Nipple discharge is any fluid that comes from the nipple outside the normal context of late pregnancy or breastfeeding. It can be a single drop noticed on the bra, a stain on a nightdress, or a fluid that appears only when the nipple is squeezed. The honest first message is that most nipple discharge is benign — fewer than one in ten cases turn out to be cancer — and the right response is to characterise it carefully and then decide if it needs evaluation, not to assume the worst.

Four questions describe a discharge usefully. What colour is it (milky, clear, yellow, green, brown, bloody, pus)? Is it from one breast or both? Is it from a single duct opening on the nipple or from several openings? And does it appear spontaneously (staining your bra without touching) or only when the breast is squeezed? Spontaneous, single-duct, single-breast and bloody or clear-watery discharge is the combination that needs urgent OB or breast-surgeon review.

Bilateral discharge from multiple ducts that only appears when the breast is squeezed is almost always benign and usually hormonal or a normal variant. Knowing the difference between these two patterns is what separates a worry that can wait for a routine clinic visit from one that needs same-week evaluation.

Pregnancy and breastfeeding are the obvious physiological causes. From the second trimester onwards the breasts begin to produce small amounts of clear or milky fluid called colostrum, and a few drops on the bra or when the nipple is touched are entirely normal. During breastfeeding and for several months after weaning the breasts continue to produce milk on stimulation; small amounts of milky discharge for up to a year after stopping breastfeeding is normal and does not need investigation.

Galactorrhoea is the term for milky discharge in a woman who is not pregnant or breastfeeding, and it is usually driven by raised prolactin (the milk-producing hormone). Common causes are certain medications — antipsychotics like haloperidol and risperidone, antidepressants, metoclopramide for nausea, some blood-pressure tablets, and combined oral contraceptive pills — physical stimulation of the nipple (sexual or repeated clinical examination), and hypothyroidism which can raise prolactin indirectly.

Perimenopausal hormone shifts in the years before menopause can cause small amounts of clear or yellowish discharge from both breasts that is not associated with any abnormality. Tight clothing repeated friction and even vigorous chest exercise can occasionally cause small amounts of discharge that is not pathological.

Milky white discharge suggests galactorrhoea and a possible prolactin issue, especially if it is bilateral and from multiple ducts and the woman is not pregnant or breastfeeding. A prolactin blood test (around 150 to 400 rupees in most Indian labs) is the next step. Yellow, green or brown discharge that is thick and from multiple ducts in both breasts is most often duct ectasia — a benign widening of the ducts under the nipple that is common after age forty — and usually needs only reassurance.

Bloody or serous (clear watery, often slightly straw-coloured) discharge is the colour combination that needs urgent evaluation. The commonest cause is an intraductal papilloma — a small benign growth inside a single duct — which is not cancer but does need a breast clinic assessment, and a smaller proportion of bloody discharge can be from an early ductal cancer that is otherwise too small to feel.

Clear watery discharge from a single duct is treated similarly and needs evaluation. Pus-like yellow or green discharge with redness pain and warmth of the breast points to mastitis or a breast abscess and needs same-day treatment with antibiotics.

Five features turn nipple discharge from a routine concern into a same-week OB or breast-surgeon appointment. First, bloody or serous (clear watery) discharge of any amount. Second, discharge from a single duct opening on the nipple rather than from several openings. Third, discharge from only one breast rather than both. Fourth, spontaneous discharge that stains the bra or appears without any squeezing or stimulation. And fifth, any new nipple discharge in a woman who has gone through menopause.

A nipple discharge that comes with a lump in the same breast, skin changes (dimpling, puckering, an orange-peel appearance), nipple retraction that is new, or persistent breast pain in one specific area is also a clear reason for urgent evaluation. The combination of single-duct single-breast spontaneous bloody discharge with a lump is the highest-risk pattern and needs an urgent breast clinic referral.

These red flags do not mean cancer — most still turn out to be a benign papilloma or duct ectasia — but they need the structured workup of a clinical breast exam, an ultrasound (and a mammogram if over forty), and sometimes a cytology of the discharge or a biopsy of any associated lump. For lump-specific evaluation see Breast Lump — When to Worry vs Benign Causes: An Indian Women's Guide.

Milky discharge in a woman who is not pregnant or breastfeeding is called galactorrhoea, and the standard workup centres on prolactin. A urine pregnancy test comes first because early pregnancy is the commonest cause of new milky discharge and needs to be ruled out before any other investigation. A serum prolactin test (around 150 to 400 rupees) measures the milk-producing pituitary hormone. TSH (around 150 to 400 rupees) is checked at the same time because hypothyroidism is a common silent cause of raised prolactin.

Medication review is the next step. The OB will ask about antipsychotics (haloperidol risperidone olanzapine), antidepressants, metoclopramide for nausea, some blood-pressure tablets including methyldopa and verapamil, opioids, combined oral contraceptive pills, and certain Ayurvedic preparations. Stopping or switching a culprit drug usually resolves the discharge over a few weeks, but any medication change should be done with the prescribing doctor rather than independently.

If prolactin is normal and there is no medication cause the diagnosis is often idiopathic galactorrhoea — a benign hormonal sensitivity that needs only reassurance. For broader prolactin information see High Prolactin in India: A Quiet Cause of Missed Periods and Difficulty Conceiving.

A small benign tumour of the pituitary gland called a prolactinoma is the most important cause of significantly raised prolactin to know about, because it has specific treatment. The combination that raises suspicion is galactorrhoea plus missed periods (amenorrhoea), persistent headaches, or visual changes (especially loss of the outer side of vision in both eyes from pressure on the optic nerves). Infertility from anovulation is another common presentation.

If prolactin is significantly raised (typically more than three to four times the normal upper limit), an MRI of the pituitary (around 6000 to 12000 rupees with contrast in private centres, free in AIIMS and major government hospitals) is the next step. An endocrinologist at Apollo Fortis Manipal Max or in the AIIMS network handles the diagnosis and treatment.

The treatment is medical, not surgical, for almost all prolactinomas. Cabergoline (Cabgolin) at 0.5 mg once or twice a week is the standard first-line and costs around 150 to 500 rupees a month; bromocriptine (around 100 to 300 rupees a month) is the older alternative. Treatment usually shrinks the tumour and restores periods within months.

Yellow, green or pus-like discharge from a nipple, combined with a breast that is red warm painful and tender to touch, points to mastitis — an infection of the breast tissue. Mastitis is commonest during breastfeeding but can occur in non-breastfeeding women too, especially around a cracked nipple, a skin infection, or rarely in association with smoking and the periductal mastitis of older women.

The treatment is warm compresses to the affected area three to four times a day, continued breastfeeding from the affected side if applicable (which actually helps clear the infection), paracetamol for pain and fever, and antibiotics. Amoxicillin-clavulanate (Augmentin, around 200 to 400 rupees for a course) or dicloxacillin (around 100 to 200 rupees) are the standard first-line antibiotics for seven to ten days.

If a hard tender lump develops, fever stays high despite antibiotics, or the area becomes fluctuant (feels like a fluid-filled bag), a breast abscess has formed and needs ultrasound-guided drainage by a breast surgeon. For breastfeeding-related mastitis and blocked ducts see Mastitis and Blocked Ducts While Breastfeeding in India: How to Spot It, Treat It and Keep Feeding Safely.

The OB or breast surgeon will start with a careful history (what colour what side single or multiple ducts spontaneous or expressed any lump any pregnancy or breastfeeding any medications any periods change) and a clinical breast examination of both breasts and the underarms. The discharge itself may be sent for cytology — a slide examination of any cells in the fluid — although the test is more useful for suggesting a benign cause than for ruling out cancer.

An ultrasound of the breast (around 500 to 1500 rupees in private centres, free in government hospitals) is the standard imaging test for women under forty and for any age with a focal area of concern. A mammogram (around 800 to 3000 rupees) is added for women over forty or with strong family history of breast cancer. A ductogram (a contrast study of the affected duct) is occasionally used but has been largely replaced by ultrasound and MRI.

If a lump is found, fine-needle aspiration cytology (FNAC, around 500 to 1500 rupees) or a core needle biopsy gives a tissue diagnosis. For bloody single-duct discharge with no visible lump, a microdochectomy — surgical removal of the affected single duct — is both diagnostic and curative for a papilloma.

The full workup for nipple discharge in India is meaningfully affordable in both private and government systems. Prolactin and TSH cost around 150 to 400 rupees each at most accredited labs (Thyrocare Dr Lal PathLabs SRL Metropolis). A breast ultrasound costs around 500 to 1500 rupees in private centres and is free in government hospitals. A mammogram costs around 800 to 3000 rupees in private centres. An MRI of the pituitary with contrast costs around 6000 to 12000 rupees in private centres and is free in AIIMS.

Cabergoline (Cabgolin) for raised prolactin costs around 150 to 500 rupees a month at standard doses; bromocriptine is around 100 to 300 rupees a month. An endocrinology consultation in Apollo Fortis Manipal Max or AIIMS-network private wing costs around 800 to 3000 rupees. A breast surgeon consultation at Tata Memorial Apollo Cancer Centre or HCG runs in a similar range.

The public-system pathway begins with the ASHA worker who refers to the local PHC or CHC, which can arrange a free breast ultrasound and refer onwards to the district hospital or a regional cancer centre. Tata Memorial in Mumbai and the AIIMS network run free or subsidised breast clinics for women who cannot afford private care.

The reassuring pattern is nipple discharge that is from both breasts, from multiple ducts, only appears when the breast is squeezed, is yellow green or brown rather than bloody or clear-watery, and is not associated with any lump or skin change. This pattern is overwhelmingly benign (duct ectasia, perimenopausal change, normal hormonal variant) and a routine clinic visit is appropriate rather than urgent evaluation; observation for a few months is reasonable.

The act pattern is any one of the red flags: bloody or clear-watery discharge, single-duct discharge, single-breast discharge, spontaneous discharge (staining bra without touching), or new discharge in a postmenopausal woman. Any one of these features means an OB or breast surgeon appointment within a week or two, not delayed for months. The combination of multiple red flags raises urgency further.

Any new nipple discharge in a woman who has gone through menopause is in a separate category — postmenopausal new discharge always needs evaluation regardless of the other features, because the background risk of breast pathology is higher. For self-examination guidance see Breast Self-Exam in India: A Calm, Practical Monthly Guide.