Guidelines 2016 – Abnormal Breast Discharge (Nipple Discharge)

Nov 20, 2019 admin PHỤ KHOA 0

Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Abnormal Breast Discharge
N64.52 – Nipple discharge

I.  DEFINITION

  1. Under certain conditions, an abnormal fluid may be expressed from the breast(s) or flow
  2. Up to 50% of women in their reproductive years may express discharge when the nipple is
  3. Most nipple discharge is associated with a benign process, but malignancy should be ruled out with all new-onset nipple
  4. Pathologic versus physiologic discharge
    1. Pathologic discharge is likely
      1. spontaneous
      2. From a single duct
      3. Persistent
      4. to contain gross or occult blood
    2. Physiologic discharge is likely
      1. With compression only
      2. From multiple ducts
      3. to resolve when refraining from compression
      4. nonbloody (milky, clear, green, brown)

II.  ETIOLOGY

  1. Physiologic causes
    1. Pregnancy, puerperium
    2. intercourse
    3. stimulation of the breast
    4. Chest wall surgery or trauma
    5. exercise
    6. emotional stress
    7. sleep (affects measurable amounts of prolactin)
  2. Pharmacologic causes
    1. numerous psychotropic drugs
    2. Cimetidine
    3. some antihypertensives
    4. opiates
    5. estrogens/oral contraceptives/progestins
    6. antiemetics
    7. alcohol (chronic abuse)
    8. Marijuana
    9. danazol
    10. isoniazid (inH)
    11. Methadone
  3. Pathologic causes
    1. Benign intraductal papilloma
    2. ductal ectasia
    3. Breast tumor
    4. Pituitary tumor
    5. Hypothalamic tumor
    6. infections
    7. empty sella syndrome
    8. Hypothyroidism
    9. Polycystic ovary syndrome (PCos)
    10. addison’s disease
    11. infections such as tuberculosis
    12. Histocytosis
    13. Metastatic tumors
    14. Chronic renal failure

III.  HISTORY

  1. What the patient may present with
    1. Breast discharge
    2. amenorrhea
    3. Possibly pain
    4. Possibly a mass
    5. Possibly localized heat and swelling
    6. Possibly nipple retraction
    7. Possibly no symptoms (discharge can be an incidental finding   of breast exam)
  2. additional information to be considered
    1. elicited versus spontaneous
    2. Unilateral versus bilateral
    3. number of ducts involved (one multiple ducts)
    4. Color of discharge
    5. duration of discharge
    6. Last menstrual period
    7. Headaches/visual changes
    8. sexual activity(decreased libido)
    9. Birth control method, hormone therapy
    10. Medications or illegal drugs currently used
    11. Medications recently taken
    12. recent pregnancy (within 1 year), regardless of outcome
    13. exercise program (e.g., jogging)
    14. nipple stimulation (e.g., fondling, sucking)
    15. recent trauma to chest or surgery
    16. Chronic illness (e.g., thyroid disease, psychiatric illness)
    17. Lifestyle changes (e.g., increased stress)
    18. alcohol consumption (chronic abuse)
    19. Family history of breast disease
    20. Breast pain or tenderness
    21. Breast surgery (biopsy, reduction, augmentation, and implants)
    22. acne/hirsutism
    23. travel history (visited countries with endemic schistosomiasis [areas in africa, asia, and south america])
    24. infertility

IV. PHYSICAL EXAMINATION

  1. Complete examination as described in the section on breast mass
  1. Closely examine the nipple
    1. Palpate nipple by compressing nipple areola with thumb and index finger, gently milking the subareolar ducts from just outside the apex of the papilla. repeat, moving around the nipple in a clockwise direction. Pay close attention to the position of the duct(s) that produces
    2. if discharge is expressed, note the following.
      1. Location of duct(s)
      2. Color
      3. Unilateral versus bilateral
    3. thyroid—palpate for nodes, size
      1. Bimanual examination
        1. ovarian irregularity or enlargement
        2. Uterine enlargement

V. LABORATORY EXAMINATION

  1. Guaiac test all discharge for occult blood
  2. Cytology of discharge is not recommended (likely to be inaccurate and may confuse workup)
  3. Prolactin level: sample should be drawn between 8 and 10 m. (literature indicates prolactin level is lowest between 8 and 10 a.m. but not directly after gynecologic examination, intercourse, exercise, or breast stimulation, including breast examination).
  4. thyroid panel
  5. Mammogram for women older than age 30
  6. subareolar ultrasound
  7. serum pregnancy test if indicated
  8. Kidney and liver function tests

VI. DIFFERENTIAL DIAGNOSIS (SEE ABNORMAL BREAST DISCHARGE,

ETIOLOGY, II) 

VII.  TREATMENT

as needed according to laboratory report and etiology

VIII.  COMPLICATIONS

Vary by individual, according to diagnosis

IX.  CONSULTATION/REFERRAL

  1. refer to endocrinology
  2. refer to subareolar ultrasound
    1. abnormal lab results
    2. Lack of definitive diagnosis
  3. refer to breast specialist for consideration of biopsy or duct excision
    1. abnormal imaging findings
    2. additional suspicious clinical exam findings
    3. all spontaneous, unilateral, and/or bloody nipple discharge
    4. Lack of definitive diagnosis
    5. When in doubt, consider referral to breast specialist

X.  FOLLOW-UP

  1. repeat laboratory work as indicated in Abnormal Breast Discharge, Laboratory Examination, V
  2. in the case of physiologic nipple discharge, encourage patients to stop squeezing/stimulating their nipples. discharge may decrease with reduced
  3. reevaluate patient in 4 to 6 weeks to confirm stability of clinical exam findings. refer women with persistent

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