Makindo Medical Notes

History Taking

• Character of Discharge:
  • Color: Clear, milky, yellow, green, or bloody.
  • Consistency: Watery or thick.
• Laterality: Is the discharge unilateral or bilateral? Bilateral discharge is often physiological, while unilateral discharge can be more concerning and warrants further investigation.
• Spontaneous vs. Expressed: Spontaneous discharge is more worrisome than discharge that occurs only when the nipple is expressed.
• Associated Symptoms: Ask about:
  • Breast pain
  • Palpable masses
  • Skin changes (e.g., redness, dimpling)
• Medication History: Some medications (e.g., antipsychotics, oral contraceptives) can cause nipple discharge due to hyperprolactinemia.
• Menstrual and Reproductive History: Establish the patient’s menstrual status (premenopausal, postmenopausal) and whether they are breastfeeding.
• Family History: Family history of breast cancer is important in determining the risk of malignancy.

Physical Examination

• Breast Inspection: Look for skin changes, nipple retraction, or asymmetry.
• Palpation: Examine for masses or tenderness in the breast tissue and axillary lymph nodes.
• Nipple Discharge Expression: If not spontaneous, attempt to express the discharge and note its colour and consistency. Determine whether it is from one duct or multiple ducts.

Diagnostic Tests

• Imaging:
  • Mammogram: For women over 40 or with suspicious findings.
  • Ultrasound: Useful for detecting underlying masses, especially in younger women or in the case of palpable abnormalities.
• Laboratory Tests:
  • Prolactin levels: To evaluate for hyperprolactinemia if galactorrhea is suspected.
  • Thyroid function tests: To rule out hypothyroidism as a cause of galactorrhea.
• Cytology: Examination of the nipple discharge for suspicious or malignant cells, especially if the discharge is bloody.
• Biopsy: Core needle or fine needle aspiration biopsy if a mass is present.

Management: depends on the underlying cause:

• Physiological or Idiopathic Galactorrhea: Reassurance, treatment of the underlying cause (e.g., hyperprolactinemia or hypothyroidism), or stopping the offending medication.
• Intraductal Papilloma or Duct Ectasia: Surgical excision of the affected duct is often recommended.
• Mastitis or Breast Abscess: Antibiotics and drainage of any abscesses, along with continued breastfeeding or expression of milk.
• Breast Cancer: Referral to a multidisciplinary team for appropriate surgical, chemotherapy, or radiotherapy treatment based on staging.

Causes