Any non-pregnant or non-lactating women and adult men with fluid accumulation in the breast ducts, spontaneously or by squeezing with overflow from the nipple opening, is called nipple overflow. Nipple overflow is one of the common symptoms of breast disease. According to statistics, the number of people who visit the doctor with nipple overflow as the primary symptom accounts for 3% to 14% of breast diseases, and is second only to breast lumps and breast pain in terms of incidence. Nipple discharge can be seen in many benign and malignant diseases of the breast and some systemic diseases. In general, nipple discharge that occurs after three months of weaning should be taken seriously, as it may be a sign of some disease.
The causes of nipple discharge are divided into four major categories: physiological, endocrine diseases, breast diseases, and drug-induced.
1. Physiological overflow is often a small amount of clear or milky white overflow from bilateral nipples, usually after squeezing. Physiological overflow does not require examination and treatment.
2, endocrine disease is often bilateral breast milk-like overflow of multiple ducts. It is mostly seen in pituitary tumor, thyroid disease, glioma, pineal tumor, liver disease, kidney disease, etc. The relevant endocrine hormones, such as estrogen, prolactin, thyroxine, etc., can be measured to understand the systemic endocrine activity; if brain tumor is suspected, cranial CT examination can also be done.
3, breast disease is often unilateral nipple overflow. It is usually seen in intraductal papilloma, breast trauma, acute mastitis, ductal dilatation, cystic hyperplasia, and plasmacytoid mastitis. Ductoscopy or mammography can be done to understand the ductal lesions. If breast disease is suspected, mammography may be done.
Cancerous overflow (also belongs to breast disease, listed separately) About 5-10% of breast cancers are accompanied by unilateral nipple overflow, which is mostly bloody or plasma blood or watery, and most of them are accompanied by breast lumps. Unilateral nipple discharge with painless small breast lumps is most often seen in early stage intraductal carcinoma. Bilateral nipple discharge breast cancer is rare. In addition, it is worth mentioning that male unilateral breast nipple overflow, whether it is bloody or plasma, should be considered as breast cancer.
4. Medicated overflow is often bilateral nipple overflow. It is usually seen after the application of anti-TB drugs, contraceptives, sleeping pills and estrogen. If you suspect drug-related overflow, you can stop using the relevant drugs and observe whether the nipple overflow will stop.
For patients and health care professionals, then how to recognize, diagnose and treat nipple overflow?
First, it is necessary to identify whether the overflow is pseudogout or true overflow.
Pseudofluid is caused by the accumulation of epidermal cells in the nipple, and after necrosis and disintegration, it causes an ooze shaped like sticky oil or tofu sludge, mostly seen in patients with sunken nipples. Since it can cause local multiplication of bacteria, it often has a foul odor and can lead to local acute inflammation or even abscesses, or it can recur leading to chronic inflammation. Therefore, such patients still need to pay attention and often pull out and clean the invaginated nipples, and surgical correction can be considered for severe invaginations.
True overflow refers to the flow of fluid through the ducts of the breast. It can also be divided into physiological: such as during breastfeeding, late pregnancy (called breast weeping in Chinese medicine), late breastfeeding (there is still a small amount of milk appearing within two years after childbirth, and as long as menstruation is normal, the possibility of disease due to it can usually be ruled out). In fact, some people can squeeze out a small amount of yellowish or colorless fluid from their nipples before and during menstruation, which can also be considered a physiological phenomenon, but can only be viewed as such after formal diagnosis to rule out disease. Of more concern are the pathological ones: such as ductal dilatation, intraductal papilloma, cystic hyperplasia of the breast, breast cancer, etc.
Second, the nature of the overflow is an important basis for determining the cause of.
1, the number of milk ducts overflowing: is it single or multiple ducts? The case of single-hole overflow is mostly diseases such as intraductal papilloma of the breast; multi-hole overflow may be physiological, pharmacological, systemic diseases, and of course, it may be mastoproliferative diseases.
2, the amount of overflow: whether it is difficult to squeeze out or easy to squeeze out, some monographs classify it into 5 levels, but it is quite subjective and rough, guiding little clinical significance, and generally unnecessary, so we will not expand the narrative here. The amount of overflow is of little use in providing diagnostic clues, but to some extent reflects the severity of the condition. It should be noted that some people have a lot of dirt on their nipples, but they cannot squeeze out the overflow, and many doctors think that there is no overflow, and the patient does not pay attention to it, but in fact there is a small amount of overflow, and the dirt is the “evidence of guilt” left after the water dries up. Pay attention to.
4, color: the site and nature of the nipple overflow has important clinical significance for inferring the nature of the disease. According to the nature of the nipple overflow can be divided into the following seven categories.
(1) Milk-like fluid: the color of the overflow resembles de-fatted milk. It is mostly physiological, such as after weaning or abortion recently, but can also be hyperprolactinemia, some patients with mastocytosis can also appear, this is often a multi-tubular overflow on both sides, automatic outflow.
(2) Pimple-like overflow: Mostly caused by ductal dilatation of the breast, the patient mostly has congenital nipple depression, the nipple has fatty pimple-like discharge with a foul odor overflow. This type of overflow is viscous, mixed with multiple colors, and spontaneously overflows. It is also usually bilateral and multi-colored. Patients often have burning, swelling, itching, and can also be seen in menopausal or young and middle-aged women with hypogonadism.
(3) Watery fluid: the overflow is thin and watery, mostly caused by diseases such as intraductal papilloma, cystic hyperplasia of the breast and breast cancer.
(4) Purulent fluid: the overflow resembles pus and is commonly seen in acute postpartum mastitis, ductal dilatation, and plasmacytoid mastitis.
(5) Plasma fluid: light yellow in color, most cases are caused by intraductal papilloma in the lower part of the nipple, also seen in cystic hyperplasia of the breast, ductal dilatation of the breast and breast cancer.
(6) Bloody fluid or plasma bloody fluid: it can be bright red, coffee, light red, brown and other different colors. This kind of overflow is a danger sign and should be highly alerted. 50% to 75% of them are intraductal papillomas and 15% of breast cancers. If the bloody overflow occurs after menopause, then 75% is breast cancer.
(7) Light green discharge: the discharge is a light-colored and lighter green liquid, which is less common. It is common in cystic hyperplasia of the breast.
III. Accompanying symptoms and significance.
(1) Nipple tingling or/and breast tingling: It is caused by poor overflow and can often be alleviated after squeezing out, when it is often accompanied by ductal dilatation. Here is a brief explanation of the relationship between ductal dilatation and overflow, ductal dilatation is almost always caused by the expansion of the ductal contents (usually liquid of various properties). When the overflow is very smooth, the dilation can be insignificant; when the dilation is not severe and blocked downstream, there can also be no overflow for the time being; both often occur simultaneously. If the overflow is not smooth or the fluid is generated too fast, the ducts may be progressively opened and expanded, resulting in a tingling sensation.
2, nipple itching: often due to poor overflow and chronic inflammatory overflow stimulation, but to exclude paget disease and nipple eczema.
3, pinpoint-sized clusters of particles on the epidermis at the tip of the nipple: due to overflow, the cause is complex.
Fourth, the diagnosis of the cause of nipple overflow: in addition to detailed medical history, comprehensive physical examination and observation of the nature of the overflow, the following diagnostic methods are commonly used.
1, exfoliative cytological examination: those who have nipple overflow can do exfoliative cytological examination, especially bloody overflow or single duct overflow exfoliative cytological examination is helpful for etiological diagnosis. This method is simple, convenient and easily accepted by patients.
2.Ultrasound imaging examination: non-invasive and can be used repeatedly. Ultrasonography is valuable for those with dense breast tissue, but it is mainly used to identify whether the mass is cystic or substantial.
Mammography: Mammography can detect ductal carcinoma in situ, which is mainly manifested by thickening of ductal shadow and microcalcifications; selective mammography has diagnostic value for ductal dilatation or cystic hyperplasia of breast and intraductal papilloma of breast.
4, histological diagnosis: fine needle aspiration cytological examination is a simple and easy method, but the diagnostic accuracy of benign diseases of nipple overflow is low. Biopsy is the most reliable method for diagnosing the cause of papillary overflow, especially for microscopic lesions, and is the last means of detection when imaging and cytological diagnosis is difficult or suspicious. Biopsy can be performed under imaging localization, endoscopic localization of breast ducts or local injection of dye into the overflowing ducts to remove the diseased ducts and glands for rapid pathological examination.
5.Fiber endoscopic technique: endoscopic examination of breast ducts is the main examination method for breast duct overflow, which can directly observe the epithelium of breast ducts and the duct lumen and decide whether surgical treatment is needed, and can save patients without lesions from surgery. For the lesions seen in the ducts can be directly located, taken and biopsied, thus reducing surgical damage.
V. Treatment of common lesions.
1.Breast cancer: standardized treatment (including surgery, chemotherapy, radiotherapy, endocrine therapy and targeted therapy).
2.Intraductal papilloma: surgery.
3, hyperprolactinemia: prolactin will spike very high, often accompanied by menopause (diaphoretic lactation syndrome), requiring cranial MRI to exclude pituitary microadenoma and do the appropriate treatment. In other cases, the lactation is stopped when the medication is discontinued because of long-term use of stomach medication, hypertension medication or antidepressants.
4, cystic fibroplasia, ductal dilatation: In fact, such ductal dilatation is also a symptom rather than a disease, or can be considered as an early stage of “ductal dilatation → plasma cell mastitis → acute abscess → chronic recurrent inflammation”, the cause of which is unknown, and the symptoms of cystic fibroplasia (a serious stage of lobular hyperplasia) of the breast have a close relationship with the symptoms of lobular hyperplasia. It is closely related to the symptoms of fibrocystic hyperplasia of the breast (the severe stage of lobular hyperplasia) and can be considered as one of the evolutionary directions after the severity of lobular hyperplasia. The first thing is not to be nervous after recognizing the condition, but to follow the principles of lobular hyperplasia treatment, with the following differences: the medication should be used for a long time and the follow-up interval should be short; the overflow should be cleaned up in time and the nipples should be kept clean and dry. From the perspective of Chinese medicine, the specific Chinese medicines and dietary considerations used are different from those for general lobular hyperplasia, but it is necessary to see the patient and make an individualized medication plan only after specific analysis.
In summary, the majority of nipple overflow is caused by benign lesions, and only a small percentage is caused by breast cancer. Therefore, it is not necessary to be very nervous when nipple overflow is found, but it is also important not to take it lightly. There are many kinds of diseases related to nipple overflow, and the clinical manifestations of various diseases are complicated, different diseases have common clinical symptoms and are not specific, and various auxiliary examinations have their own limitations. Therefore, it is difficult to diagnose and differential diagnosis of nipple overflow diseases. When patients have nipple overflow, they should try to go to a hospital for specialist examination to make a clear diagnosis so as not to miss the best treatment time.