II. History
- Pregnancy and Lactation history
- Galactorrhea is normal during pregnancy and for up to one year after cessation of Lactation
- Does the Nipple Discharge occur spontaneously?
- "Does discharge stain underclothing or bed clothing?"
- What Color is the Nipple Discharge?
- Bloody Nipple Discharge is NOT synonymous with cancer
- However bloody Nipple Discharge carries a higher risk of cancer
- Is more than one duct involved?
- Is the Nipple Discharge Unilateral or Bilateral?
- How long has the Nipple Discharge been present?
- Is the Nipple Discharge persistent?
III. Types: Discharge associated with Cancer
- Watery: 45%
- Sanguineous: 25%
- Serosanguinous: 12%
- Serous: 6%
IV. Exam
- See Clinical Breast Exam
- Pressure point exam (in spontaneous Nipple Discharge evaluation)
- Elicit discharge from periphery toward nipple
- Distribute pressure evenly from each number of clock
- Document location that elicits Nipple Discharge
V. Findings
-
Galactorrhea
- Milky, bilateral discharge
- Hormonal and does not reflect intrinsic Breast disease
- See Galactorrhea
- Physiologic discharge
- Bilateral, multi-ductal, non-spontaneous, non-bloody Nipple Discharge
- Provoked by nipple stimulation or Breast compression
- Physiologic discharge may be yellow or gray, or even green or black
- Nipple Discharge may persist normally for up to 1 year after Breast Feeding discontinued (or delivery)
- Pathologic discharge
- Spontaneous, unilateral from a single duct opening at the nipple
- Discharge may be bloody, serous, serosanguinous or watery
VI. Labs: Galactorrhea
- See Galactorrhea
- Urine Pregnancy Test (key, first-line study)
- Thyroid Stimulating Hormone
- Serum Prolactin
VII. Diagnostics
- Cytology (of Breast Discharge)
- NOT recommended due to high False Negative Rate
- Breast Discharge culture and sensitivity
- NOT recommended (not useful)
- Usually grows skin contaminant
VIII. Imaging
-
Mammogram
- First-line study for pathologic Nipple Discharge in age >30 years
- Also obtain breast Ultrasound for women >40 years old
- Low Test Sensitivity (10-25%)
- Small subareolar masses without microcalcifications
- First-line study for pathologic Nipple Discharge in age >30 years
- Breast Ultrasound
- First-line study for pathologic Nipple Discharge in age <30 years
- Adjunct to Mammogram in women age >40 years
- Variable Test Sensitivity and Specificity
- Galactogram (Ductogram or Ductography)
- Contrast-enhanced mamogram
- Inject Radiocontrast Material into involved duct
- May be used to isolate intraductal pathology for surgery when Mammogram and Ultrasound negative
- Technically challenging and limited availability
IX. Causes
- Galactorrhea
- Bloody Nipple Discharge Etiologies
- Intraductal Papilloma (most common)
- Duct ectasia (Benign Breast duct tortuosity)
- Breast Cancer (represents <3%)
X. Evaluation
-
Breast Mass present
- See Breast Mass for evaluation and management
-
Galactorrhea
- Obtain Pregnancy Test, and if negative, TSH and Serum Prolactin levels
- See Galactorrhea for evaluation and management
- Physiologic Nipple Discharge (Non-Spontaneous bilateral, non-bloody discharge with Breast manipulation)
- Normal, physiologic Breast secretions
- Eliminate Breast compression, nipple stimulation that increases Nipple Discharge expression
- Re-examination in 3 months
- If age >40 years, obtain diagnostic Mammogram and breast Ultrasound (if not done in prior 6 months)
- Pathologic Nipple Discharge (Unilateral, single duct spontaneous Nipple Discharge)
- Breast Cancer risk: 10%
- Obtain breast Ultrasound and Mammogram
- May forego Mammogram if age <30 years, Ultrasound definitive, and no increased Breast Cancer risk
- Precaution: Normal Mammogram and breast Ultrasound does not exclude pathology
- Management for BI-RADS 1 to 3
- Surgically excise involved ductal system and send for pathology
- Duct localization may utilize dye injection, ductography or MRI
- Management for BI-RADS 4 to 5
- Tissue biopsy