October 04, 2010

Q&A: Evaluation of Nipple Discharge (Galactorrhea)

Nipple discharge is the third most common breast-related complaint, after breast pain and breast mass. During their reproductive years, up to 80 percent of women will have an episode of nipple discharge. Most nipple discharge is of benign origin. The primary goals of evaluation and management are to differentiate patients with benign nipple discharge from those who have an underlying papilloma, high-risk lesion, or cancer and to manage patients with underlying pathologic nipple discharge.

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This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Women's Health articles more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.
In this article:
Diagnostic evaluation of nipple discharge
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Diagnostic evaluation of nipple discharge

Nipple discharge is categorized as normal milk production (lactation), physiologic nipple discharge (galactorrhea), or pathologic (suspicious) nipple discharge based on the characteristics of presentation.

Patients with suspected physiologic nipple discharge require laboratory evaluation, whereas those with suspected pathologic nipple discharge should undergo imaging studies.

Physiologic discharge — Nipple discharge that is bilateral and nonbloody is likely physiologic, which requires medical evaluation for possible hyperprolactinemia, but no specific breast imaging, provided that, for women, routine screening mammography is up-to-date.

Pathologic discharge — After clinical evaluation, all patients presenting with one of the following should undergo breast imaging to search for any underlying abnormality in the duct (or elsewhere in the breast) and direct surgical intervention:
  • Unilateral nipple discharge
  • Bloody nipple discharge
  • Nipple discharge associated with a mass or skin lesions
Laboratory tests for galactorrhea are not indicated for evaluation of suspected pathologic nipple discharge.

MCQ exam: clinical scenario

A 28-year-old woman sought medical attention for amenorrhea of two years' duration. Normal menarche had occurred at age 13, followed by regular menstrual cycles. At age 25, she had noticed a diminution in the frequency of menses, and at age 26, menses had ceased. Around that time she also had noticed a milky discharge from both breasts. A visual field test reveals bitemporal hemianopsia. Family history is unremarkable.

The investigation of choice at this stage would be:

a) Skull x-ray
b) Non-contrast CT scan brain
c) Contrast CT scan brain
d) Contrast enhanced MRI of the optic nerves
e) MRI pituitary gland
f) Four vessel cerebral angiogram
g) MRI cerebral angiography

MCQ questions & answers on medicalnotes.info

MCQ exam: answer

The correct answer is E.

MCQ exam: explanation

The most important positive finding in the history is the development of milky discharge from the breasts, concurrent with secondary amenorrhea. On the basis of the history, one can make a presumptive diagnosis of amenorrhea and galactorrhea from hyperprolactinemia. Causes of hyperprolactinemia that must be considered include a prolactin-secreting pituitary tumor (although the negative family history reduces the likelihood of MEN type I); a functional disorder in the hypothalamus that has blocked the release of dopamine, which inhibits the pituitary's production of prolactin; and rare disorders such as ectopic production of prolactin by a tumor (e.g., lung or kidney carcinoma). Primary hypothyroidism is another consideration, since it is also a cause of hyperprolactinemia.

Skull films and CT-scans have been replaced by MRI for imaging of the pituitary fossa and sella turcica. These may still be used in centers without an MRI.

The results of the eye examination in this patient are very important because a pituitary macroadenoma--that is, an adenoma larger than 1 cm--that extends above the level of the sella turcica may impinge on the optic chiasm and cause a bitemporal hemianopsia or impinge on the optic nerves and cause blind spots. Upward enlargement can involve hypothalamic tissue and the brain stem, as well as the optic chiasm. The classic finding of chiasmatic involvement is bitemporal hemianopsia. An additional finding of a junctional scotoma (a central scotoma in one eye with reduced visual acuity and an upper temporal field defect in the opposite eye) combines with bitemporal hemianopsia to account for up to 96% of all visual defects.

Hypothalamic damage can result in hypotension, disturbed thermoregulation, and cardiac dysrhythmias. Brain stem compression causing altered levels of consciousness and changes in muscle tone, respiratory and pupillary reactions, and unusual signs such as hiccoughs and retraction nystagmus.

Reference(s)
1). UpToDate: Nipple discharge. Available online: https://www.uptodate.com/contents/nipple-discharge

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