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Nipple discharge

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Physiological Causes

  • Pregnancy and Lactation: Nipple discharge is common and normal during pregnancy and lactation; discharge is usually milky or colostrum-like.
  • Hormonal Imbalance: Conditions like hyperprolactinemia (e.g., due to pituitary adenoma) can cause galactorrhea, which is bilateral and non-bloody.
  • Fibrocystic Changes: Benign condition causing bilateral, multi-ductal, and often green or brown discharge, commonly associated with cyclical breast pain.

Pathological Causes

  • Intraductal Papilloma: Benign tumor within the breast duct, often causing unilateral, single-duct, spontaneous discharge which may be bloody or serous.
  • Duct Ectasia: Dilatation of the mammary ducts, usually seen in perimenopausal women; presents with bilateral, multi-ductal, thick, and green or black discharge.
  • Mastitis/Abscess: Infection of the breast tissue, more common during lactation; presents with purulent discharge, breast pain, erythema, and systemic symptoms like fever.
  • Breast Cancer: Particularly ductal carcinoma in situ (DCIS) or invasive ductal carcinoma; may present with bloody, serous, or clear discharge, often unilateral and associated with a palpable mass or skin changes.
  • Paget’s Disease of the Breast: Rare form of breast cancer presenting with eczematous changes of the nipple and areola, often with associated bloody nipple discharge.

Drug-Induced Causes

  • Antipsychotics: Drugs such as risperidone or haloperidol can cause galactorrhea due to dopamine antagonism leading to increased prolactin levels.
  • Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) can also increase prolactin levels, potentially leading to nipple discharge.
  • Hormonal Contraceptives: Can cause breast changes and discharge due to their effects on hormonal balance.
  • Opioids: Chronic use can increase prolactin levels, potentially leading to galactorrhea.

Key Points in History 🥼

Symptomatology

  • Discharge Characteristics: Note the color, consistency, and whether it is unilateral or bilateral. Bloody or serous discharge is more concerning and may suggest malignancy or intraductal papilloma.
  • Spontaneous vs. Expressed: Spontaneous discharge is more concerning than discharge that only occurs with manipulation, as it may suggest an underlying pathology.
  • Associated Symptoms: Look for symptoms such as breast pain, palpable lumps, skin changes (e.g., dimpling, peau d’orange), or systemic symptoms like fever (suggestive of infection).
  • Menstrual and Reproductive History: Consider the impact of hormonal changes, recent pregnancy, or breastfeeding on the presentation.
  • Medications: Ask about any medications that could cause hyperprolactinemia or other breast changes, such as antipsychotics or hormonal therapies.

Background

  • Past Medical History: Important to note any history of breast disease, endocrine disorders, or prior breast surgeries.
  • Drug History: Review all current and recent medications, particularly those known to affect prolactin levels or hormonal balance.
  • Family History: Consider family history of breast cancer or other breast diseases, which may increase the patient’s risk.
  • Social History: Include lifestyle factors such as alcohol use, smoking, and occupation that might influence breast health.
  • Reproductive History: Inquire about age of menarche, menopause, pregnancies, and use of hormonal contraceptives or hormone replacement therapy.

Possible Investigations 🌡️

Laboratory Tests

  • Prolactin Levels: Elevated levels may suggest hyperprolactinemia due to a pituitary adenoma or drug-induced causes.
  • Thyroid Function Tests: Hypothyroidism can cause elevated prolactin levels and should be excluded.
  • Hormonal Profile: Consider assessing estrogen, progesterone, and other relevant hormones depending on the clinical context.
  • Microbiological Culture: If infection is suspected, culture the discharge to identify the causative organism.
  • Cytology of Nipple Discharge: May help in identifying malignant cells, particularly in cases of bloody discharge.

Imaging and Specialist Tests

  • Mammography: First-line imaging for women over 40 or if malignancy is suspected; helps identify masses, microcalcifications, and other abnormalities.
  • Ultrasound: Useful in younger women or for further evaluation of palpable lumps or suspicious areas seen on mammography; particularly good for differentiating cystic from solid lesions.
  • MRI: Consider if there is a strong suspicion of malignancy with inconclusive mammography/ultrasound findings, or in cases of high-risk patients.
  • Ductography (Galactography): Specialized imaging technique to evaluate the ductal system; useful for identifying intraductal lesions such as papillomas.
  • Biopsy: Indicated if imaging suggests malignancy or if cytology is suspicious; may be performed via fine-needle aspiration, core biopsy, or excisional biopsy.

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Endocrine & metabolic