creation date: 2026-01-05 14:53
tags: Workups
Nipple Discharge
Background
Nipple discharge refers to fluid that leaks from one or both nipples of non-pregnant and non-breastfeeding women.
Diagnoses can range from benign to a number of diseases, including breast cancer which requires careful evaluation and reassurance to the patient due to heightened public awareness.
Physiology
The human breast has 15-20 milk ducts, of which nipple discharge can originate from.
Nipple discharge is physiologically normal during:
- Last few weeks of pregnancy
- After childbirth
- During breastfeeding period
In nonpregnant, non-breastfeeding women during reproductive years, discharge can be normal if:
- Certain manipulation such as fondling, sucking, or massaging stimulates glands
- Stress
Nipple discharge is always abnormal in men and rarely benign in postmenopausal women.
Differential Diagnosis
Benign/Physiological
- Pregnancy
- Lactation
- Postpartum galactorrhea (up to 2 years post-delivery)
- Following spontaneous or intentional termination of pregnancy
- Fibrocystic changes of the breast
- Hormonal fluctuations associated with menstrual cycle
- Duct ectasia
- Intraductal papilloma
Pathological
- Infection (periductal mastitis)
- Breast abscess
- Neoplastic process of the breasts (ie. breast cancer)
- Pituitary tumour/prolactinoma
- Thoracic/breast trauma
- Systemic disease/endocrinopathies that elevate prolactin (eg. hypothyroidism)
- Medications that inhibit dopamine secretion (eg. opioids, OCPs, antidepressants)
Initial Evaluation
History
Patient information for risk stratification:
- Age (>40 is higher risk)
- Menopause status
HPI should include:
- Onset of discharge and association with menstrual cycle
- Persistence
- Character and colour of discharge
- Reproductive history (age at menarche, menopause, first pregnancy; pregnancy history)
Pertinent symptoms include:
- Fever (mastitis or breast abscess)
- Symptoms of hypothyroidism
- Symptoms of liver disease
- Symptoms of pituitary tumour
Medical history relating to:
- Breast problems and surgery
- Surgical history (eg. hysterectomy and whether ovaries were removed)
- Family history (especially breast and ovarian cancer)
- Medication history
Physical Exam
Exam should include breast exam. If no discharge is visible, the examiner should attempt to extract discharge by applying even pressure from the periphery towards the nipple. It is reasonable to ask the patient to attempt to extract themselves first.
Physiological discharge is typically:
- Bilateral
- Clear discharge
- Involves multiple ducts
- Non-sticky
Pathologic discharge is typically:
- Unilateral
- Spontaneous
- Varied in appearance (eg. bloody)
- Involves a single duct
- Associated with other findings on exam
Investigations
In patients with concerning demography, history, and/or physical exam, further work-up with urgency is warranted.
Patients with physiological discharge
Rule out systemic disease:
- TSH levels
- Prolactin
If patient is > age 40, mammography is indicated.
Patients with pathological discharge
Mammography and/or ultrasound is used and if abnormal, a breast biopsy is performed.
Fluid cytology can be used if discharge is bloody and breast cancer is suspected.
In cases of suspected or obvious breast abscess, referral to general surgery should be made.