Is nipple eversion in women a medical concern?

Nipple Eversion in Women: Medical Significance and Management

Nipple eversion in women is not a medical concern by itself, but new or acute nipple inversion requires medical evaluation to rule out underlying malignancy.

Understanding Nipple Anatomy and Variations

Nipple inversion is relatively common, affecting approximately 10% of the female population 1. It can be:

• Congenital: Present from birth or developing during adolescence
• Acquired: Developing later in life due to various causes

Types of Nipple Presentation

1. Everted nipples (normal outward projection)
2. Inverted nipples (classified by severity)
   • Grade I: Easily pulled out manually and maintains projection
   • Grade II: Can be pulled out but returns to inverted position
   • Grade III: Cannot be easily pulled out manually 2

Clinical Significance

When Nipple Eversion Is NOT a Concern

• Lifelong nipple eversion is a normal anatomical variant
• Temporary nipple eversion in response to cold, touch, or arousal is a normal physiologic response

When Nipple Inversion IS a Concern

• New or acute nipple inversion requires prompt evaluation
• Recent studies show 6.5% of patients with new nipple inversion have an underlying malignancy 3
• Diagnostic mammography/ultrasound has high sensitivity (92.6%) and negative predictive value (99.3%) for detecting cancer in cases of acute nipple inversion 3

Evaluation of Nipple Changes

Assessment Algorithm

1. Determine if the nipple change is new or longstanding

   • Longstanding/congenital: Generally benign
   • New/acute: Requires further evaluation

2. Evaluate for pathologic nipple discharge

   • Physiologic discharge: Often provoked, from multiple ducts, bilateral, white/green/yellow 4, 5
   • Pathologic discharge: Spontaneous, single duct, unilateral, serous or bloody 4, 5

3. Imaging based on age and presentation

   • Women ≥30 years: Diagnostic mammography with possible tomosynthesis AND ultrasound 5
   • Women <30 years: Ultrasound first, followed by mammography if indicated 5
   • If initial imaging negative but symptoms persist: Consider MRI or ductography 5

Management Recommendations

For Longstanding/Congenital Nipple Inversion

• Reassurance that this is a normal variant
• No medical intervention required unless causing functional issues or psychological distress
• Surgical correction options exist with 12.6% recurrence rate 6

For New/Acute Nipple Inversion

• Immediate medical evaluation is required
• Diagnostic mammography and ultrasound as first-line imaging 5
• Further investigation based on imaging findings

Special Considerations

• Men with nipple discharge or inversion: Requires immediate evaluation as there is a 57% association with underlying malignancy 5
• Pregnancy and lactation: Physiologic changes are common, but new inversion still warrants evaluation

Common Pitfalls to Avoid

1. Dismissing new nipple inversion as normal variation

   • Always evaluate acute changes to rule out malignancy

2. Over-investigating longstanding nipple inversion

   • Congenital or longstanding inversion rarely indicates pathology

3. Failure to recognize pathologic nipple discharge

   • Spontaneous, unilateral, single-duct, or bloody discharge requires thorough evaluation 4

4. Unnecessary breast MRI in all cases

   • Reserve for cases with suspicious findings on mammography/ultrasound or persistent symptoms with negative initial imaging 3

Remember that while nipple eversion itself is not a medical concern, any new nipple inversion should be properly evaluated to rule out underlying pathology.