This document discusses nipple discharge in women of reproductive age. It describes the anatomy and physiology of the mammary ducts and hormones that can cause physiological or pathological discharge. Pathological discharges may be associated with conditions like duct ectasia, intraductal papillomas, or breast cancer. The document recommends investigations like ultrasound, mammography, ductography, cytology and biopsy to evaluate the cause of nipple discharge and determine appropriate management.

1. Nipple discharge in reproductive age group women
Dr. Sujata Mittal
Sr. Consultant – Gynec. Oncology
PARAS HOSPITALS, GURGAON

2. Breast and Nipple discharge
Hormone dependent
sweat gland
Responds
to
emotions
Hence secretions
Physiological
Pathological
situation

3. Nipple Discharge: Anatomy & Physiology
• Mammary ducts lined by actively dividing epithelial cells which slough
• Orifice of non lactating women blocked by keratin plug
• Ductal system responds to estrogen, progesterone and prolactin.(Pituitary
Gland)
• Hormones interplay in Pregnancy, lactation and in non lactating women
• Pathological discharge is caused by growth or proliferation of mammary
ductal epithelial lining
• Mammary ducts are the seat of origin of Breast cancer and hence of
significance. Stagnant pool

4. Anatomy & Physiology (Contd.)
Breast cancer studies have
shown that majority of lesions are
multifocal
within the
confines of single duct

5. Opportunity
Detect, Predict & Treat
BC
Systematically
via BLOOD
At The
WHOLE
ORGAN
The Individual
ductal lobular
structure

6. Partial list of Nipple Aspirate Fluids
Proteins Immunoglobulins Fats Hormones Electrolytes Cells
Alpha 1 lipoprotein IgA Lauric Prolactin Sodium Epithelial
Alpha 1 acid
glycoprotein
IgM Myristic Estrone Potassium Myoepithelial
Alpha 2
macroglobulin
IgG H chain Myristoleic Estradiol Chloride Macrophages
Alpha 2 HS
glycoprotein
IgG L chain Palmitic DHEAS Calcium Neutrophils
Alpha 1 antitrypsin IgE Palmitoleic Progesterone Phosphate Lymphocytes
Trypsin IgD Cholesterol
Growth
hormone
Mast Cells
Beta liprotein
Cholesterol
epoxides
Testosterone Erythrocytes
Beta glycoprotein III TGF-α
Ceruloplasmin EGF

7. Definition of Discharge
When Secretions abundant/persistent enough
to
DISCHARGE
SPONTANEOUSLY
from
DUCT ORIFICE
DISCHARGE

8. Definition of discharge
If Ductal system is Normal Physiological
If Ductal system affected Pathological

9. Types of discharges associated with cancer
• Watery: 45%
• Sanguineous: 25%
• Serosanguinous: 12%
• Serous: 6%
•Bloody: < 3%

10. Types of Discharges with etiology
Lactation
Physiological
Pathological
• Milk
• Colostrum (can last up to 2 years post partum)
• Bloody/Guiac Postive in 30% women in 2nd/3rd trimester
• Hyperprolactnaemia: Neurogenic stimulation, medications, stress
• Exogenous/Endogenous Hormones, Endocrine abnormalities
• Medical & surgical conditions
• Papilloma
• Duct Ectasia
• Eczema of skin
• DCIS/ Malignancy

11. Etiology of Physiological Discharges
Neurogenic stimulation
• Stress
• Sleep
• Exercise
• Excessive Stimulation
• High Midday Protein Meal
Medications
• Hormones
• Antidepressants
• Antianxiolytics
• H2Receptor Antagonists
• Phenothiazines
• Amphetamines
• Antiemetics
• Danazol
• INH
• Opiates
• Antifungals
Medical & Surgical
Conditions
• Pituitary Adenoma
• Hypothyroidism
• CRF
• Herpes Zoster
• Thoractomy scar
• Hypernephroma
• Bronchogenic Carcinoma

12. Evaluation
Investigations
USG,Mammography,Ductography, Cytology, FNAC,
HPR
CEMRI, Direct / Indirect MR Ductography,
Intraductal Approach
Physical examination
Induced / spontaneous, B /L / Unilateral, Single /
multiple Duct, Color, Texture / Consistency
Examine for Lump, lympnodes,
Examine Subareolar tissue
History taking
spontaneous or expressed only? bilateral or
unilateral? uni-ductal or is it multi-ductal ? Color,
LUMP
Lactation, Medications, medical / surgical
conditions, Recent ammenorrhoea /
Hypogonadism

17. Take Home Message
• Breast Manipulation
• Normal Breast Secretions
Non
spontaneous
• Unilateral Multiple Duct Benign F/U
• Unilateral Single Duct Breast Path/BC
USG+- Mammo If Normal Excise HPR
Spontaneous
• B/L Systemic Cause/ Galactorrhoea
• Non Galactorrhoea Evaluate on principles
of Unilateral
Spontaneous

18. Mammography
• Standard Imaging Technique
• Microcalcifications/Other signs of malignancy
But
Not useful for diagnosis of etiology of ND
But
High NPV and Specificity(94%)

19. USG
• Non invasive
• Limitations in small lesions without dialation
& with dense fatty tissue.
• Duct Dilation, solid internal echoes, Duct wall
thickening in central or subareolar areas.
• Important for FNAC

20. ND CYTOLOGY
• Simple and useful
• Controversial as aspirate is normally very less.
• Recent Studied revealed Sensitivity of 85%
and Specificity of 97%.
• Should always be done

21. FNAC
Quite Sensitive
If Aspirate is less
Indicated

22. DUCTOGRAPHY
• Secreting Duct is identified Canulated
Dye is Injected
• More Sensitive than ND Cytology & MMG
But invasive, time consuming
complications
• Can’t Differentiate between benign & Malignant

23. CEMRI
• Increasingly being used.
• Diagnostic Sensitivity is 86-100% for invasive
Ca.
• Diagnostic Sensitivity is 46-100% for
intraductal Ca.
• Useful for evaluation of ND with occult
disease
• Useful for differentiating Benign & Malignant.

24. HPR
• Excision of duct
• Reference To Onco surgeon

25. Nipple Discharge
Q. Which of the following history questions is
LEAST helpful in assessing woman with
Breast discharge complaint?
1. Is the discharge spontaneous (comes out on its own)
or only with expression of the nipple?
2. Is the discharge unilateral or bilateral?
3. What color is the discharge?
4. Is there pain associated with the discharge?

26. Duct Ectasia (periductal mastitis)
Benign Disease in middle aged to elderly females
Can mimic malignancy
Pathological feature:
Dilated duct → engorged with breast secretion → infection →
retroareolar abscess → fibrosis → nipple retraction.
Clinical features:
Non Cyclical Mastalgia.
 Periareolar erythema.
 Nipple discharge: thick & creamy or greenish brown.
 Periareolar tender mass.
-Nipple retraction (when healing occurs by fibrosis).

27. Duct Ectasia (Contd.)
Etiology: Not known. Smoking is implicated in pathogenesis.
Investigations:
o Mammogram: opaque mass of dilated ducts & skin indentation.
- Cytology: for discharge.
Management:
- Infection: aspiration & antibiotic.
- Abscess: drainage.
- Severe discharge or recurrent sepsis: mammadochectomy (nipple
ducts excised through a circumareolar incision preserving the
nipple).

28. Intraduct papilloma
 Benign.
 Occurring in middle-aged women.
 Clinical features:
- Bloodstained discharge.
- Bleeding from a single duct orifice
- (pressure over a certain spot or the palpable mass).
- Small mass: NOT usually.
 Investigation:
- Mammogram (exclude carcinoma).
- Cytology assessment.
 Management:
- Duct orifice (bleeding) is identified: microdochectomy.
- If not: excision of the major nipple ducts.