{{Infobox medical condition | name = Nipple discharge | image = File:Lactation.jpg | caption = Milk coming from the nipple | field = [[Gynecology]] | symptoms = | complications = | onset = | duration = | types = Physiologic, pathologic<ref name=AFP2012/> | causes = | risks = | diagnosis = '''Normal''': Late pregnancy, [[postpartum period|after childbirth]], newborns<ref name=Saj2020/><ref name=NHS2017/><br>'''Abnormal''': [[Intraductal papilloma]], [[duct ectasia]], blocked [[milk duct]], [[mastitis|infected breast]], [[breast cancer]], [[high prolactin]]<ref name=AFP2012/><ref name=Mazza2011/><ref name=NHS2017/> | differential = | prevention = | treatment = Depends on the cause<ref name=Saj2020/> | medication = | prognosis = | frequency = Common<ref name=Saj2020/> | deaths = }} <!-- Definition and symptoms -->
'''Nipple discharge''' is fluid from the [[nipple]], with or without squeezing the [[breast]].<ref name=Saj2020>{{Citation|last1=Saj2020|first1=Karima R.|title=Breast Nipple Discharge|date=2020|url=https://www.ncbi.nlm.nih.gov/books/NBK430938/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=28613688|access-date=2 November 2020|last2=Sugumar|first2=Kavin|last3=Adigun|first3=Rotimi}}</ref><ref name=Bren2005/> The discharge can be milky, clear, green, [[purulent]], bloody, or faintly yellow.<ref name=Barry1990/> The consistency can be thick, thin, sticky, or watery.<ref name=Bren2005/><ref name=Barry1990>{{Citation|last=Barry|first=Michele|title=Nipple Discharge|date=1990|url=https://www.ncbi.nlm.nih.gov/books/NBK284/|work=Clinical Methods: The History, Physical, and Laboratory Examinations|editor-last=Walker|editor-first=H. Kenneth|edition=3rd|place=Boston|publisher=Butterworths|isbn=978-0-409-90077-4|pmid=21250127|access-date=2020-10-30|editor2-last=Hall|editor2-first=W. Dallas|editor3-last=Hurst|editor3-first=J. Willis}}</ref>
<!-- Causes --> Nipple discharge may be normal, such as [[milk]] in late pregnancy or [[postpartum period|after childbirth]], and in newborns during the first weeks of life.<ref name=Saj2020/><ref name=NHS2017/> It may also be normal following squeezing, in women during the reproductive years.<ref name=Saj2020/><ref name=Bren2005/> It is likely abnormal if it occurs in men, contains blood, is from only one breast, or is associated with a [[breast lump]], swelling, redness or overlying skin changes.<ref name=Saj2020/><ref name=NHS2017>{{Cite web|date=19 October 2017|title=Nipple discharge|url=https://www.nhs.uk/conditions/nipple-discharge/|url-status=live|archive-url=https://web.archive.org/web/20201030094750/https://www.nhs.uk/conditions/nipple-discharge/|archive-date=30 October 2020|access-date=30 October 2020|website=nhs.uk|language=en}}</ref> Reasons for abnormal discharge include an [[intraductal papilloma]], [[duct ectasia]], blocked [[milk duct]], infected breast ([[mastitis]] or [[breast abscess]]), [[breast cancer]], certain medications, and conditions that raise [[prolactin]].<ref name="AFP2012">{{cite journal |last1=Salzman |first1=B |last2=Fleegle |first2=S |last3=Tully |first3=AS |title=Common breast problems. |journal=American Family Physician |date=15 August 2012 |volume=86 |issue=4 |pages=343–9 |pmid=22963023|url=https://www.aafp.org/afp/2012/0815/p343.html}}</ref><ref name=NHS2017/><ref name=Mazza2011/>
<!-- Evaluation --> [[galactorrhea|Milky discharge]] in a non-pregnant, non-breast feeding women is evaluated differently to other abnormal nipple discharge.<ref name=Mazza2011/> Often, the cause can be determined based on symptoms and examination.<ref name=Bren2005>{{Cite journal|last1=Brennan|first1=Meagan|last2=Houssami|first2=Nehmat|last3=French|first3=James|date=May 2005|title=Management of benign breast conditions. Part 3 – other breast problems|url=https://www.racgp.org.au/afp/200505/200505brennan.pdf|journal=Australian Family Physician|volume=34|issue=5|pages=353–355|pmid=15887938 }}</ref> Blood tests may be done to rule out [[hypothyroidism|low thyroid]] or [[hyperprolactinemia|high prolactin]].<ref name=Arthur2014>{{cite book|last=Arthur|first=Rhonda|editor=Jill C.|editor-first=Cash|editor-last2=Glass|editor-first2=Cheryl A.|title=Family Practice Guidelines, Third Edition|chapter-url=https://books.google.com/books?id=SLPWAgAAQBAJ&pg=PR450|year=2014|publisher=Springer Publishing Company|isbn=978-0-8261-9782-5|page=450|chapter=13. Gynaecologic guidelines}}</ref> Other tests may include [[mammography]], [[breast ultrasound]], breast biopsy, or [[skin biopsy]].<ref name=DeMuro2018/>
<!-- Treatment and epidemiology --> Treatment depends on the underlying cause.<ref name=Saj2020/> Duct ectasia may be treated with surgical removal of the ducts involved.<ref name=Saj2020/> Infectious causes may require [[antibiotics]] or [[incision and drainage]].<ref name=Saj2020/> Nipple discharge is the third most common breast complaint by women, after [[mastalgia|breast pain]] and a [[breast lump]].<ref name=Mazza2011>{{cite book|author=Danielle Mazza|title=Women's Health in General Practice|chapter-url=https://books.google.com/books?id=_Q7IO4ACO1cC&pg=PA189|year=2011|publisher=Churchill Livingstone Elsevier|isbn=9780729538718|page=189|chapter=11. Nipple discharge}}</ref> About 3% of [[breast cancer]] cases are associated with discharge.<ref name=Mazza2011/><ref name=Bib2008>{{cite book|last1=Saad|first1=Reda S.|last2=Silverman|first2=Jan F.|editor=Marluce Bibbo|others=David Wilbur|title=Comprehensive Cytopathology |chapter-url=https://books.google.com/books?id=kj21b_1EUTIC&pg=PA760|edition=Third|year=2008|publisher=Saunders Elsevier|language=en|isbn=978-1-4160-4208-2|pages=760–761|chapter=25. Breast}}</ref>
==Signs and symptoms==
Nipple discharge is fluid from the [[nipple]], with or without squeezing the [[breast]].<ref name=Saj2020/><ref name=Bren2005/> The discharge can be milky, clear, green, [[purulent]], bloody, or faintly yellow.<ref name=Barry1990/> The consistency can be thick, thin, sticky, or watery.<ref name=Bren2005/><ref name=Barry1990/>
==Causes== Nipple discharge can arise from any one or more of the 15 to 20 milk ducts that each breast contains, and its causes can be divided into normal (physiological) and abnormal (pathological).<ref name=Saj2020/><ref name=Bren2005/>
===Normal===
Milky liquid from nipples is normal during the last few weeks of pregnancy, after childbirth and during [[breastfeeding]].<ref name=Saj2020/><ref name=Bren2005/> Some newborn babies may leak a [[Witch's milk|milky liquid]] which is usually normal and lasts a couple of weeks.<ref name=NHS2017/>
Stimulation of breasts by massage, using a breast pump or after mammography, may induce yellow, milky, or green nipple discharge in many healthy women of reproductive age.<ref name=Bren2005/>
===Abnormal=== Spontaneous nipple discharge unrelated to pregnancy or lactation is considered abnormal, but mostly have a non-serious cause.<ref name=Bren2005/> Nipple discharge in men is not normal.<ref name=NHS2017/> Discharge from nipples is also more likely to be abnormal (pathological) if it is crystal clear or blood-stained, is from only one breast, or is associated with a [[breast lump]], swelling, redness or overlying skin changes.<ref name=Saj2020/><ref name=NHS2017/><ref name="Mazza2011"/>
A blocked or enlarged [[milk duct]] can result in nipple discharge.<ref name=NHS2017/>
[[Intraductal papilloma]]s are non-cancerous lesions and most common in women age 30 to 50. Divided into central and peripheral papillomas, nipple discharge is more frequently observed when they are central.<ref name="SchnittCollins2009p.205">{{cite book|author1=Stuart J. Schnitt|author2=Laura C. Collins|title=Biopsy Interpretation of the Breast|chapter-url=https://books.google.com/books?id=7FD8MLc26NUC&pg=PA205|year=2009|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-9146-5|chapter=8. Papillary lesions|pages=205–206}}</ref> Up to half of women with intraductal papillomas may present with bloody nipple discharge, but it can also be straw-coloured.<ref name="Mazza2011"/> They are usually too small to feel and have a rare association with breast cancer.<ref name=Bren2005/><ref name="SchnittCollins2009p.205"/>
15-20% of people with nipple discharge are found to have [[duct ectasia]].<ref name="Mazza2011"/> This is usually in perimenopausal and menopausal women, who may have associated pain and retraction of the nipple. A lump may also be present.<ref name="SchnittCollins2009p.36">{{cite book|author1=Stuart J. Schnitt|author2=Laura C. Collins|title=Biopsy Interpretation of the Breast|url=https://books.google.com/books?id=7FD8MLc26NUC&pg=PA36|year=2009|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-9146-5|pages=35–36}}</ref>
[[Ductal carcinoma in situ]] (DCIS) usually presents with abnormal findings on [[mammography]], but can less frequently present with a lump or nipple discharge in women,<ref name="SchnittCollins2009p.69">{{cite book|author1=Stuart J. Schnitt|author2=Laura C. Collins|title=Biopsy Interpretation of the Breast|url=https://books.google.com/books?id=7FD8MLc26NUC&pg=PA69|year=2009|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-9146-5|page=69}}</ref> whereas in men with DCIS, nipple discharge is the common presentation.<ref name="SchnittCollins2009p.403">{{cite book|author1=Stuart J. Schnitt|author2=Laura C. Collins|title=Biopsy Interpretation of the Breast|url=https://books.google.com/books?id=7FD8MLc26NUC&pg=PA403|year=2009|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-9146-5|page=403}}</ref>
Infection in a breast, either [[mastitis]] or [[breast abscess]] may cause a discharge.<ref name=AFP2012/><ref name=NHS2017/> Eczema of the nipple may result in a discharge with crusting of the nipple skin.<ref name=Bren2005/>
Nipple discharge may be due to [[breast cancer]], particularly if there is an accompanying breast lump.<ref name="Mazza2011"/> A blood-stained discharge may appear in [[Paget's disease of the breast|Paget's disease]].<ref name=Bren2005/>
<gallery widths="200px" heights="200px" > File:Inverted-nipple-03.jpg|Dust ectasia, with nipple retraction<ref name="Mazza2011"/> File:Mastitis in breast.jpg|Mastitis in breast<ref name=AFP2012/> File:Diagram showing ductal carcinoma in situ (DCIS) CRUK 115.svg|Diagram showing ductal carcinoma in situ (DCIS)<ref name="SchnittCollins2009p.69"/> File:Paget Disese of the Nipple.jpg|Paget's disease of the nipple<ref name=Bren2005/> </gallery>
===Milky=== {{Main|Galactorrhea}} Some condition that cause a raised [[prolactin]] can result in a [[galactorrhea|milky liquid]] appearing from nipples. These include endocrine causes such as pituitary and thyroid disease, and some medications.<ref name=Bren2005/> Such medications include:<ref name=AFP2012/><ref name=NHS2017/><ref name="Hall2014">{{cite book|last1=Hall|first1=Mellisa|chapter-url=https://books.google.com/books?id=SLPWAgAAQBAJ&pg=PR644|title=Family Practice Guidelines, Third Edition|last2=Cash|first2=Jill C.|publisher=Springer Publishing Company|year=2014|isbn=978-0-8261-9782-5|editor=Jill C.|editor-first=Cash|page=644|chapter=19. Endocrine guidelines|editor-last2=Glass|editor-first2=Cheryl A.}}</ref> *Medication for hypertension: [[Methyldopa]], [[reserpine]], [[verapamil]] *Gastrointestinal agents: [[Cimetidine]], [[metoclopramide]] *Hormones: [[Estrogen]], [[birth control pill]] *Opiates: [[Codeine]], [[heroin]], [[methadone]], [[morphine]] *Psychotropic drugs: [[Antipsychotics]], [[monoamine oxidase inhibitors]], [[neuroleptics]], [[selective serotonin reuptake inhibitors]], [[tricyclic antidepressants]]<ref name=AFP2012/>
Some herbs including [[anise]] and [[fennel]] have also been implicated as causing leaking of fluid from nipples.<ref name=DeMuro2018/>
==Diagnosis== The evaluation of milky nipple discharge in a non-pregnant, not breast feeding women is different to the assessment of other abnormal nipple discharge.<ref name="Mazza2011"/> Often, the cause can be ascertained without performing tests.<ref name=Bren2005/> When blood tests are requested, they usually include [[thyroid stimulating hormone|thyroid tests]] and [[prolactin]] to rule out [[hypothyroidism]] and [[hyperprolactinemia]].<ref name="Arthur2014"/> Other tests that may be considered include [[mammography]], [[breast ultrasound]], [[CT head|CT scan of the head]] to rule out a pituitary tumour, breast biopsy, x-ray imaging of breast ducts or skin biopsy.<ref name=DeMuro2018>{{Cite web|last=DeMuro|first=Jonas|date=30 October 2018|title=Nipple discharge: MedlinePlus Medical Encyclopedia|url=https://medlineplus.gov/ency/article/001515.htm|url-status=live|archive-url=https://web.archive.org/web/20201103134503/https://medlineplus.gov/ency/article/001515.htm|archive-date=3 November 2020|access-date=3 November 2020|website=medlineplus.gov|language=en}}</ref>
The absence of cancerous cells in samples of nipple discharge does not exclude cancer, hence [[cytology]] of the nipple discharge is not usually performed.<ref name=AFP2012/><ref name=Bib2008/> However, guidance on investigations varies and tests are more likely performed if the discharge is bloody, from one breast, and the woman is age over 50.<ref name="Mazza2011"/> If the test is performed and malignant cells are found, an underlying cancer is highly likely.<ref name=Bren2005/><ref name="EuroCyt">{{cite web |title=Nipple discharge cytology {{!}} Eurocytology |url=https://www.eurocytology.eu/en/course/347 |website=www.eurocytology.eu |access-date=7 December 2020 |archive-date=30 December 2020 |archive-url=https://web.archive.org/web/20201230130747/https://www.eurocytology.eu/en/course/347 |url-status=dead }}</ref>
==Treatment== Initially, an evaluation for cancer is indicated. Treatment will depend on the cause found, and may involve changing medication, having a lump removed, applying a cream to treat a skin condition or being given medication to treat the condition causing the discharge. Duct ectasia may be treated with surgical removal of the ducts involved.<ref name=Saj2020/><ref name=DeMuro2018/> Infectious causes may require [[antibiotics]] and/or [[incision and drainage]].<ref name=Saj2020/> Sometimes, no treatment is required.<ref name=DeMuro2018/>
If no abnormality is found, a surgical duct excision may resolve the symptoms. Treatment also depends on whether single-duct or multiple-duct discharge is present, and whether the symptoms of nipple discharge are distressing to the person. In some cases, there may be no need for any further intervention; in others, [[microdochectomy]] or a [[Central duct excision|total duct excision]] may be appropriate. If the person wishes to conserve the ability to [[breastfeed]] and only single-duct discharge is present, then [[ductoscopy]] or [[galactography]] should be considered in view of performing a localised duct excision.<ref name=Saj2020/><ref name=Dixon2013>{{cite book|author=J Michael Dixon|title=Breast Surgery: Companion to Specialist Surgical Practice|url=https://books.google.com/books?id=_luP4nceyDkC&pg=PA274|date=22 June 2013|publisher=Elsevier Health Sciences|isbn=978-0-7020-4967-5|pages=274}}</ref>
==Epidemiology== Nipple discharge is the third most common breast complaint by women, after [[mastalgia|breast pain]] and a breast lump. 10% of women can notice a nipple discharge when squeezing their breast and more than 50% of women can experience this using a [[breast pump]].<ref name="Mazza2011"/>
Most abnormal nipple discharge is not associated with [[breast cancer]], but 1-5% of breast cancers present with nipple discharge.<ref name="Mazza2011"/><ref name=Bib2008/>
==References== {{reflist}}
== External links == {{Medical resources | ICD10 = {{ICD10|N|64|5|n|60}} | ICD9 = {{ICD9|611.79}} | DiseasesDB = 23444 }} {{Diseases of the breast}}
{{DEFAULTSORT:Nipple Discharge}} [[Category:Breast diseases]] [[Category:Symptoms and signs]] [[Category:Breast milk]]