Nipple Discharge
This guideline applies to women over 18 years.
Red flags
-
Breast implant-associated anaplastic large cell lymphoma
-
Previous breast cancer
-
Significant family history of breast or ovarian cancer
-
Signs and symptoms suggestive of breast cancer
- Bloody or serous unilateral nipple discharge, discharge from a single duct.
- Unexplained discrete breast or axillary lump, ulceration, skin dimpling, breast distortion.
- Persistent nipple eczema, ulceration, new breast contour change
- Breast infection or inflammation that fails to respond to antibiotics.
- New asymmetric nodularity persisting after menstruation or for 2-3 weeks.
Key Features of Assessment
History:
In addition to usual breast symptom history:
-
If implants – ask about unexplained breast enlargement, asymmetry, fluid build-up (see breast implants), whether saline or silicone and whether a PIP implant was used
-
Previous breast disease/investigations
-
Most recent mammogram (offered to all women aged 50-71yrs every 3 yrs)
-
Risk factors – obesity, Ashkenazi Jewish ancestry, chest wall radiation, smoking, excess alcohol
-
Family history: breast/ovarian cancer (see Familial Breast and Ovarian Cancer), sarcoma under 45yrs, complicated multiple cancers at a young age, glioma or childhood adrenal carcinomas
- If galactorrhoea suspected– check contributing medications (see below), menstrual disturbance/acne (prolactinoma), visual fields and headaches (pituitary tumour)
Differential Diagnosis:
Nipple discharge is usually benign especially if bilateral.
-
Suspicious features:
- Spontaneous and unilateral
- Associated with a suspicious lump
- Bloodstained
-
Occurs in patient >50yrs old
-
Duct ectasia – a benign condition due to inflammation of the walls of the ducts. Usually: postmenopausal women, bilateral and causes a yellow/green/brown discharge from more than one duct.
-
Galactorrhoea– milky discharge from multiple ducts
- Physiological
- Hyperprolactinaemia
- Sec. to thyroid
- Medications - antipsychotics, antidepressants, opiates, prokinetics e.g. metoclopramide, verapamil, H2 antagonists
- Pregnancy
-
Duct ectasia
- Periductal mastitis
Investigation
Nipple discharge:
If galactorrhoea (bilateral milky discharge) – prolactin and TFTs
Management
Nipple discharge in pregnant patient:
If no other abnormal features - reassure her that nipple discharge including blood-staining is usually normal. Re-assess her at 2/12 postpartum.
Nipple discharge in non-pregnant patients:
-
Unilateral and:
- >50 years– refer 2ww
- <50 years, with persistent blood-stained or clear discharge, discharge from a single duct or sufficient to stain clothes– refer symptomatic breast clinic
-
Bilateral:
-
Galactorrheoa (milky discharge)
- If very high serum prolactin(and not pregnant/breastfeeding): – consider assessing for pituitary adenoma. Ask about headaches and examine visual fields. Refer urgent endocrinology.
- Manage abnormal TFT
- Review and consider stopping causative medications
- Periductal mastitis or duct ectasia – Give smoking cessation advice if appropriate
- Physiological– advise the patient to stop expressing the fluid as this will cause the breast to produce more fluid. Refer if persistent.
- If over 50 years and persistent refer symptomatic breast clinic (on 2ww form)
-
Galactorrheoa (milky discharge)
Referral
2ww criteria (seen with imaging in one-stop clinic):
- 50yrs+ with unilateral nipple discharge
Symptomatic Breast Clinic criteria (refer using 2ww form, reviewed in clinic and imaging may be done at a later date):
- Any age - persistent nipple discharge
- <50 yrs with bloodstained/clear nipple discharge, discharge of any nature from a single duct, discharge sufficient to stain clothes.
Do not usually need referral:
- <50 yrs with a small volume of coloured or milky discharge from multiple ducts with no other breast symptoms
Refer urgent endocrinology:
- Galactorrhoea with very raised prolactin
Supporting Information
For professionals:
- NHS Royal Cornwall Hospitals – Breast Webinar 2022 [video: 1 hour 17 minutes]
- NICE: Clinical Knowledge Summaries (CKS) – Breast Cancer: Recognition and Referral
- Association of Breast Surgery – Guidelines for the Investigation and Management of Spontaneous Nipple Discharge in the Absence of a Breast Lump
For patients:
- Breast Cancer Now:
- CoppaFeel – Information and Resources
Page Review Information
Review date |
12 January 2024 |
Next review date |
12 January 2026 |
Clinical editor |
Dr Madeleine Attridge |
Contributors |
Mr Iain Brown (Consultant Breast surgeon) Miss Polly King (consultant Breast surgeon) Dr Rebecca Osborne (GPwSI Breast) |
|
|