In order of decreasing frequency, the following are the most common causes of nipple discharge in the nonlactating breast: duct ectasia, intraductal papilloma, and carcinoma. The important characteristics of the discharge and some other factors to be evaluated by history and physical examination are listed in Table 17–1.
Table 17–1.Characteristics of nipple discharge in the nonpregnant, nonlactating woman. ||Download (.pdf) Table 17–1. Characteristics of nipple discharge in the nonpregnant, nonlactating woman.
|Finding ||Significance |
|Serous ||Most likely benign FCC, ie, duct ectasia |
|Bloody ||More likely neoplastic–papilloma, carcinoma |
|Associated mass ||More likely neoplastic |
|Unilateral ||Either neoplastic or non-neoplastic |
|Bilateral ||Most likely non-neoplastic |
|Single duct ||More likely neoplastic |
|Multiple ducts ||More likely FCC |
|Milky ||Endocrine disorders, medications |
|Spontaneous ||Either neoplastic or non-neoplastic |
|Produced by pressure at single site ||Either neoplastic or non-neoplastic |
|Persistent ||Either neoplastic or non-neoplastic |
|Intermittent ||Either neoplastic or non-neoplastic |
|Related to menses ||More likely FCC |
|Premenopausal ||More likely FCC |
|Taking hormones ||More likely FCC |
Spontaneous, unilateral, serous or serosanguineous discharge from a single duct is usually caused by an ectatic duct or an intraductal papilloma or, rarely, by an intraductal cancer. A mass may not be palpable. The involved duct may be identified by pressure at different sites around the nipple at the margin of the areola. Bloody discharge is suggestive of cancer but is more often caused by a benign papilloma in the duct. Cytologic examination may identify malignant cells, but negative findings do not rule out cancer, which is more likely in women over age 50 years. In any case, the involved bloody duct—and a mass if present—should be excised. A ductogram (a mammogram of a duct after radiopaque dye has been injected), like cytology, is of limited value since excision of the suspicious ductal system is indicated regardless of findings. Ductoscopy, evaluation of the ductal system with a small scope inserted through the nipple, has been attempted but is not effective management.
In premenopausal women, spontaneous multiple duct discharge, unilateral or bilateral, most noticeable just before menstruation, is often due to fibrocystic condition. Discharge may be green or brownish. Papillomatosis and ductal ectasia are usually detected only by biopsy. If a mass is present, it should be removed.
A milky discharge from multiple ducts in the nonlactating breast may occur from hyperprolactinemia. Serum prolactin levels should be obtained to search for a pituitary tumor. Thyroid-stimulating hormone (TSH) helps exclude causative hypothyroidism. Numerous antipsychotic medications and other medications may also cause a milky discharge that ceases on discontinuance of the medication.
Oral contraceptive agents or estrogen replacement therapy may cause clear, serous, or milky discharge from a single duct, but multiple duct discharge is more common. In the premenopausal woman, the discharge is more evident just before menstruation and disappears on stopping the medication. If it does not stop, is from a single duct, and is copious, exploration ...