Nipple Discharge

📝 History Taking (Nipple Discharge)

• Key triage question: “Is this likely physiological or pathological?” Pathological discharge is classically spontaneous, unilateral, and from a single duct (especially if bloody/serous).
• Character of discharge
  • 🎨 Colour: clear/serous, milky 🥛, yellow 💛, green 💚, brown/black, or bloody ❤️.
  • 💧 Consistency: watery vs thick/sticky (duct ectasia often thick/dirty-green).
  • 🧴 Amount & frequency: intermittent vs daily; soaking clothing is more concerning.
  • 🧭 Single duct vs multiple ducts: multi-duct is more often benign/physiological; single-duct warrants more caution.
• Laterality & onset 🔀 Bilateral is often physiological/endocrine; unilateral 🖐️ is more concerning. Ask timing (acute vs chronic), and whether it’s worsening.
• Spontaneous vs expressed ⚠️ Spontaneous discharge (without squeezing) is more worrying than discharge only produced by expression. Ask about frequent checking/squeezing—this can perpetuate discharge and hyperprolactinaemia.
• Pregnancy/lactation & reproductive context
  • 👩‍🍼 Post-partum or breastfeeding (normal to have milky discharge, sometimes persist months after stopping).
  • 🩸 Cycle relation (some cyclical changes can occur).
  • 🧑‍🦳 Postmenopausal discharge is higher-risk → lower threshold for breast clinic referral.
• Associated breast symptoms
  • 📦 Lump (new mass or focal thickening)
  • 🤕 Focal pain (especially with a lump or redness)
  • 🌡️ Infection features: fever, erythema, warmth (mastitis/abscess)
  • 🍊 Skin/nipple changes: eczema-like rash (think Paget’s), dimpling, nipple inversion/retraction
  • 🧠 Neurological symptoms: headache/visual field change (pituitary pathology if galactorrhoea)
• Medication & endocrine history
  • 💊 Prolactin-raising drugs: antipsychotics (esp. risperidone), metoclopramide, SSRIs/opioids; oestrogens/OCPs can contribute.
  • 🧬 Endocrine: hypothyroidism (↑TRH → ↑prolactin), CKD, liver disease.
• Cancer risk context
  • 🧬 Family history: breast/ovarian cancer, young onset, known BRCA/Lynch patterns.
  • 🎗️ Past breast disease: atypia, DCIS, prior radiotherapy, previous breast cancer.

🩺 Physical Examination

• 👀 Inspection: symmetry, skin tethering/dimpling, erythema, peau d’orange, nipple inversion, eczema/crusting of nipple (Paget’s red flag).
• ✋ Palpation: systematic breast exam including retroareolar region; check axillary/supraclavicular nodes.
• 💧 Discharge assessment: if not spontaneous, gentle expression once only:
  • Single duct vs multiple ducts
  • Colour/volume
  • Any associated subareolar mass (papilloma) or tenderness (infection)

🚩 Red Flags (Refer urgently to Breast Clinic)

• ❤️ Blood-stained or clear/serous discharge that is spontaneous and unilateral
• 📦 Associated lump or new focal thickening
• 🍊 Skin/nipple distortion, eczema-like nipple changes (possible Paget’s)
• 🧑‍🦳 Postmenopausal discharge

🔎 Diagnostic Tests (Triple Assessment Logic)

• Imaging 🖼️
  • 📷 Mammography (often first-line if ≥40 or suspicious features).
  • 🌀 Ultrasound (younger patients, dense breasts, palpable lump, ductal lesions).
  • 🧲 Breast MRI (selected cases: persistent single-duct discharge with negative standard imaging; specialist decision).
• Laboratory tests 🧪 (when galactorrhoea or endocrine picture)
  • 📈 Prolactin (ensure correct sampling—stress and nipple stimulation can elevate)
  • 🧬 TSH/T4 (hypothyroidism → hyperprolactinaemia)
  • 🤰 Pregnancy test in relevant patients
• Sampling 🔬
  • Cytology of discharge is not reliably sensitive for cancer; it may be used selectively (especially bloody discharge) but does not replace imaging/biopsy.
  • If a mass/abnormal imaging is present: core biopsy (or FNA in some settings) as part of triple assessment.

📊 Causes of Nipple Discharge (Pattern recognition)

⚕️ Management (Practical approach)

• 1) Identify red flags → urgent breast clinic referral (don’t “watch and wait” if spontaneous unilateral single-duct, blood/serous, postmenopausal, lump, or skin/nipple changes).
• 2) If galactorrhoea pattern → pregnancy test + prolactin + TFTs; review medications; avoid repeated nipple stimulation; treat underlying cause.
• 3) If infection pattern → antibiotics ± ultrasound for abscess; breastfeeding support if lactational.
• 4) If benign duct disease suspected (duct ectasia/papilloma) → breast clinic assessment when unilateral/single-duct or persistent; consider excision if recurrent or concerning.

📚 Teaching Pearl

🧠 Think “single-duct + spontaneous + unilateral = pathological until proven otherwise.” Galactorrhoea is usually bilateral and endocrine/drug-related; cancer risk tracks with age, postmenopausal status, and associated lump/skin change.