Nipple problems

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).

Alternative Names

Discharge from breasts; Milk secretions; Lactation - abnormal; Witch's milk; Galactorrhea; Inverted nipple; Nipple discharge

Causes, incidence, and risk factors

Nipple tenderness or skin changes may be caused by:

• Bacterial or fungal infections
• Dry skin in the areolar region (the darker area surrounding the nipple) of the breast
• Injury to or friction over the nipple area
• 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:

• A tumor in the brain called a prolactinoma or microadenoma
• A small, noncancerous growth in the breast called an intraductal papilloma
• Breast abscess located underneath the areola (most commonly seen in women during breast-feeding)
• Injury to the breast or chest wall (milky discharge)
• Pregnancy, usually during the second trimester
• Severe hypothyroidism
• Use of certain drugs, including birth control pills, cimetidine, methyldopa, metoclopramide, phenothiazines, reserpine, tricyclic antidepressants, or verapamil
• Widening of the milk ducts (called ductal ectasia), normally not a cancerous problem
• "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:

• Breast lump or irregularity
• Breast tenderness, swelling, or increased warmth

Changes in the shape of the nipples may include:

• Inverted nipples, in which the nipple is indented into the areola, but will often come out with breast stimulation or during pregnancy
• 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:

• Milky (galactorrhea)
• Clear, bloody, or discolored (green or brown) discharge
• Present only with pressure on the breast or without pressure (called spontaneous discharge)
• Present in one or both nipples

Skin changes around the nipple may include:

• Redness, tenderness, and cracking of the skin surface of the nipple
• Dimples, puckers, or a rash on the skin of the nipple or the areola (darker skin that surrounds the nipple)

Signs 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:

• Prolactin level
• Thyroid function tests
• Head CT scan or MRI to look for pituitary tumor

Other tests that may be done include:

• Mammography, performed in all cases
• Ultrasound of the breast
• 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
• Ductography or ductogram, an x-ray with contrast dye injected into the affected milk duct
• 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:

• Overcoming breastfeeding problems
• Breastfeeding tips
• Breastfeeding mothers - self-care

Expectations (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.

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.

Calling your health care provider

Call for an appointment with your health care provider if:

• Your nipple becomes retracted or pulled in when it was not that way before
• Your nipple has changed in shape
• Your nipple becomes tender and it is not related to your menstrual cycle
• Your nipple has skin changes
• You have new 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.