Basics
Description
- There are many variations of breast discharge including:
- Color of discharge: Clear, white, gray, brown, yellow, green, red
- Provoked (i.e., with nipple stimulation) vs. spontaneous
- Unilateral vs. bilateral
- Rarely a sign of malignancy
- Increased concern regarding malignancy if:
- Discharge occurs without provocation, is persistent, and unilateral
- Discharge is serous, serosanguineous, or bloody
- Occurs in older patient
- Associated with a mass or lump
- Intraductal papilloma (benign) is the most common cause of bloody nipple discharge.
- Most common malignancy causing discharge is ductal carcinoma in situ.
- Galactorrhea is bilateral milk production occurring in a nonlactating woman.
Epidemiology
Incidence
- Discharge is a common complaint from women of all ages; 10-15% of the women with benign breast disease experience breast discharge.
- Only 5-15% of patients with breast discharge have cancer.
Risk Factors
Pathophysiology
Varies depending on etiology of the breast discharge
- A trigger to the pituitary gland (i.e., from nipple stimulation or certain medications) causes the release of prolactin, which may induce nipple discharge.
- Malignant invasion of the duct lining can cause bloody discharge, as can an intraductal papilloma.
- Most bilateral discharge from multiple ducts that comes only with manipulation is a normal physiologic response.
Etiology
- Causes of galactorrhea include pituitary tumor, thyroid dysfunction, and chronic renal failure.
- Several medications can cause galactorrhea:
- Tranquilizers (e.g., Thorazine)
- Birth control pills
- Antihypertensives (e.g., Methyldopate HCl)
- Illicit drugs (e.g., marijuana)
Associated Conditions
- Pregnancy
- Prolactinoma
- Thyroid disease
- Renal failure
Diagnosis
History
- Practitioners should obtain a thorough history including, timing and quality of the breast discharge and if occurring from one or both breasts.
- History regarding the location of the draining duct or ducts should be obtained.
- Relationship to menstrual cycle, menopause, or of starting a new medication
- Symptoms of thyroid disease
Physical Exam
- Clinical breast exam
- Evaluation of the breast discharge
- Increased suspicion for malignancy if breast discharge is associated with a mass or lump.
Tests
Lab
- Pregnancy test
- Lab tests to check for galactorrhea include prolactin level and thyroid function tests.
- Evaluation of breast discharge includes cytology, immunology (i.e., carcinoembryonic antigen), and occult blood testing (likely to be done by a breast specialist after referral).
Imaging
- Mammography and ultrasound should be done initially as the first radiological studies.
- Galactography: To visualize a space-occupying lesion by inserting dye into a single breast duct
- MR galactography
- Fiber-ductoscopy
- Duct injection mammography
Surgery
- Duct lavage for cytology
- Exploration and/or removal of breast ducts
- Breast biopsy
- Excision of a prolactinoma if there is a pituitary adenoma
Pathological Findings
- Cytological findings of atypia or malignancy
- Occult blood (via hemoccult testing)
Differential Diagnosis
- Thrombophlebitis
- Infection
- Fat necrosis
Treatment
Medication
Medication for galactorrhea caused by a hyperprolactin state is the dopamine agonist, bromocriptine.
Additional Treatment
General Measures
- The majority of patients with breast discharge require no further treatment outside of reassurance.
- Anyone with possible pathological discharge (unilateral, single duct, spontaneous, and persistent discharge) should have a complete evaluation and likely will need a central duct excision and biopsy of the region of concern.
- Treatment of the underlying condition (i.e., prolactinoma) when indicated.
Issues for Referral
Refer all patients with discharge suspicious for malignancy (i.e., unilateral and spontaneous) to a breast surgeon.
Ongoing Care
Prognosis
- Excellent if not related to malignancy.
- Removal of an intraductal papilloma is curative.
Additional Reading
1Cabioglu N, Hunt K, Singletary SE. Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge. J Am Coll Surg. 2003;196:354-364. [View Abstract]2Leung A, Pacaud D Diagnosis and management of galactorrhea. Am Fam Physician. 2004;70:543-550, 553-554. [View Abstract]3Okazaki A, Hirata K, Okazaki M. Nipple discharge disorders: Current diagnostic management and the role of fiber-ductoscopy. Eur Radiol. 1999;9:583-590. [View Abstract]4Orel S, Dougherty C, Reynolds C. MR imaging in patients with nipple discharge: Initial experience. Radiology. 2000;216:248-254. [View Abstract]5Santen R, Mansel R. Current concepts: Benign breast disorders. N Engl J Med. 2005;353:275-285. [View Abstract]
Codes
ICD9
- 611.6 Galactorrhea not associated with childbirth
- 611.79 Other signs and symptoms in breast
ICD10
- N64.3 Galactorrhea not associated with childbirth
- N64.52 Nipple discharge
SNOMED
- 54302000 discharge from nipple (disorder)
- 290113009 bloody nipple discharge (disorder)
- 78622004 galactorrhea not associated with childbirth (disorder)
- 290110007 serosanguineous nipple discharge (disorder)
Clinical Pearls
- Rarely associated with malignancy
- High index of suspicion if:
- Unilateral, unprovoked, from a single duct
- Serous, serosanguineous, bloody
- Older patient
- Associated with a mass
- Galactorrhea is always bilateral.