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Definition
Nipple problems can include
tenderness, skin changes, changes in shape, or discharge from the nipple
portion of the breast.
This article is about nipple problems or changes in women who are not
breast-feeding or who have not just had a baby (postpartum).
Causes
Nipple tenderness or skin changes
may be caused by:
1. Bacterial or fungal infections
2. Dry skin in the areolar region (the darker area surrounding the nipple)
of the breast
3. Injury to or friction over the nipple area
4. Paget's disease.
The likelihood of nipple discharge
increases with age. It is somewhat common in women who have had at least one
pregnancy or during the final weeks of pregnancy.
A milky nipple discharge is rare in men or women, but it does occur. When it
occurs in men or in women who have never been pregnant, it is likely to be
caused by an underlying disease. However, even then nipple discharge has
many other causes that are NOT breast cancer, including:
1. A tumor in the brain called a prolactinoma or microadenoma
2. A small, noncancerous growth in the breast called an intraductal
papilloma
3. Breast abscess located underneath the areola (most commonly seen in women
during breast-feeding)
4. Injury to the breast or chest wall (milky discharge)
5. Pregnancy, usually during the second trimester
6. Severe hypothyroidism
7. Use of certain drugs, including birth control pills, cimetidine,
methyldopa, metoclopramide, phenothiazines, reserpine, tricyclic
antidepressants, or verapamil
8. Widening of the milk ducts (called ductal ectasia), normally not a
cancerous problem
9. "Witch's milk," a term used to describe nipple discharge in a newborn.
The discharge is a response to hormones from the mother before birth, and
should disappear within 2 weeks.
Nipple inversion is a condition
that you are born with. Nipple retraction may be caused by aging, duct
ectasia, infections in the milk duct, or breast cancer.
Symptoms
Breast changes that may occur:
1. Breast lump or irregularity
2. Breast tenderness, swelling, or increased warmth
Changes in the shape of the nipples
may include:
1. Inverted nipples, in which the nipple is indented into the areola, but
will often come out with breast stimulation or during pregnancy
2. Retracted nipples, in which the nipple was raised above the surface but
begins to pull inward and does not come out when stimulated
Nipple discharge may be:
1. Milky (galactorrhea)
2. Clear, bloody, or discolored (green or brown) discharge
3. Present only with pressure on the breast or without pressure (called
spontaneous discharge)
4. Present in one or both nipples
Skin changes around the nipple may
include:
1. Redness, tenderness, and cracking of the skin surface of the nipple
2. Dimples, puckers, or a rash on the skin of the nipple or the areola
(darker skin that surrounds the nipple)
Exams and Tests
The health care provider will take
your medical history and perform a physical examination.
Tests that may be done to look for causes of nipple discharge:
1. Prolactin level
2. Thyroid function tests
3. Head CT scan or MRI to look for pituitary tumor
Other tests that may be done
include:
1. Mammography, performed in all cases
2. Ultrasound of the breast
3. Breast biopsy if a mass or lump is found, if the mammogram is abnormal,
or if the discharge is occurring on its own without any pressure on the
breast
4. Ductography or ductogram, an x-ray with contrast dye injected into the
affected milk duct
5. Skin biopsy, if Paget's disease is a concern
Treatment
Treatment of nipple discharge
caused by conditions outside of the breast include:
Treatment for breast infections, hypothyroidism, and pituitary tumors
Changing any medications that caused the discharge
Abnormal findings on a mammogram or breast ultrasound will be biopsied and
often removed.
Most women with breast discharge who have a normal mammogram, breast
ultrasound, and physical exam can be followed safely over 1 - 2 years with a
mammogram and physical exam repeated during that time.
Removing all or some of the breast ducts (called subareolar duct excision)
may be done right away, or after a period of observation. Often a ductogram
is done before surgery.
Steroid creams, antifungal creams, and antibiotic creams may be used to
treat skin changes around the nipple.
For information on breast and nipple care while breast-feeding, see:
1. Overcoming breastfeeding problems
2. Breastfeeding tips
3. Breastfeeding mothers - self-care
Outlook (Prognosis)
Most women with inverted nipples
who give birth are able to breast-feed without complications.
In most cases nipple problems do not involve breast cancer. These problems
will either go away with the right treatment, or they can be watched closely
over time.
Possible
Complications
Nipple discharge may be a symptom
of breast cancer or a pituitary tumor.
Skin changes around the nipple may be caused by Paget's disease.
When to Contact a
Medical Professional
Call for an appointment with your
health care provider if:
1. Your nipple becomes retracted or pulled in when it was not that way
before
2. Your nipple has changed in shape
3. Your nipple becomes tender and it is not related to your menstrual cycle
4. Your nipple has skin changes
5. You have new nipple discharge
Alternative Names
Discharge from breasts; Milk
secretions; Lactation - abnormal; Witch's milk; Galactorrhea; Inverted
nipple; Nipple discharge
References
Valea FA, Katz VL. Breast diseases:
diagnosis and treatment of benign and malignant disease. In: Katz VL, Lentz
GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed.
Philadelphia, PA: Mosby Elsevier; 2007:chap 15.
Leitch AM, Ashfag R. Discharges and secretions of the nipple. In: Bland KI,
Copeland EM III, eds. The Breast: Comprehensive Management of Benign and
Malignant Disorders. 4th ed. Philadelphia, Pa: Saunders Elsevier;2009:chap
4.
Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern
treatment algorithm for nipple discharge. Am J Surg. 2007;194:850-854.
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