Breast Nipple Discharge and Its Evaluation

Frederick R. Jelovsek MD, MS

"For about the last 2 months I have been having a severe burning, some swelling and a rust colored discharge from one nipple. That breast is also very tender. My GYN ordered a mammogram which was ok, then he ordered a ductogram, which the radiologist says can't be performed since " my nipples are too small". My GYN has now recommended that I see a surgeon. No one has said yet what this could be. How is it treated? Also, the radiologist made me feel as if I was a freak, because he complained so forcefully that my nipples were too small. Is there such a thing as too little? What is the appropriate treatment for this breast and nipple problem?" Terry

Rust colored nipple discharge implies blood in the secretions from the gland and ducts of the breast. Bloody discharge is worrisome for basically two conditions: intraductal papilloma (about 90% of bloody nipple discharge) and intraductal or other types of breast cancer (about 10% of bloody nipple discharge). Rarely it can indicate other benign or inflammatory conditions but intraductal papilloma and cancer are the main two to rule in or rule out.

Almost always, a rust colored or bloody nipple discharge come from only one of the breast ducts. A ductogram is an xray procedure in which a very small, blunt-ended plastic tube is placed in the nipple duct that is producing the discharge in order to inject dye and see if there is a papilloma in the duct.

I have not heard that size of nipples affects the ability to perform a ductogram and certainly your recent radiologist was a clod about making such an issue about it even if it was the case. It is possible that there are other radiologists in the area that have more experience with this and can perform the procedure for you. Ask the breast surgeon if there is some other radiologist he or she has worked with that could be recommended.

The usual contraindications to ductogram are:

• history of dye allergies
• previous surgery disconnecting the ducts from the openings on the nipple
• severe retraction of the nipple

In either case, whether an intraductal papilloma is seen or not, you will likely have surgery to remove the duct that is bleeding to be examined for possible malignancy or premalignancy (in situ carcinoma) or to remove the papilloma. The likelihood of finding the precise cause of the discharge is increased significantly by preoperative ductograms (galactography) (1) but until recently ductography was not ever performed. You will need to see the breast surgeon about this and be sure to ask any questions you have. Write them down beforehand if you need to so you will not forget.

While bloody nipple discharge is the most concerning for possible malignancy, 4 other types of nipple discharge, clear (watery) or yellowish, milky, pus-like (purulent) or greenish black and sticky, also need to be evaluated. If the cause is not due to cancer, about 75% of breast nipple discharge goes away within about 5 years (1).

Any time a nipple discharge comes from just one duct in a nipple, it needs to be investigated as a possible sign of breast cancer. When you express discharge from the nipple, you can see if it comes from just one point (duct) on the nipple or whether there are multiple droplets from several ducts or more. For example, a milky, lactational discharge which is hormonal in origin always comes from several ducts and it may even be bilateral. Clear or yellowish discharge due to fibrocystic condition often comes from multiple ducts and may be bilateral. When it is unilateral and from only one duct, an exam, mammogram, a ductogram if there is no mass and sometimes cytology (a Pap smear of the breast) should be done to look for a cancer.

Types of Breast Nipple Discharge

When the doctor evaluates you for a clear or milky discharge, the most important step is to assign the discharge to either a physiologic one or a pathologic one, i.e., hormonal or due to some disease or condition. One way to do this in the office is to touch a glass slide to the discharge, add a drop of any colored stain such as methylene blue, iodine, gram stain dye etc., and put on a cover slip to look at the slide under the microscope. If round fat globules are seen, this is a lactational discharge due to endocrine causes. No further work up with mammograms, ductography or cytology needs to be performed. If no fat globules are seen, then it needs to be evaluated like a clear discharge.

All breast nipple discharges should be evaluated by a physician and if they persist, even though thought to be due to benign causes, they need to be reevaluated with studies on a regular basis.