Nipple discharge
Accounts for 5% of all breast clinic referrals, but is usually innocent
Aetiology
[edit | edit source]Pathological (suspicious)
[edit | edit source]- Cancer (4-5%)
- Solitary intra-ductal papilloma (60-80%)
- Subareolar duct ectasia (20%)
- Infection
Physiological - galactorrhoea - mostly secondary to hyperprolactinaemia/drug-induced - generally copious, milky bilateral discharge
[edit | edit source]- Primary pituitary tumour
- Hypothyroidism
- Medication - primarily antipsychotics, antidepressants, opioids
- Can also get bilateral bloody discharge with these conditions
- Refer to endocrinologist
Lactational
[edit | edit source]| Medication class | Frequency of prolactin elevation* | Mechanism |
| Antipsychotics, first generation | ||
| Chlorpromazine | Moderate | Dopamine D2 receptor blockade within hypothalamic tuberoinfundibular system. |
| Fluphenazine | High | |
| Haloperidol | High | |
| Loxapine | Moderate | |
| Perphenazine | Moderate | |
| Pimozide | Moderate | |
| Thiothixene | Moderate | |
| Trifluoperazine | Moderate | |
| Antipsychotics, second generation | ||
| Aripiprazole | None or low | Dopamine D2 receptor blockade. |
| Asenapine | Moderate | |
| Clozapine | None or low | |
| Iloperidone | None or low | |
| Lurasidone | None or low | |
| Olanzapine | Low | |
| Paliperidone | High | |
| Quetiapine | None or low | |
| Risperidone | High | |
| Ziprasidone | Low | |
| Antidepressants, cyclic | ||
| Amitriptyline | Low | Not well understood. Possibly by GABA stimulation and indirect modulation of prolactin release by serotonin. |
| Desipramine | Low | |
| Clomipramine | High | |
| Nortriptyline | None | |
| Antidepressants, SSRI | ||
| Citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline | None or low (rare reports) | Same as for cyclic antidepressants. |
| Antidepressants, other | ||
| Bupropion, venlafaxine, mirtazapine, nefazodone, trazodone | None | Not applicable. |
| Antiemetic and gastrointestinal | ||
| Metoclopramide | High | Dopamine D2 receptor blockade. |
| Domperidone (not available in United States) | High | |
| Prochlorperazine | Low | |
| Antihypertensives | ||
| Verapamil | Low | Not well understood. Specific to verapamil. May involve calcium influx inhibition within tuberoinfundibular dopaminergic neurons. |
| Methyldopa | Moderate | Decreased conversion of L-dopa to dopamine; suppression of dopamine synthesis. |
| Most other antihypertensives (including other calcium channel blockers) | None | Not applicable. |
| Opioid analgesics | ||
| Methadone, morphine, others | Transient increase for several hours following dose | Potentially an indirect effect of mu opiate receptor activation. |
Concerning features (even with these findings, the majority are benign)
[edit | edit source]- Spontaneous (as opposed to expressed manually) and copious in amount
- Recurrent
- Unilateral
- Involving a single duct
- Bloody or clear
On review
[edit | edit source]- Nature of discharge
- Spontaneous or provoked
- Any medications being taken
- Examination - see separate topic
Differential diagnosis
[edit | edit source]- Multiple duct discharge is usually physiological or ectasia
- Even if high-risk factors are present, usually benign
Investigation
[edit | edit source]- Mammography if over 40
- USS of any clinical or radiological lesions
- Bloods if suspected galactorrhoea (prolactin, renal function, TSH, b-hCG, then MRI pituitary)
- Further tests
- Ductogram?
- Can sometimes identify filling defects within duct
- Cytology
- Low diagnostic yield but can be done
- Companion series says it has no role in routine management due to low sensitivity
- Core or excisional biopsy
- Endoscopic examination of ducts
- Companion series does not sound enthusiastic
- Ductogram?
Management
[edit | edit source]- Work up with examination, mammogram and USS, along with any other tests indicated based on the history
- If still unable to identify a diagnosis, excisional biopsy of duct in question is indicated
- Macrodochectomy in older women or those with completed families
- Microdochectomy in younger women intending to breastfeed - excision of just the affected duct