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Breast Discharge

Basics

Description

- 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)

  • There are many variations of breast discharge including:Color of discharge: Clear, white, gray, brown, yellow, green, redProvoked (i.e., with nipple stimulation) vs. spontaneousUnilateral vs. bilateral
  • Rarely a sign of malignancy
  • Increased concern regarding malignancy if:Discharge occurs without provocation, is persistent, and unilateralDischarge is serous, serosanguineous, or bloodyOccurs in older patientAssociated 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 pillsAntihypertensives (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 ductSerous, serosanguineous, bloodyOlder patientAssociated with a mass
  • Galactorrhea is always bilateral.