gynecology and obstetrics
Nipple Discharge
Evaluation of Nipple Discharge
History of present illnessshould include the following: Whether the current discharge is unilateral or bilateral What its color is and whether it is bloody or blood-tinged How long it has lasted Whether it is spontaneous or occurs only with nipple stimulation Whether a Breast Masses (Breast Lumps) or Review of systemsshould seek symptoms suggesting possible causes, including the following: Fever: Mastitis or breast abscess Cold intolerance, constipation, or weight gain: Hypothyroidism None Amenorrhea, infertility, headache, or visual disturbances: Pituitary Lesions None Ascites or Nonlactational mastitis may be periductal mastitis, idiopathic granulomatous mastitis, or tuberculous mastitis. Past medical historyshould include possible causes of hyperprolactinemia, including chronic renal failure, pregnancy, liver disorders, and thyroid disorders, as well as history of infertility, hypertension, depression, breastfeeding, menstrual patterns, and cancer. Clinicians should ask specifically about drugs that can cause prolactin release such as oral contraceptives, antihypertensive drugs (eg,methyldopa, reserpine,verapamil), H2-antagonists (eg,cimetidine,ranitidine), opioids, anddopamineD2 antagonists (eg, many psychoactive drugs, including phenothiazines and tricyclic antidepressants). Physical examination focuses on the Evaluation . In male patients, A bright light and magnifying lens can help assess whether the nipple discharge is uniductal or multiductal. Certain findings are of particular concern: Palpable Breast Masses (Breast Lumps) or skin changes Bloody discharge Unilateral discharge Spontaneous discharge Age≥40 Male sex If a mass is present or discharge is guaiac-positive, even if bilateral, cancer must be considered. Discharge that is bilateral and/or multiductal and guaiac-negative suggests an endocrine cause. Presence of any of the following requires follow-up with a surgeon who is experienced with breast disorders: A breast mass A bloody (or guaiac-positive) discharge A spontaneous unilateral discharge History of an abnormality on a mammogram or a breast ultrasound For other suggestive findings, see table. If endocrine causes are suspected, the following are measured: Prolactin level Thyroid-stimulating hormone (TSH) level If discharge is guaiac-positive, the following is done: Cytology If there is a palpable breast mass, evaluation may include Ultrasonography, cyst aspiration, or mammography If there is no mass but cancer is otherwise suspected or if other tests are indeterminate, the following is done: Mammography If results of imaging or cytology (of cyst aspirate) are abnormal, image-guided biopsy is done. If mammography and ultrasonography do not identify a source and the discharge is spontaneous and comes from a single duct or breast, evaluation may include Ductography (contrast-enhanced imaging of the milk duct) or image-guided biopsy 