A 28-year-old woman comes to the office for evaluation of nipple discharge. The patient has had bilateral yellow nipple discharge for the past month. She has gained 5 lb (2.3 kg) in the past year. The patient has had no missed menses, and her last menstrual period was 2 weeks ago. She takes sertraline for anxiety and depression. The patient's mother had breast cancer at age 59. She does not use tobacco, alcohol, or illicit drugs. BMI is 29 kg/m². Blood pressure is 122/74 mm Hg and pulse is 78 /min. On examination, there is dense breast tissue with no palpable dominant masses. The breasts are nontender and the nipples have bilateral white-yellow crusting. There is no axillary or clavicular lymphadenopathy. The remainder of the physical examination is unremarkable. Urine pregnancy test is negative. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d98a_77f9_bc81_b7d926d87c0e_MD0003_00 Nipple discharge is a common finding in women of reproductive age and can be either physiologic (ie, galactorrhea) or pathologic (ie, malignancy), which are classified and managed based on discharge characteristics and clinical breast examination. Patients with pathologic discharge features (eg, bloody or unilateral discharge) or nipple discharge plus an abnormal breast examination (eg, palpable mass, lymphadenopathy, skin/nipple changes) are at higher risk for an underlying malignancy. These women require breast imaging with either breast ultrasound (age <30) or mammogram plus ultrasound (age ≥30) (Choice D). Men with pathologic nipple discharge also require mammography plus ultrasound regardless of age due to higher risk for malignancy. In contrast, patients with bilateral, nonbloody nipple discharge and a normal breast examination likely have physiologic nipple discharge (ie, galactorrhea). In these patients, the risk of malignancy is low, so typically no breast imaging is indicated. However, galactorrhea can be an adverse effect of endocrine disorders (eg, hyperprolactinemia, hypothyroidism), medication use (eg, antipsychotics), and excessive breast/nipple stimulation. Therefore, these patients require evaluation with prolactin and TSH levels and pregnancy testing. This patient has bilateral, nonbloody nipple discharge with a normal clinical breast examination and laboratory evaluation; therefore, she requires no additional management other than routine breast screening. Premenopausal women can have transient idiopathic galactorrhea that is benign and typically self-resolves. (Choice A) Core needle biopsy is indicated in patients with a suspicious breast mass (determined by examination and/or imaging). It is not indicated for galactorrhea because the risk of malignancy is low. (Choice B) Cytologic evaluation is generally not recommended for nipple discharge because it has low sensitivity and specificity for malignancy. (Choice C) Although some antipsychotic medications (eg, risperidone, haloperidol) cause galactorrhea by inhibiting dopamine, SSRIs (eg, sertraline) are not typically associated with nipple discharge because they do not affect dopamine receptors. (Choice E) MRI of the pituitary may be needed in patients with elevated prolactin and/or symptoms of a pituitary mass (eg, vision disturbances, headaches). This patient's prolactin level is normal. Educational objective: Nipple discharge can be physiologic (ie, galactorrhea) or pathologic (eg, bloody, unilateral, abnormal breast findings). Bilateral, nonbloody nipple discharge is typically physiologic and requires prolactin and TSH levels and pregnancy testing. Patients with a normal laboratory evaluation require no additional management because the risk of malignancy is low. References: Evaluation and management of galactorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/22962879) Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023)

A 28-Year-Old Woman Comes to the Office for Evaluation of Nipple