Nipple Discharge – Watery – A Medical Anecdote – Learning Notes and Recommendations – 12oct14

October 11, 2012, Ms. CL came for her usual check-up with me for her watery nipple discharge.

Ms. CL is now 57 years old.  The first time she consulted me in 1998, she was 42 years old.  She has been having a breast check-up with me for the past 15 years for watery nipple discharge on her right breast.

A year before she consulted me in 1998, she was seeing an obstetrician-gynecologist who prescribed her bromocryptine mesylate (Parlodel) and danazole (Ladogal) with no response.  She also had serum prolactin test done which was normal.  She also had mammography which showed no abnormal findings.

When I saw her in 1998, I gave a diagnosis of watery nipple discharge related to fibrocystic breast changes.  She had no palpable breast mass.  I told her that there was no need to take any medicine, just monitoring and check-up.   I told her the discharge may not disappear.  What is more important is that there is no change in color to red and there is no development of a breast mass.

She has no family history of breast cancer.

For the past 15 years, she has been doing monthly breast self-examination.  She has been regularly coming to me at an interval of every 3 to 4 months for the past 15 years.  She does not want a mammography even when she reached the age of 50.   I respected her wish.  She does not want the pain associated with mammogram.  She trusts and prefers my gentle clinical breast examination over a mammogram.

The watery nipple discharge is still there, 16 years after it appeared.  There has not been any change in the color of the nipple discharge.  There is no development of a breast mass.

Learning Notes and Recommendations:

1.  In patients with watery nipple discharge without a dominant breast mass, my recommended primary clinical diagnosis is watery nipple discharge related to a fibrocystic breast condition.

2. Management will just be monitoring and check-up.   There is no need for drugs such as bromocryptine mesylate (Parlodel) and danazole (Ladogal) as they are not effective and are very expensive (more than P100 per tab with the patients spending thousands of pesos for the “trial” course).  There is no need to have a serum prolactin test done unless there are data in the history and physical examination findings that suggest a prolactin secreting tumor.  There is no need for a diagnostic imaging procedure like mammography and ultrasound unless there is uncertainty on whether a dominant mass is present or not.

3. Monitoring and check-up includes at least monthly breast self-examination on the part of the patient and regular breast specialist clinical breast examination at planned intervals.

4. Things to monitor include change in the color of the nipple discharge (red color is a red flag) and development of a dominant mass (another red flag).



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