Nipple Problems — Assessment & Management

Safety

Red Flags — Breast Cancer, Paget's Disease & Pituitary Emergency

Done

Bloodstained or serosanguineous unilateral nipple discharge Benign and malignant causes cannot be reliably distinguished clinically. → aged 50 and over: breast surgery suspected cancer pathway referral (NICE NG12); under 50: breast clinic referral via the local pathway. Do NOT squeeze nipple repeatedly. Refer first — specialist breast services arrange imaging and tissue diagnosis; do not delay referral to arrange mammography or ultrasound in primary care.

Persistent unilateral nipple eczema, scaling, erosion, ulceration, bleeding or distortion — especially starting at the nipple Paget's disease of the nipple (underlying DCIS or invasive breast cancer). Never assume benign without specialist review. → Refer urgently for breast assessment at any age when unilateral nipple eczema, erosion or scaling persists despite appropriate topical treatment. Use the suspected cancer pathway where the patient meets NICE criteria and the local breast pathway for other patients. Do not delay referral for a 3–4 week topical trial if the lesion is clinically suspicious, ulcerated, bleeding or associated with a lump. Specialist assessment and biopsy (not in primary care). Do not reassure solely because the rash resembles eczema.

Galactorrhoea + headache + visual field defect (bitemporal hemianopia) + amenorrhoea Prolactinoma compressing the optic chiasm. → New visual loss, bitemporal field loss, ophthalmoplegia/diplopia, severe acute headache, vomiting or reduced consciousness in suspected pituitary disease requires immediate emergency assessment, usually via the emergency department with urgent endocrine/neurosurgical and ophthalmological advice. Sudden severe headache with visual loss or reduced consciousness (possible pituitary apoplexy) → 999. A stable patient with suspected prolactinoma and no acute neurological deficit needs urgent endocrine assessment rather than 999.

New unilateral nipple retraction in an adult with no previous history of retraction Breast malignancy until proved otherwise. → aged 50 and over: breast surgery suspected cancer pathway referral even in the absence of a palpable mass; recent nipple distortion: aged 50 and over, suspected cancer pathway referral (NICE NG12 1.4.1: changes of concern in one nipple only), urgent breast referral at any other age; under 50 otherwise: breast clinic referral via the local pathway.

Male breast lump, nipple discharge, nipple retraction or concerning skin change Male breast cancer. → unexplained breast lump in men aged 30 and over (classically a unilateral firm subareolar mass, usually at 50 and over), with or without nipple distortion or skin change: breast surgery suspected cancer pathway referral (NICE NG12). Men aged 50 and over with a new concerning change in one nipple (discharge, retraction or other change): suspected cancer pathway — the NG12 criterion applies regardless of sex. Unexplained breast lump aged 30 and over: suspected cancer pathway (NG12 applies to men too). Other male nipple discharge, retraction or skin change: assess via the local breast pathway. Later diagnosis is common; prognosis relates mainly to stage and tumour biology.

Periareolar pain + swelling + fluctuance + discharge (non-breastfeeding) Subareolar abscess from periductal mastitis. → Arrange breast assessment and ultrasound the same or next working day — the same day if fluctuant, systemically unwell, rapidly progressive, severely painful or needing urgent drainage. A confirmed abscess usually requires aspiration or drainage; antibiotic choice should follow the local breast/antimicrobial pathway; culture any aspirated material. Suspected sepsis with high-risk features (NICE NG253) → 999. Not every stable abscess requires a 999 ambulance.

Paget's disease of the nipple is the most important differential to exclude in any persistent nipple dermatitis — it is DCIS or invasive carcinoma extending along lactiferous ducts to the nipple epidermis, mimicking contact or atopic eczema. Distinguishing features from benign eczema: strictly unilateral (bilateral rash is almost always contact dermatitis); starts at the nipple spreading to the areola (not vice versa); does not respond promptly to appropriate topical treatment; may have associated underlying breast lump or bloodstained discharge. A normal breast examination does not exclude Paget's disease or an intraductal lesion. The medicolegal principle: any persistent unilateral nipple rash that has not resolved promptly with appropriate topical treatment requires urgent breast referral at any age regardless of how benign it appears (suspected cancer pathway where NICE NG12 criteria are met; local breast pathway otherwise) — and a suspicious, ulcerated or bleeding lesion should be referred without waiting for a topical trial.

Diagnose

Classification of Nipple Problems

Done

Nipple discharge

Pathological (requires breast referral — suspected cancer pathway at 50 and over under NICE NG12; local breast clinic pathway under 50): unilateral, spontaneous (soaks clothes), bloodstained or serosanguineous, single duct, associated with lump or retraction. Spontaneous unilateral discharge from a single duct, particularly if bloody or serous, is more concerning than bilateral discharge expressed only after nipple manipulation. Bloodstained or serous unilateral discharge requires specialist assessment because benign (e.g. intraductal papilloma, duct ectasia) and malignant causes cannot be reliably distinguished clinically. Physiological: bilateral, milky, expressed only on squeezing, multiple ducts — common in reproductive-age women. Galactorrhoea: bilateral milky outside of pregnancy/breastfeeding — elevated prolactin (drug-induced most common). Duct ectasia: bilateral brown/green/multicoloured pasty discharge from multiple ducts with periareolar changes — suggestive of duct ectasia/periductal disease but does not exclude malignancy where there is unilateral persistence, an associated lump, nipple retraction, skin change or postmenopausal presentation.

Nipple skin disorders

Paget's disease: unilateral, starts at nipple, non-responsive to topical treatment. Contact/irritant dermatitis: bilateral, symmetric, areola more affected than nipple, responds to avoidance + mild topical steroid. Atopic eczema: associated with eczema elsewhere. Psoriasis: well-defined plaques. Nipple adenoma: benign but mimics Paget's — specialist assessment and biopsy required (not primary-care punch biopsy). Raynaud's of nipple (breastfeeding): colour change white-blue-red after feeding with intense burning pain — misdiagnosed as Candida.

Nipple retraction and inversion

Congenital (bilateral, since puberty): benign, no action unless functional problem with breastfeeding. New adult-onset unilateral retraction: suspected cancer pathway referral at 50 and over (urgent breast clinic referral via the local pathway under 50) — malignancy until proved otherwise. Recent nipple distortion: suspected cancer pathway referral at 50 and over (NICE NG12 1.4.1, one nipple only); urgent breast referral at any other age. Bilateral acquired: may be periductal mastitis fibrosis — but malignancy must still be excluded.

Galactorrhoea causes

Pregnancy and breastfeeding (exclude first). Drug-induced (most common pathological cause): antipsychotics (D2 antagonists — haloperidol, risperidone, amisulpride most potent), metoclopramide, domperidone, TCAs and other antidepressants, opioids, verapamil, methyldopa, oestrogens. Chest-wall stimulation/injury and repeated nipple expression. Prolactinoma: pituitary adenoma — microprolactinoma (<10 mm) or macroprolactinoma. Hypothyroidism: TRH stimulates prolactin. Chronic renal failure: reduced clearance. Idiopathic (mild elevation, no identifiable cause).

Bloodstained or serous unilateral discharge requires specialist assessment because benign causes (such as intraductal papilloma) and malignant causes cannot be reliably distinguished clinically — do not let a presumed benign cause falsely reassure. All patients with spontaneous unilateral bloodstained discharge require breast referral (suspected cancer pathway at 50 and over; local pathway under 50); specialist breast services arrange imaging and tissue diagnosis — the diagnosis cannot be made in primary care.

Diagnose

Assessment — History, Examination & Investigations

Done

History

Discharge: spontaneous vs expressed, unilateral vs bilateral, single duct vs multiple, colour (clear, milky, yellow, green, brown, bloodstained), duration. Associated: breast lump, pain, skin change. Nipple retraction: new or longstanding, unilateral or bilateral. Medications: antipsychotics, antiemetics (metoclopramide, domperidone), antidepressants (including TCAs), opioids, verapamil, methyldopa, oestrogens/OCP (all can raise prolactin). Chest-wall stimulation or injury, recent breastfeeding, repeated nipple expression. Menstrual: amenorrhoea (hyperprolactinaemia). Headache + visual change (prolactinoma). Fertility concerns. Smoking (periductal mastitis). Reproductive status: pregnant, breastfeeding, postpartum. PMH: previous breast disease or surgery.

Examination

Both breasts systematically. Nipple: shape (retracted, inverted), symmetry, skin changes (erosion, scaling — bilateral or unilateral, distribution). Do not repeatedly express the nipple to elicit discharge. If examination of the discharge is clinically necessary, use gentle, minimal pressure and document whether it is spontaneous or provoked, type, colour and single vs multiple ducts. Breast: both breasts, nipple and areola, all 4 quadrants + axillae; skin tethering, peau d'orange, erythema and ulceration; document exact side, site and characteristics of any lump. Cervical, axillary + supraclavicular lymphadenopathy. A normal examination does not exclude Paget's disease or an intraductal lesion. Visual fields by confrontation (if galactorrhoea); formal perimetry if a pituitary lesion is suspected or close to the optic chiasm. Thyroid examination.

Investigations

Pregnancy test (where relevant) · Serum prolactin (rested conditions — not immediately after nipple stimulation, breast examination, strenuous exercise or acute stress; repeat a modest elevation before imaging; interpret against the local laboratory reference range) · TFTs (hypothyroidism raises prolactin via TRH) · Renal function (where clinically indicated) · Liver function (where indicated) · Macroprolactin test (persistent mild/moderate elevation — macroprolactinaemia is biologically inactive) · MRI pituitary (usually arranged by endocrinology; no fixed prolactin threshold — guided by repeat level, mass-effect symptoms, medication causes, degree and persistence of elevation, and endocrine advice) · Breast imaging (arranged by the breast service after referral — do not delay referral to arrange mammography/USS in primary care) · LH/FSH + oestradiol (amenorrhoea + galactorrhoea workup)

Prolactin interpretation requires important caveats: a single elevated result can reflect macroprolactinaemia (biologically inactive complex of prolactin + IgG — detected by standard immunoassay but clinically insignificant), stress, or exercise-related transient elevation. Protocol: exclude pregnancy where relevant, review medication before changing it, and measure prolactin under rested conditions — not immediately after nipple stimulation, breast examination, strenuous exercise or acute stress. Repeat a modest elevation before proceeding to imaging; check TSH and renal function where indicated; consider macroprolactin in persistent mild/moderate elevation. There is no absolute MRI threshold — imaging is guided by the repeat level, symptoms of pituitary mass effect, medication causes, the degree and persistence of elevation, and endocrine advice. Interpret prolactin using the local laboratory reference range and clinical context.

Diagnose

Galactorrhoea Assessment & Periductal Mastitis

Done

Galactorrhoea systematic evaluation

TFTs (hypothyroidism — TRH stimulates prolactin release). Medication review (antipsychotics, metoclopramide, domperidone, antidepressants, opioids, verapamil, methyldopa, oestrogens — most common pathological cause in clinical practice). Pregnancy test (where relevant). Renal function (where indicated). Liver function (where indicated). Serum prolactin (repeat if mildly raised) + macroprolactin (see Step 3). MRI pituitary (generally arranged by endocrinology — guided by repeat level, headache, visual symptoms, hypogonadism or other pituitary features — no fixed threshold). Management by cause: drug-induced = medication review (do not stop or switch antipsychotics without the prescribing psychiatrist); hypothyroid = levothyroxine; suspected prolactinoma or persistent significant elevation = endocrinology referral; macroprolactinaemia = reassure (no treatment needed). New visual loss or field loss, double vision or severe headache = immediate emergency assessment via the emergency department (sudden severe headache with visual loss: 999 — see Step 1). Idiopathic mild elevation: follow endocrine advice.

Periductal mastitis (duct ectasia complex)

Strongly associated with smoking (squamous metaplasia of lactiferous ducts → secondary infection). Presentation: periareolar pain, erythema, nipple retraction (slit-like bilateral — unlike unilateral cancer retraction), thick pasty discharge (brown/green, multiple ducts). Subareolar abscess: fluctuant, hot, tender periareolar swelling — mixed anaerobic + gram-negative infection. Management: for non-lactational periductal mastitis without abscess, follow the local antimicrobial guideline — at the time of review the preferred regimen is co-amoxiclav 500/125 mg three times daily for 10–14 days (penicillin allergy: clarithromycin + metronidazole), subject to allergy, renal function, pregnancy, microbiology and local updates. Do not routinely add metronidazole to co-amoxiclav unless advised by the local guideline or microbiology team. Arrange review within 48–72 hours (sooner if worsening) and by 5–7 days if not clearly improving. Fluctuance or significant systemic illness → same-day breast service assessment for imaging, aspiration/drainage and culture (999 if suspected sepsis with high-risk features); recurrence or failure to improve → breast service referral. Smoking cessation is an important intervention because of its association with recurrent periductal mastitis. Persistent or recurrent non-lactational mastitis, especially in women over 40, requires breast assessment to exclude malignancy — do not rely on antibiotic response alone.

Raynaud's of the nipple

Vasospasm of nipple blood vessels in breastfeeding women — colour change (white → blue → red flushing) after feeding with intense burning/throbbing/shooting pain. Frequently misdiagnosed as Candida nipple infection (antifungal treatment ineffective). Evidence: published case series describe nipple Raynaud's being repeatedly misdiagnosed and treated as 'thrush'. Treatment: warm compress immediately after feeding; avoid cold and smoking. Nifedipine is an off-label treatment that may be considered after confirming the diagnosis and checking blood pressure, interactions with other vasodilators, breastfeeding status and alternative causes of nipple pain (trauma, infection). Evidence is limited; check current lactation advice and the local formulary.

Periductal mastitis recurrence is strongly predicted by smoking — cigarette smoke toxins (methylfurans) cause squamous metaplasia of lactiferous duct epithelium, disrupting the mucus-secreting lining and creating a nidus for ductal infection. Smoking is strongly associated with periductal mastitis and with recurrence, including after surgical duct excision. The GP should frame smoking cessation as a direct therapeutic intervention: 'Stopping smoking is the single most effective way to prevent this recurring — the chemicals in cigarettes directly damage the milk ducts.'

Refer

Referral Pathways

Done

Suspected cancer: breast surgery

NICE NG12: aged 50 and over + new unilateral nipple discharge, retraction or other concerning nipple change: suspected cancer pathway · Aged 30 and over + unexplained breast lump: suspected cancer pathway · Unilateral nipple eczema not responding to treatment or recent nipple distortion: aged 50 and over, suspected cancer pathway referral (NICE NG12 1.4.1 — discharge, retraction or other changes of concern in one nipple only); under 50, urgent breast referral on clinical grounds · Skin changes suggestive of breast cancer: consider suspected cancer pathway at any age · Male breast mass, especially firm subareolar mass in men aged 50 and over: suspected cancer pathway (men aged 50 and over with a concerning change in one nipple: suspected cancer pathway; other male nipple discharge, retraction or skin change: local breast pathway). Under 50 with other nipple change alone: urgent breast clinic via the local pathway. Do not arrange mammography/ultrasound before referral.

Same-day urgent

Same-day breast/hospital assessment: suspected abscess with fluctuance, systemic illness or need for urgent drainage · suspected sepsis (999 if high-risk features, NICE NG253) or rapidly progressive breast infection · severe pain or tissue compromise. Galactorrhoea with acute visual loss, bitemporal field loss, ophthalmoplegia, severe headache, vomiting or reduced consciousness → emergency department (urgent endocrine/neurosurgical and ophthalmological advice), not breast unit. Stable suspected prolactinoma without acute neurological deficit → urgent endocrinology, not 999.

Endocrinology

Suspected pituitary disease or confirmed prolactinoma. Persistent unexplained hyperprolactinaemia on repeat testing (interpreted against the local laboratory range), symptomatic hypogonadism, markedly raised prolactin, or when the causative drug cannot be stopped. Thresholds are not absolute: drug-induced elevation can occasionally be substantial, a large pituitary lesion may cause only modest elevation (stalk effect or assay interference), and very high results can rarely be under-read (hook effect).

GP management

Bilateral milky expressed discharge + normal prolactin: physiological, reassure. Drug-induced galactorrhoea: medication review (antipsychotic changes only with the prescribing psychiatrist). Bilateral contact nipple dermatitis: remove allergen + mild topical corticosteroid. Periductal mastitis without abscess: antibiotics per local antimicrobial guideline + review within 48–72 hours (and by 5–7 days if not clearly improving) + smoking cessation.

Local pathways

Use the current local breast-service, endocrinology and GUM referral pathways.

NICE NG12 (updated April 2026) sets the suspected cancer pathway threshold for nipple symptoms at age 50 and over with discharge, retraction or other changes of concern in one nipple only; skin changes suggestive of breast cancer also warrant consideration of referral. Below 50, unilateral spontaneous or bloodstained discharge is referred to the breast clinic under local pathways rather than an NG12 criterion. Bilateral expressed milky discharge with no other features in a non-pregnant, non-breastfeeding woman does not automatically require suspected cancer pathway referral — it requires prolactin testing and investigation for physiological or drug-induced causes. This distinction prevents unnecessary suspected cancer pathway referrals for physiological galactorrhoea while ensuring that all potentially pathological discharge receives timely specialist assessment.

Treat

Hyperprolactinaemia (Specialist-led) & Periductal Mastitis

Done

Prolactinoma — endocrinology management

Confirmed prolactinoma requires endocrinology management. Cabergoline dosing, prolactin monitoring, pituitary imaging and pregnancy planning should follow the endocrinology plan and current SPC — cabergoline should not be started or dose-titrated from this primary-care pathway. Before and during treatment: confirm pregnancy status where relevant; do not prescribe in pregnancy without specialist advice; counsel about nausea, dizziness, postural hypotension and headache, and rare psychiatric effects (mood disturbance, psychosis, impulse-control symptoms); review interacting medicines and hypotension risk. GP continuation only under the current local shared-care agreement. Echocardiography: the MHRA advises baseline echocardiography and ongoing monitoring for fibrotic/valvular reactions; a UK joint position statement (British Society of Echocardiography, British Heart Valve Society and Society for Endocrinology, 2019) proposes less frequent monitoring at prolactinoma doses — these approaches differ, so follow the current local endocrinology protocol. Fertility may return quickly, sometimes before menstruation normalises: discuss contraception if pregnancy is not desired. Anyone planning pregnancy or who becomes pregnant should contact the endocrine team promptly — cabergoline should not be stopped or continued automatically by primary care.

Drug-induced hyperprolactinaemia

Most common antipsychotics: haloperidol, risperidone, amisulpride (most potent D2 blockers); quetiapine and aripiprazole (lowest prolactin-raising profile). Do not stop or switch antipsychotic treatment without discussion with the prescribing psychiatrist. If symptomatic hyperprolactinaemia is suspected, discuss alternatives with psychiatry/endocrinology. Dopamine agonists may worsen psychosis and should be specialist-led. Metoclopramide + domperidone: prescribe short-term only — not for chronic use (prolactin elevation + movement disorder risk at long-term doses).

Periductal mastitis — antibiotics & escalation

Treat uncomplicated non-lactational periductal mastitis according to the local antimicrobial guideline (currently co-amoxiclav 500/125 mg three times daily for 10–14 days; penicillin allergy: clarithromycin + metronidazole; do not routinely add metronidazole to co-amoxiclav) — choice depends on severity, abscess versus cellulitis, lactational versus non-lactational mastitis, allergy, microbiology and need for drainage. Review within 48–72 hours. Fluctuance or significant systemic illness → same-day breast service assessment for imaging, aspiration/drainage and culture (999 if suspected sepsis with high-risk features); recurrence or failure to improve → breast service referral. Review again by 5–7 days if not clearly improving. Recurrent or persistent: breast unit referral for assessment and consideration of duct excision; in patients over 40, do not repeatedly treat persistent inflammation without excluding malignancy. Smoking cessation is a key treatment intervention.

Dopamine-agonist treatment of prolactinoma — including starting, titration, monitoring, imaging schedules and any withdrawal — is specialist-led and follows the endocrinology plan and current SPC. The GP role is to recognise hyperprolactinaemia, exclude pregnancy, medication, hypothyroid and renal causes, repeat modest elevations, escalate visual or severe headache symptoms urgently, and refer persistent significant elevation or suspected prolactinoma to endocrinology.

Treat

Breastfeeding Nipple Problems & Skin Disorders

Done

Breastfeeding nipple pain — approach

Latch assessment first (most common cause): refer to lactation consultant (IBCLC) + health visitor. Tongue tie assessment (see the postnatal disorders protocol). Candida nipple infection (over-diagnosed): only if infant has oral thrush OR burning persists between feeds OR clearly burning within the breast. Do not diagnose nipple Candida solely from burning pain or a shiny nipple — assess latch, trauma, vasospasm, dermatitis and infant oral findings. Diagnosis is clinical; treatment of mother and/or infant (not automatically both) should follow the current local infant and breastfeeding formulary; miconazole oral gel in infants must be prescribed and administered according to the current product information and local paediatric guidance because of choking risk. Avoid routine systemic fluconazole without specialist or breastfeeding-medicine advice. Misdiagnosis delays treatment of Raynaud's or latch issues.

Raynaud's of nipple

Warm compress immediately after each feed. Avoid cold environments, smoking, caffeine. Nifedipine is off-label and may be considered after confirming the diagnosis and checking blood pressure, interactions with other vasodilators, breastfeeding status and alternative causes of nipple pain — do not start it for any nipple colour change without excluding trauma, infection and other causes. Evidence is limited and largely observational. Modified-release 30 mg once daily is one possible regimen — check the local formulary and current lactation advice, and monitor the infant. Check for dizziness, flushing and hypotension. Persistent symptoms: review latch, trauma, dermatitis and infection.

Nipple skin disorders — management

Contact/irritant nipple dermatitis: identify and remove allergen (fragranced soaps, shower gels, laundry detergent, certain breast pads). Hydrocortisone 1% cream BD x 2-4 weeks if inflammatory. Avoid topical steroid treatment as a prolonged diagnostic trial when the change is unilateral, persistent, erosive, bleeding or associated with nipple distortion — refer rather than repeatedly escalating topical treatment. If persisting: patch testing (dermatology). Atopic nipple eczema: treat as eczema (emollient + mild-moderate topical corticosteroid). Psoriasis: mild topical corticosteroid + calcipotriol (as for skin psoriasis). Nipple adenoma, erosive nipple disease and persistent unilateral dermatitis require specialist assessment and biopsy (not primary-care punch biopsy). Any persistent unilateral nipple skin change: urgent breast referral at any age (suspected cancer pathway where NICE criteria are met) regardless of clinical impression.

Next steps: see Benign breast disorders · Mastitis and breast abscess · Breast cancer · Raynaud's phenomenon

The nipple Candida misdiagnosis in breastfeeding is well-documented — published case series describe Raynaud's phenomenon of the nipple as a frequent cause of burning breastfeeding pain that had been labelled and treated as thrush. Do not diagnose nipple Candida solely from burning pain or a shiny nipple. The diagnostic principle: Candida nipple infection should only be diagnosed with corroborating evidence — visible oral thrush in the infant; positive nipple swab; or burning pain that persists between feeds AND within the breast tissue (ductal spread). Nipple surface pain only occurring during feeding is not Candida.

Lifestyle

Breast Awareness, Screening & Prevention

Done

Breast awareness Encourage breast awareness and prompt assessment of any new persistent change (shape, size, skin texture, nipple appearance) — no rigid monthly self-examination technique. Breast Cancer Now (breastcancernow.org): excellent patient leaflets for self-examination technique.

NHS breast screening programme Follow the current NHS Breast Screening Programme and local familial-breast-cancer service criteria (NICE CG164). The programme routinely invites women aged 50 to 71 every 3 years; women over 71 are not automatically invited but can self-refer to the NHS Breast Screening Programme (not GP-organised screening). Familial-risk surveillance (e.g. annual MRI aged 30–49 for BRCA1/BRCA2 carriers and aged 20–49 for TP53 carriers) is arranged by specialist genetics/familial breast cancer services using validated risk assessment (e.g. CanRisk/BOADICEA), not by the GP; MRI is not routinely offered to everyone with a family history. Do not use screening eligibility to determine investigation of symptoms — symptomatic patients require diagnostic assessment regardless of screening status.

Alcohol and breast cancer risk Alcohol increases breast cancer risk. Mechanism: acetaldehyde (DNA-damaging), increased circulating oestrogens. Support reduction to no more than 14 units per week, spread over 3 or more days (UK Chief Medical Officers' advice). Advise reduction in all patients with breast concerns or breast cancer history.

Smoking cessation for breast health Smoking is associated with periductal mastitis (direct causal link), modest breast cancer risk increase, poor wound healing after breast surgery. NHS Stop Smoking Services at every breast-related consultation.

Periductal mastitis patient education Do not squeeze the nipple repeatedly (perpetuates discharge). Keep periareolar skin dry and clean. Wide-fit, non-underwired bra or sports bra during flares. Smoking cessation is the most important preventive intervention. Teach recognition of abscess signs (rapidly increasing swelling, fluctuance, fever) — return to GP or breast unit same day.

Galactorrhoea patient education Do not repeatedly stimulate the nipples to check for discharge — nipple stimulation raises prolactin and perpetuates galactorrhoea. If drug-induced: explain which medication and why. If prolactinoma: treatment, imaging and pregnancy planning are managed by endocrinology. Fertility can return quickly on treatment — use contraception if pregnancy is not desired, and contact the endocrine team promptly if planning pregnancy or pregnant.

Bra support and nipple chafing Correctly fitted bra reduces repetitive nipple trauma in physically active women. Sports bra: essential for high-impact exercise. Nipple guards/protectors (Body Glide, Nip Guard): for runners experiencing friction nipple chafing. Professional bra fitting after pregnancy, significant weight change, or breast surgery.

Hormone replacement therapy and breast disease Risk varies by age, duration, formulation, baseline risk and whether oestrogen is used alone or with a progestogen — use current NICE NG23 Menopause and shared menopause guidance for individualised counselling. HRT is not contraindicated solely because of benign nipple or breast disease. Discuss breast-cancer risk using NICE NG23, taking account of age, formulation, duration and family history. Previous breast cancer: specialist advice required.

The breast self-awareness approach has largely replaced formal monthly self-examination as the recommended strategy in UK public health guidance — Breast Cancer Now and NHS public health advice now encourage women to be familiar with how their breasts look and feel throughout the month (including normal variation with the menstrual cycle) rather than following a rigid monthly protocol. The rationale: rigid monthly examination can cause anxiety and false reassurance (not finding a 'lump' at the exam may lead to dismissing a subtle change noticed at another time). The self-awareness message is: 'Know your normal — report any new persistent change to your GP promptly.' This is the message GP consultations should reinforce at every breast-related contact.

Safety

Follow-Up & Safety-Netting

Done

Awaiting breast suspected cancer appointment

Check the referral has been received and an appointment offered. If symptoms worsen before appointment (increasing discharge, new lump, rapid progression): contact breast unit same day. Document: referral date, clinical basis, patient safety-netted.

Prolactinoma monitoring

During dose titration, monitor prolactin at intervals agreed with endocrinology. Repeat pituitary MRI according to tumour size, symptoms and biochemical response — routine indefinite annual MRI is not required for every stable microprolactinoma. Long-term imaging, dose changes and any withdrawal trial are endocrinology-led. New visual loss or field loss, double vision or severe headache → emergency department the same day (sudden severe headache with visual loss: 999 — see Step 1).

Periductal mastitis follow-up

Review within 48–72 hours (and by 5–7 days if not clearly improving): response to antibiotics, abscess forming? Fluctuance or systemic illness → same-day breast service assessment for imaging, aspiration/drainage and culture (999 if suspected sepsis with high-risk features); failure to improve → breast service referral. Smoking cessation documented. If recurrent: breast unit referral (duct excision). In women over 40: malignancy must be excluded in any persistent or recurrent breast inflammation.

Suspected cancer

Aged 50 and over (one nipple only): unilateral discharge, retraction or other concerning change · Unexplained breast lump aged 30 and over · Male unexplained breast lump aged 30 and over, e.g. a firm subareolar mass (the one-nipple criterion at 50 and over applies to men too). Unilateral nipple eczema not responding to treatment or recent nipple distortion: suspected cancer pathway at 50 and over (NG12 1.4.1), urgent breast referral under 50 · Any age, urgent breast referral: skin changes suggestive of breast cancer. Under 50, other nipple change alone: breast clinic via the local pathway.

Urgent same-day breast unit

Suspected abscess with fluctuance, systemic illness or need for urgent drainage · Suspected sepsis (999 if high-risk features, NICE NG253) or rapidly progressive breast infection · Severe pain or tissue compromise. Galactorrhoea with acute visual loss, bitemporal field loss, ophthalmoplegia, severe headache, vomiting or reduced consciousness: emergency department, not breast unit.

The unilateral vs bilateral rule in nipple assessment is the single most rapid discriminating principle — unilateral nipple symptoms have a significantly higher probability of structural or malignant pathology and require breast referral (suspected cancer pathway at 50 and over); bilateral symptoms are far more likely to be physiological, drug-related, or hormonal. This is a simple, rapid screening question that should be the first assessment in any nipple problem: 'Does this affect one breast or both?' — and the answer should direct the consultation immediately.