Nipple Discharge

Women’s breasts continue to undergo changes throughout the duration of their lives, not only in terms of shape and size but also in terms of function.

Younger women have firmer breasts, which undergo changes during pregnancy and breastfeeding. As lactation (breast milk secretion) is the primary function of the breasts, the nipples may continue to secrete some fluid on and off even after stopping breast feeding.This is not an alarming sign.

Nipple discharge is an often neglected and undertreated symptom, both by women themselves and doctors as well, due to lack of awareness and inadequate evaluation.

Symptomatic/Pathological nipple discharge: (SND)

A very specific term, it is reserved for the following conditions:

  • Unilateral (one sided) discharge; occasionally bilateral (both-sided)
  • Sudden, spontaneous discharge, often noticed on the underclothes
  • Discharge from a single spot(duct) on the nipple.
  • Bloody, black- coloured, greenish, turbid, watery or milky discharge.
  • May or may not be associated with a breast lump.

SND needs to be evaluated thoroughly because it can often be an early sign of breast cancer.

The commonest causes of SND are intraductal papillomas (small non cancerous growths inside the milk ducts) and duct ectasia ( loss of elasticity of the duct walls).

Less commonly though, we may find cancer in and around these problematic areas, hence the need for a thorough evaluation.

How do we evaluate?
  • Clinical examination:

It tells us whether the discharge is from a single duct or multiple ducts , unilateral/bilateral and if there is a lump associated with the discharge

  • Tests:
  1. Mammography+ ultrasound of both breasts: To look for a problem insider the milk ducts and to ensure that the other breast is normal.
  2. Nipple discharge cytology: To look for any suspicious/ cancerous cells in the discharge and to look for occult blood.
  3. Breast MRI: A high resolution MRI is very informative and can tell us about tiny changes in the milk ducts which would otherwise go undetected.
Causes of SND:
  • Pituitary adenomas:

Small benign tumours in the pituitary gland can cause galactorrhoea, a condition where there is milk secretion from both breasts in a non-pregnant lady. The diagnosis is made by performing nipple discharge cytology, assessment of serum prolactin levels, an x-ray of the skull and an MRI brain.

Treatment here depends on the size of the tumour and may be surgical ( transsphenoidal endoscopic sinus surgery) or medical ( desmopressin nasal spray).

  • Duct ectasia: Commonest cause of scanty discharge, it happens due to loss elasticity of the duct walls.. But diagnosis may require surgery.
  • Papillomas: proliferative finger-like vascular growths occurring inside the lumen of the milk ducts, these may cause bloody nipple discharge . Papillomas may / may not be associated with carcinoma.
  • Carcinoma: As stated above, carcinoma may/may not be associated with papillomas.

Treatment of suspicious intraductal lesions is surgical, in the form of Ductoscopy and ductoscopy directed wide excision.

The earlier surgical modality was microdochectomy, which was an essentially blind procedure with higher rates of inadequate excision and hence higher recurrence.

Ductoscopy entails the direct visualisation of the offending duct using a thin 1 mm semiflexible endoscope. This procedure gives us a clear view of the duct, with direct visualisation of any proliferative growths like Papillomas and is then followed with a wide ductoscopy directed excision of the entire terminal ductolobular unit, right upto the base ( in short, revival of the entire offending area with complete visualisation).

If evaluated and treated appropriately, SND can be managed much better today and may prove beneficial in detecting breast cancer earlier..