What is the appropriate evaluation and treatment for a patient presenting with nipple yellow discharge and symptoms of depression?

Evaluation and Management of Yellow Nipple Discharge

Yellow nipple discharge is classified as physiologic discharge and does not require imaging beyond routine screening mammography if the patient is up to date, as this type of discharge has no association with in situ or invasive carcinoma. 1, 2

Discharge Characterization

The first critical step is determining whether the discharge is physiologic or pathologic:

Physiologic discharge characteristics (your patient):

• Yellow, white, green, or milky color 1, 2, 3
• Bilateral presentation 1, 2
• Multiple ducts involved 1, 2
• Only occurs with manipulation/compression (non-spontaneous) 1, 2
• Malignancy risk: essentially 0% - only 0.3% of nonspontaneous discharge cases have carcinoma 2

Pathologic discharge characteristics (requiring workup):

• Spontaneous occurrence 1, 3
• Unilateral presentation 1, 3
• Single duct involvement 1, 3
• Bloody, serous, or serosanguineous appearance 1, 3
• Malignancy risk: 11-16% in women, 23-57% in men 3

Management Algorithm for Yellow Discharge

For physiologic yellow discharge:

1. Confirm screening mammography is current - if up to date within past 6 months, no additional imaging is needed 1, 2

2. Patient education:

   • Instruct patient to stop compressing or manipulating the breast 2
   • Advise patient to report if discharge becomes spontaneous 2
   • Explain that continued manipulation perpetuates the discharge 2

3. Clinical surveillance:

   • If discharge persists despite stopping manipulation, re-evaluate in 3-6 months 2
   • No routine ultrasound or other imaging is indicated 1, 2

Red flags requiring immediate re-evaluation:

• Discharge becomes spontaneous 2
• Change to bloody or serous appearance 2
• Development of palpable mass 2
• Discharge becomes unilateral or single-duct 2

Addressing the Depression Component

The "depress" mentioned in your question likely refers to nipple retraction/depression rather than psychological depression. However, I'll address both:

If nipple retraction/inversion is present:

• This changes the clinical picture significantly and warrants immediate diagnostic mammography and ultrasound regardless of discharge characteristics 1, 3
• Nipple retraction with discharge raises concern for underlying mass or malignancy 3

If psychological depression:

• Evaluate medication list - antipsychotics and other medications causing hyperprolactinemia can cause physiologic nipple discharge 4
• Consider endocrine evaluation if galactorrhea (milky discharge) is present with depression symptoms 4

Common Pitfalls to Avoid

• Do not order imaging for yellow discharge alone - this leads to unnecessary procedures and patient anxiety when screening mammography is current 1, 2
• Do not perform ductography or MRI for physiologic discharge - these are specifically contraindicated and rated "usually not appropriate" by ACR 2
• Do not refer for surgical duct excision - this is reserved only for pathologic discharge 2, 3
• Do not biopsy - image-guided biopsy has no role in physiologic discharge management 2

Age-Specific Considerations

• Women under 30 years: Mammography not routinely recommended due to dense breast tissue and extremely low cancer risk 2
• Women 30-39 years: If concerns arise, ultrasound is preferred initial imaging 1
• Women 40+ years: Standard screening mammography protocols apply 1, 3

The key message: Yellow nipple discharge is benign, requires only patient reassurance and education to stop breast manipulation, with routine screening mammography as appropriate for age. 1, 2