Breast Discharge

Introduction

Breast discharge is a common presenting symptom in gynecology and primary care settings across Canada. As a future Canadian physician preparing for the MCCQE1, understanding the nuances of breast discharge is crucial for providing high-quality patient care within the Canadian healthcare system.

Types of Breast Discharge

Breast discharge can be classified based on various characteristics. Understanding these classifications is essential for accurate diagnosis and management in the Canadian healthcare context.

Etiology and Differential Diagnosis

Understanding the various causes of breast discharge is crucial for MCCQE1 success and effective patient management in Canadian healthcare settings.

Physiological Causes

• Pregnancy
• Lactation
• Nipple stimulation

Pathological Causes

1. Benign

   • Intraductal papilloma
   • Fibrocystic changes
   • Mammary duct ectasia
   • Infection (mastitis, abscess)

2. Malignant

   • Breast cancer (invasive or in situ)
   • Paget's disease of the breast

Systemic Causes

• Medications (e.g., antipsychotics, antidepressants)
• Endocrine disorders (e.g., hypothyroidism, prolactinoma)

Clinical Approach to Breast Discharge

When preparing for the MCCQE1, focus on developing a systematic approach to patients presenting with breast discharge. This aligns with the CanMEDS framework, particularly the roles of Medical Expert and Communicator.

Management

Management of breast discharge in the Canadian healthcare context focuses on addressing the underlying cause while providing patient-centered care.

1. Reassurance and observation for physiological discharge
2. Discontinuation of offending medications if drug-induced
3. Treatment of underlying endocrine disorders
4. Surgical intervention for intraductal papillomas or suspicious lesions
5. Antibiotics for infectious causes, following Canadian antibiotic stewardship guidelines
6. Referral to a breast specialist for persistent or suspicious discharge

Canadian Guidelines for Breast Discharge Management

The Canadian Association of Radiologists (CAR) and the Canadian Society of Breast Imaging (CSBI) provide guidelines for breast imaging in the context of nipple discharge:

1. For women <30 years with non-suspicious discharge: Ultrasound is the primary imaging modality
2. For women ≥30 years or with suspicious discharge: Mammography and ultrasound are recommended
3. MRI may be considered in cases where conventional imaging is inconclusive

Key Points to Remember for MCCQE1

• Breast discharge can be physiological or pathological
• Unilateral, spontaneous, and bloody discharge are more concerning
• Always consider breast cancer in the differential diagnosis
• Age-appropriate imaging is crucial in the diagnostic workup
• Management depends on the underlying cause and patient factors
• Familiarity with Canadian guidelines is essential for proper patient care

Sample Question

# Sample Question

A 45-year-old woman presents with spontaneous, unilateral, bloody nipple discharge. She has no palpable breast masses or skin changes. Which one of the following is the most appropriate next step in management?

- [ ] A. Reassurance and observation
- [ ] B. Prolactin level measurement
- [ ] C. Nipple discharge cytology
- [ ] D. Mammography and ultrasound
- [ ] E. MRI of the breast

Explanation

The correct answer is:

• D. Mammography and ultrasound

Explanation: In a 45-year-old woman with spontaneous, unilateral, bloody nipple discharge, the most appropriate next step is to perform mammography and ultrasound. This aligns with Canadian guidelines for breast imaging in women ≥30 years with suspicious discharge. Mammography can detect calcifications or masses, while ultrasound can identify intraductal lesions. This approach provides a comprehensive evaluation of the breast tissue and helps rule out malignancy.

Options A (reassurance) and B (prolactin measurement) are inappropriate given the concerning nature of the discharge. Option C (nipple discharge cytology) has limited utility and is not recommended as a first-line investigation. Option E (MRI) may be considered if conventional imaging is inconclusive, but it is not the initial step in this scenario.

References

1. Canadian Association of Radiologists. (2016). CAR Practice Guidelines and Technical Standards for Breast Imaging and Intervention. https://car.ca/patient-care/practice-guidelines/ (opens in a new tab)

2. Golshan, M., & Iglehart, D. (2021). Nipple discharge. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA.

3. Koo, M. M., von Wagner, C., Abel, G. A., McPhail, S., Rubin, G. P., & Lyratzopoulos, G. (2017). Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis. Cancer Epidemiology, 48, 140-146.

4. Canadian Cancer Society. (2021). Breast cancer statistics. https://cancer.ca/en/cancer-information/cancer-types/breast/statistics (opens in a new tab)

5. Partridge, A. H., & Seah, D. S. E. (2019). Approach to the patient with a breast mass. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA.