Nipple Discharge History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today about the discharge you have noticed from your nipple(s). I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presenting, for example, “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE), to pick up on later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

Examples of open questions here would be: “What does this discharge look like?” or “Have you noticed any other symptoms alongside the discharge?” Examples of closed questions include: “Is the discharge white?” or “Have you felt any lumps?”

When taking a history of nipple discharge, it may be useful to think about the following structure for your questions, as well as what useful information the patient’s answers give you about the likely diagnosis:

• Site – is the discharge unilateral or bilateral? If unilateral, which breast is involved? Physiological or systemic causes of nipple discharge (e.g., lactation or galactorrhoea of any cause) generally present as bilateral nipple discharge. Unilateral discharge usually has a more localised cause (e.g., mammary duct ectasia, intraductal papilloma). Unilateral nipple discharge in a patient over 50 years old warrants urgent referral for further investigation.
• Onset – when did the discharge start? Is there a physiological process occurring which may explain the discharge (e.g., the third trimester of pregnancy and the production of colostrum in preparation for breastfeeding)? How long has the discharge been present?
• Character – what type of discharge is being produced? Does it look milky (e.g., physiological lactation, or galactorrhoea), greenish (mammary duct ectasia), watery, or blood-stained (intraductal papilloma)?
• Associated symptoms – has the patient experienced any other symptoms alongside the nipple discharge? 
• Timing – is the discharge spontaneous, or only present when the nipple is squeezed? Discharge that occurs only when the nipple is squeezed is generally less associated with underlying pathology than discharge occurring spontaneously.
• Exacerbating & relieving factors – does anything make the symptoms better or worse? Is the patient able to express more discharge if they squeeze the nipple?

System-specific History

After obtaining further details of the presenting complaint, you need to gather any relevant system-specific information. In this case, the system in question is the breast. 

Consider symptoms that may occur alongside nipple discharge, and ask about these specifically. 

It is important not only to ask about these symptoms, but also to consider why their presence or absence is significant in narrowing the differential diagnosis. 

Symptoms related to the breast to enquire about include, but are not limited to:

• Breast lumps – it is very important to determine whether the patient has noticed any lumps on self-examination, and to examine all patients presenting with nipple discharge. The presence of breast lumps alongside nipple discharge increases the risk of underlying sinister pathology (e.g., malignancy) and warrants urgent referral for further investigation.
• Skin changes – puckering, tethering, thickening, dimpling, or a peau d’orange appearance are all concerning for malignancy and warrant further assessment. Eczematous skin around the nipple or areola may be associated with watery or weepy nipple discharge and could represent Paget’s disease of the nipple.
• Nipple changes – has the patient (or anyone else) noticed any nipple changes, e.g., inversion that is new for them? Inversion may be present in mammary duct ectasia due to ductal dilatation and shortening, but is also a concerning symptom for malignancy and warrants urgent referral to breast services. 
• Breastfeeding – is the patient breastfeeding, or are they pregnant? The production of colostrum is a normal physiological change that occurs towards the end of pregnancy as the body prepares for breastfeeding.

Red Flags

It is important to ask about symptoms that may lead you to consider more sinister causes of nipple discharge in the differential diagnosis, which may require more urgent investigation and management, e.g., malignancy. 

Some of these symptoms have been covered in the sections above, but are listed below for clarity.

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information, as they might find the symptoms worrying or may lack the same insight into the significance as you do. 

Red flag symptoms to screen for when taking a history of nipple discharge include:

• Breast lumps – any patient over the age of 30 presenting with a breast lump should be referred urgently to rule out breast malignancy.
• Nipple retraction or inversion – anyone over 50 with unilateral nipple retraction or inversion should be referred urgently  to rule out malignancy.
• Unilateral discharge – any patient over 50 with unilateral nipple discharge should be referred urgently.
• Age – as above, patients aged greater than 50 years old presenting with unilateral nipple discharge meet the criteria for an urgent referral.
• Weight loss – a non-specific symptom, but if unexplained it could indicate malignancy.

Relevant Systems Review

A systems review is a useful tool to ensure no key information from the history has been missed. However, it is important to consider which systems are relevant to review, so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of nipple discharge include the following:

• Endocrine – galactorrhoea is a symptom of hyperprolactinaemia. Endocrine causes of hyperprolactinaemia include prolactinoma and hypothyroidism. High prolactin levels, in turn, suppress GnRH, so it is important to ask about symptoms such as low libido, oligo- or amenorrhoea, and hirsutism in females, and gynaecomastia, low libido, and erectile dysfunction in males. 
• Neurological – if a prolactinoma is present and large enough to cause local compression of surrounding structures, the patient may experience headaches or visual changes (bitemporal hemianopia). 

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing this discharge?”
• Concerns – “Is there anything that is worrying you about this?” “Have you read or Googled anything about your symptoms that has made you anxious?”
• Expectations – “Was there anything specific you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of nipple discharge. For example, a patient who is perimenopausal and presents with green unilateral nipple discharge may have mammary duct ectasia. A patient with known multiple endocrine neoplasia type 1 (MEN1) is at increased risk of developing a prolactinoma. 

Patients who have previously had breast cancer may be at risk of recurrence, and will almost certainly be worried about this if they develop new breast-related symptoms including nipple discharge. 

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer e.g., over-the-counter medications, herbal or alternative remedies, contraception, HRT, or injections such as B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis. For example, consider a patient who presents with nipple discharge and has recently started a medication associated with hyperprolactinaemia, such as an antipsychotic.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, other than their presenting complaint. Consider asking the following:

• Who do they live with? Do they have a social support network they could depend on if they were to receive a life-changing or life-limiting diagnosis, e.g., malignancy?
• Do they work? Is the patient going to require time off work to attend appointments, investigations, or treatment?
• Do they drive? Does their condition affect their ability to drive or to attend appointments?
• Do they smoke? Smoking is associated with mammary duct ectasia and with increased risk of malignancy.
• Do they drink alcohol?
• Do they use recreational drugs?

Family History

Does anyone in the family have any breast conditions, e.g., breast cancer? Patients may ask whether they are at increased risk of breast cancer due to a positive family history. It is worth familiarising yourself with the criteria that define increased risk of familial breast cancer, which may prompt discussion about referral for genetic counselling.

Do any other health conditions run in the family?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation and imaging.

Last updated May 2025

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