What Is Nipple Discharge?
Nipple discharge describes the fluid coming through the nipple in different colors and consistency excluding the periods of pregnancy and breastfeeding. It is a common complaint in women. It occurs in about 5% -10% of women and accounts for 10 – 15% of benign diseases of the breast. It is the third most common breast-related complaint after mass and pain in women.
What Causes Breast Discharge?
1. Physiological nipple discharge: It usually occurs due to benign causes. This type of discharge comes from multiple milk ducts in the breast. It may be observed in one of the breasts or in both of them simultaneously. The fluid usually comes out of the nipple by squeezing. The color of the fluid coming out of the nipple may vary ranging from whitish milk color to yellow to brown, green, and black. Nipple discharge may occur in the absence of diseases, too, due to physical traumas, stress, excessive exercising or breast stimulation during sexual activity.
2. Galactorrhea: Milk secretion excluding the periods of pregnancy and lactation is called galactorrhea. The discharge looks like milk, bilateral, comes from multiple milk ducts, and occurs spontaneously. The causes of galactorrhea may not be identified or it may occur due to medications, chest wall trauma, and some hormonal disorders. It can occur in young adolescent girls, too, and can last for months without any underlying diseases.
3. Pathologic nipple discharge: This type of nipple discharge is usually bloody or pale pink and comes out from one of the breasts or from a single milk duct spontaneously without squeezing the nipple. Patients often notice the problem because of the stain on the bra or underwear. Pathologic nipple discharge occurs due to intraductal papillomas, periductal mastitis and ductal ectasia, atypical ductal hyperplasia, cancer, fibrocystic disease, hormonal causes (elevation of prolactin hormone levels), side effects of some drugs (some medications used for the treatment of disorders of the stomach and high blood pressure) .
How Is the Diagnosis Made and Treatment Carried Out?
First, a detailed medical history should be obtained from the patient. It is important to determine whether the discharge is spontaneous or whether it comes out of the nipple by squeezing. Discriminating between spontaneous and non-induced discharge is important. The color of the discharge and its laterality should be questioned. Because pink-colored or blood-containing nipple discharge can be related to cancer or precancerous lesions, they should be managed with caution. The relationship of the nipple discharge with the menstrual cycles, the age of the patient, comorbid diseases, and the medications received by the patient should be questioned to obtain information.
In the physical examination, a clock-wise compression is applied to the breast to identify the origin of nipple discharge. The number of milk ducts involved with the discharge, the location of its origin, and the presence of mass should be identified and noted.
Routine ultrasonography is the right approach after obtaining medical history and performing the physical examination. Mammography may be necessary for women over 40 years of age. Recently, ductoscopy is recommended for locating where nipple discharge originates. It is recommended for the treatment, too.
Fiberoptic Ductoscopy is the direct visualization of the milk duct opening to the nipple using a microendoscope after dilating it. This method allows the surgeon to find the precise location of the origin of the nipple discharge, take intraductal biopsy samples under direct visualization, and excise small intraductal papillomas.
There are two treatment options for the surgical treatment of nipple discharge; which are central duct excision and excision of a single duct. Central duct excision: It is the surgical removal of all milk ducts in the involved breast. This method is performed in patients with severe discharge from multiple milk ducts. Single canal excision: It is the excision of only the diseased milk duct. It is especially preferred in women younger than 35 years old, planning to have children because it preserves the breast tissue and milk ducts to allow breastfeeding.