Nipple Discharge

This guideline applies to women over 18 years.

Red flags

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

Nipple discharge:

If galactorrhoea (bilateral milky discharge) – prolactin and TFTs

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)

2ww criteria (seen with imaging in one-stop clinic):

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:

For professionals:

For patients:

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)