has limited accuracy and should only be performed selectively in women with spontaneous bloodstained single duct discharge.
In this group, the finding of malignant cells is highly specific for underlying malignancy
mammography
Subareolar ultrasound
ductography/galactography
may be helpful
not widely available and may be painful for the patient
breast MRI
sensitivity for malignancy 77%
specificity for malignancy 62 %,
Management
the risk of carcinoma, despite being low cannot be eliminated without surgical duct excision and histologic confirmation.
Thus, duct excision in all patients with pathologic nipple discharge has been widely recommended
in a broader population of women with nipple discharge, the rate of underlying carcinoma was found to be only 3%
Hyperprolactinemia
Prolactin is a hormone produced by the anterior pituitary gland in the brain
main function = assist in development of breast tissue and facilitation of lactation.
Hyperprolactinemia is a frequently encountered endocrine condition.
occur in about in 1 in 200 individuals and is much more common in women
Among women with menstrual irregularities and fertility concerns, hyperprolactinemia occurs even more commonly – in up to 10 % of individuals
1 in 2,000 individuals have a prolactin producing tumor/prolactinoma – most common in women in the age group 25-35.
SSRIs account for up to 95% of medication causes
Symptoms of elevated prolactin in women may include:
Irregular menstrual cycles (short luteal phase)
No menstrual cycles (amenorrhea)
Low energy
Infertility
Decreased libido
Breast enlargement
Breast milk production (galactorrhea) in non-pregnant individuals
Weight gain
Hot flushes
Vaginal dryness
Low muscle mass
Decreased bone density
Headaches, nausea, vomiting
Vision problems
Symptoms of elevated prolactin in men may include:
