Nipple discharge

Nipple discharge

Nipple discharge is the leakage of fluid from one or both nipples of women who are not pregnant or breastfeeding. There are 15-20 milk ducts in the human breast. Nipple discharge may be coming from one or more of these milk ducts. Nipple discharge is usually a benign condition. It often occurs due to overstimulation of the nipple. However, since it can also occur as a symptom of some diseases, it would be good to have it checked.

Nipple discharge is the third most common breast complaint after breast pain and breast mass. Fifty percent to 80 percent of women of reproductive age have nipple discharge, and 6.8 percent of these are evaluated for breast surgery. Most nipple discharges are benign (97%).

Many women experience nipple discharge. In men, nipple discharge is not normal and must be evaluated in detail. It is also common for babies to have milk coming out of their nipples after birth. This discharge in babies usually stops and disappears on its own within a few weeks.

With the increase of breast cancer awareness in the society, nipple discharge has always been a subject that is emphasized and examined in detail for physicians.

In the last few weeks of pregnancy, nipple discharge may begin to appear. Even after giving birth or during breastfeeding, nipple discharge may occur and this is normal. Overstimulation of the nipple or stress is known to cause nipple discharge. However, all postmenopausal nipple discharges are important and require detailed evaluation.

Causes of nipple discharge

What are the physiological causes of nipple discharge?

• Pregnancy
• Breast-feeding
• Postpartum galactorrhea (can last up to two years after birth)
• After spontaneous or deliberate termination of pregnancy
• Fibrocystic changes of the breast
• Hormonal fluctuations associated with the menstrual cycle
• Canal ectasia
• Intraductal papilloma

Sensitive evaluation is required as possible causes are usually abnormal conditions in men with nipple discharge. The age of the patient is very important when evaluating women. When nipple discharge is seen in women over 40 years of age, it is more likely to be caused by pathological causes. It is rarely benign when seen after menopause.

What are the pathological causes of nipple discharge?

• Infection (periductal mastitis)
• breast abscess
• Neoplastic process of the breasts (eg, intraductal carcinoma, Paget’s disease of the breast)
• Pituitary tumor/prolactinoma
• Thoracic/breast trauma
• Systemic disease/endocrinopathies that increase prolactin levels (e.g. hypothyroidism, pituitary or hypothalamus disorders, chronic kidney or liver disorders)
• Side effects of drugs that inhibit dopamine secretion (eg, opioids, oral contraceptives, antihypertensives (methyldopa, reserpine, verapamil), antidepressants, and antipsychotics)

In women with nipple discharge, when the symptom started, its relationship with the menstrual cycle, whether it is continuous, its character and color are examined. The color of the discharge does not make a clear decision about the severity of the situation. Because normal discharge can be any color.

The reproductive history of the patient with nipple discharge is examined. Pregnancy history, including age at menarche, age at menopause, and first full-term gestational age, is questioned. It is important whether a breast biopsy was performed for any reason or if there is any breast problem. Past surgeries, operations such as hysterectomy or ovariectomy are questioned. Pregnancy or childbirth, breastfeeding history, history of using birth control methods or taking hormone therapy are questioned in women with postmenopausal nipple discharge complaints.

In women with nipple discharge, family and close relatives history of breast cancer or related diseases are questioned. Medication history is also very important, as many medications can cause nipple discharge.

Fever may accompany the picture in women with mastitis or breast abscess. At the same time, the patient is questioned about weight gain, intolerance to cold or heat, constipation, jaundice, headache or other expected symptoms.

Breast mass, shape changes or asymmetrical appearance are examined in breast examination. It is observed whether there is spontaneous discharge or not. It is also evaluated whether there is a discharge with pressure.

Symptoms of nipple discharge

Physiological discharges of the nipple are usually seen on both sides. It is often clear and non-sticky. Pathological discharge is usually unilateral. Pathological discharges may be accompanied by breast swelling, redness, dimpling of the skin, or retraction of the nipple. Sometimes a mass may accompany.

Diagnosis of nipple discharge

In patients with nipple discharge, thyroid hormone profile and prolactin level are checked first. If there is no abnormality in these tests and the discharge is thought to be physiological, follow-up is performed in patients under 40 years of age. In patients older than 40 years, mammography is required.

In all patients who are thought to have pathological discharge, mammography and ultrasonography are useful for diagnosis. If an abnormality is detected in imaging methods, a biopsy may be required. If the breast biopsy is normal, MRI imaging and surgical removal of the abnormal mass, if any, are provided. If cancer is suspected, detailed cytological examination is performed.

Sometimes the cause of nipple discharge can also be an abscess. In patients who are evaluated to have an obvious abscess, it is recommended that these patients should apply to the emergency department if they also have pain and fever. If the patient’s abscess does not involve the nipple, relief can be provided by surgical drainage. If it includes the nipple, the treatment is arranged by evaluating it with the relevant branches in terms of aesthetics and by making a joint decision with the patient.

Treatment of nipple discharge 

Treatment of nipple discharge depends on the cause of the discharge and the clinical situation. There is no need for any treatment for physiological currents. There are separate treatment options for pathological causes. If there is duct obstruction or papilloma, microdocectomy can be performed.

Nipple discharge due to breast cancer may require different treatments depending on the stage of breast cancer. Surgery, chemotherapy, or radiotherapy may be required. If an infection or abscess has developed, surgery and antibiotic therapy can be applied. These treatments should be evaluated and applied by authorized physicians.