Nipple discharge

Nipple discharge means fluid coming from the breast outside pregnancy and breastfeeding. The causes are benign in most cases, and even so it is a symptom to take to a clinician: a small proportion of cases relate to conditions best found early. Assessment usually takes a single appointment and settles the question.

What gets assessed

What matters to a clinician is less the discharge itself than its characteristics — they are what determine how urgently investigation is needed.

• Colour. Milky, yellowish, greenish and brownish discharge is more often linked to benign changes. Clear, watery and especially bloodstained discharge calls for closer attention.
• One breast or both. Discharge from both breasts usually points to a hormonal cause; from one, to a local one.
• One duct or several. Fluid appearing from a single point on the nipple deserves particular attention.
• Spontaneous or on pressure. Discharge that appears by itself and marks underwear is taken more seriously.
• Accompanying signs. A lump in the breast, pulling in of the nipple or skin, a change in the shape of the breast, redness, enlarged lymph nodes in the armpit.

When to see a clinician

• any nipple discharge has appeared outside pregnancy and breastfeeding;
• the discharge is bloodstained, or clear and watery;
• it comes from one breast and one duct;
• it appears spontaneously, without pressure;
• it coincides with a lump, nipple retraction or skin changes;
• milky discharge has appeared in a woman who is not breastfeeding, or in a man;
• you are a man — in that case assessment is needed whatever the picture.

Common causes

• Pregnancy and breastfeeding, including residual discharge for a long time after feeding has finished;
• duct ectasia — age-related widening of the ducts, usually in women approaching menopause; the discharge is thick, greenish or brownish;
• intraductal papilloma — a small benign growth inside a duct, a frequent cause of bloodstained discharge from a single point;
• raised prolactin — from a pituitary adenoma, thyroid disease, or as an effect of medication: some antidepressants, antipsychotics, anti-sickness drugs, hormonal contraceptives;
• mastitis and abscess — with pain, redness and fever;
• fibrocystic change;
• injury or excessive stimulation of the nipple;
• breast cancer — an uncommon cause, but the first to be excluded with bloodstained discharge.

What happens at the appointment

The clinician will examine the breasts and armpits and establish the character of the discharge, your cycle and the medication you take. Imaging usually follows: a breast ultrasound and, in women over 40, a mammogram — sometimes both. With discharge from a single duct, a ductogram or MRI may be needed. If a suspicious area is found, a biopsy is taken — a small sample of cells with a needle. Where the discharge is milky, prolactin and thyroid hormones are checked as well.

Some results may be available the same day; a histology report usually takes from a few days to a couple of weeks.

Treatment

The cause is what gets treated. With duct ectasia, monitoring is often enough. A papilloma is removed together with the affected duct, in a minor operation. If prolactin is raised, medication to lower it is prescribed, or the drug responsible is changed for an alternative. Mastitis is treated with antibiotics. If a malignant process is found, treatment is planned by an oncologist.

Common questions

Should I squeeze the nipple to check? No. Continued stimulation keeps the discharge going by itself. It is enough to notice what appears spontaneously.

Is discharge from both breasts more reassuring? Generally yes, it more often has a hormonal cause. But it still needs checking.

Can medication be the cause? Yes, and it is not an unusual situation. Do bring a list of everything you take to the appointment.

Online consultation

In an online appointment a doctor can go through the characteristics of the discharge, judge which call for urgent investigation, explain which tests to begin with, check whether your medication is involved and refer you to a breast clinic. Breast examination and biopsy are done in person.

This article is for general information and does not replace a consultation with a doctor.