Nipple Discharge

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Non-blood-stained nipple discharge

Nipple discharge is a very common symptom.  The colour of the discharge may range from clear to straw-coloured, yellow or green through to black.  The usual cause for this is when the major ducts, which are anatomically present below the nipple and areola, become dilated.  There are 15 to 20 major ducts that are the final part of a branching network of milk forming glandular ducts that open onto the nipple.  This dilatation may either occur spontaneously, or be secondary to external insults such as smoking.  The condition of dilated breast ducts is termed duct ectasia.  The surrounding membrane of these dilated ducts may become more leaky and allow some of this fluid to cause a mild inflammation around the ducts.  This inflammation is termed periductal mastitis.  There is evidence to suggest that duct ectasia and periductal mastitis are distinct conditions. 

Inflammation around these ducts behind the nipple may occur.  When this process heals by scarring, contracture may occur and the ducts shorten.  This sometimes results in the nipple having a transverse slit-like appearance.  Over time, the nipple may become inverted.  It is very important that you report all nipple changes to be formally evaluated by your doctor. Special investigations of nipple discharge usually include an ultrasound scan of the breast and analysis of the fluid under a microscope for its cellular content.  Over the age of 35 years, you may be advised to have a mammogram.

If there is multiduct, non-blood-stained nipple discharge, the treatment is often conservative.  Many women are not unduly troubled by the nipple discharge.  It is important that you do not manipulate your nipples in order to "squeeze out" the discharge, as this could provoke further secretion within the ducts and make the symptoms worse.  Most women find that nipple discharge reduces with time, thus avoiding the need for an operation.  Surgery may be recommended if an abnormality is detected in any of the tests performed, if the nipple discharge is increasingly troublesome or socially embarrassing. 

The operation aims to remove a disc of tissue behind the nipple and areola that contains the major ducts.  Surgery is avoided in women of childbearing age as, if you were to become pregnant, transection of the ducts would result in severe milk congestion and failure of lactation.  As a result of surgery, there is also a risk of altered nipple sensation and erectability.

Non-blood stained nipple discharge may sometimes arise from a single duct.  If surgery is necessary in younger women of childbearing age, then the single duct is removed at surgery under general anaesthetic

Blood-stained nipple discharge

Bloodstained nipple discharge may be visible as frank blood, or lighter coloured blood-stained fluid.  Blood staining may also be detected as a result of a special test such as the microscopic analysis of a cell smear or a biochemical test, in which small amounts of blood may be shown in a drop of the nipple discharge.  The majority of bloodstained nipple discharge is benign and the underlying pathology is usually related to a benign tumour called a papilloma within the major ducts.  In women over 50, the treatment is usually major duct excision where a disc of tissue beneath the nipple is removed together with the papilloma.  If the bloodstained fluid emanates from an obvious single duct, the duct is usually probed at the time of the operation to ensure that the offending duct is specifically removed. 

In younger women, the discharge usually arises from a single duct containing the papilloma.  As removing all the major ducts in pre-menopausal women poses the risk of milk congestion, if an operation is necessary, the single offending duct is usually excised at an operation called a microdochectomy.  The incision for surgery is neatly hidden around the areola for the best aesthetic result.

A small cancer within the ducts sometimes causes bloody nipple discharge.  Any suspicion of blood stained nipple discharge should therefore be reported to your specialist.

Galactorrhoea

Galactorrhoea is the spontaneous nipple discharge of milk or milk-like fluid as a result of stimulation of the breast by hormones associated with lactation.  The commonest cause of this of course is pregnancy and breast-feeding.  Rarely, milk production may occur in non-pregnant women as a result of an abnormally high milk producing hormone called prolactin.  This can sometimes occur because of oral contraceptive use.  Less commonly this is associated with a benign tumour in the pituitary gland in the brain or rarely with thyroid disease.  These conditions can be diagnosed clinically and with a blood test.  The treatment, where indicated, is usually directed at the underlying cause.

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