Are inverted nipples a concern for women?

Inverted Nipples in Women: Clinical Significance and Management

Primary Recommendation

Congenital bilateral inverted nipples are a benign anatomical variation affecting approximately 10% of women and do not require medical intervention unless functional problems develop or the patient desires cosmetic correction. 1, 2

When Inverted Nipples Are NOT a Concern

Congenital Inverted Nipples

• Congenital bilateral inverted nipples without discharge, mass, or skin changes are physiologic variants, not pathologic findings. 1
• The American Academy of Pediatrics does not list congenital nipple inversion as an indication for surgical referral, as it is considered a benign anatomical variation. 1
• These require no imaging or further evaluation in the absence of other concerning features. 1

Key Reassuring Features

• Bilateral presentation (present since puberty or earlier) 1
• No associated breast mass 1
• No nipple discharge 1
• No skin changes (erythema, dimpling, or retraction of surrounding tissue) 3

When Inverted Nipples ARE a Concern

Red Flags Requiring Prompt Evaluation

Acquired nipple inversion or changes in previously normal nipples require immediate evaluation to exclude underlying malignancy. 1

Specific concerning features include:

• New unilateral nipple inversion (may indicate underlying breast cancer causing tissue retraction) 1
• Change in a previously everted nipple 1
• Associated palpable breast mass 3
• Skin changes including erythema, dimpling, or retraction 3
• Pathologic nipple discharge (spontaneous, unilateral, single-duct, bloody or serous) 4

Functional Considerations

Breastfeeding Impact

• Inverted nipples can cause difficulty with breastfeeding, with 31.6% of affected women reporting resultant breastfeeding problems. 2
• The severity varies from slight to severe inversion, with grade I and II nipples having better outcomes for lactation. 5, 6
• Non-surgical interventions (such as nipple distractors) can improve breastfeeding success rates to 84.9% for grade I and 79.3% for grade II inverted nipples. 6

Nipple Piercing Complications

If inverted nipples are pierced, additional concerns arise:

• Abscess formation and infection risk 3
• Breastfeeding impairment from jewelry or scar tissue that can block milk ducts 3
• Risk of bacterial endocarditis in patients with moderate- to high-risk cardiac conditions 3
• Jewelry must be removed during lactation to prevent infant aspiration 3

Management Algorithm

For Congenital Inverted Nipples:

1. Reassure the patient that this is a benign anatomical variation 1
2. Counsel about potential breastfeeding challenges and available interventions 2, 6
3. Offer intervention only if:
   • Functional problems develop (breastfeeding difficulty) 1, 5
   • Patient desires cosmetic correction 1, 5
4. Consider non-surgical options first (nipple distractors, exercises) as they preserve lactiferous ducts and sensation 7, 6

For Acquired Nipple Inversion:

1. Perform immediate clinical breast examination assessing for masses, skin changes, and lymphadenopathy 3
2. Order diagnostic imaging:
   • Age ≥40 years: Diagnostic mammography with ultrasound 4
   • Age 30-39 years: Mammography or ultrasound initially, with the other as complementary 4
   • Age <30 years: Ultrasound as initial examination 4
3. Refer for tissue diagnosis if imaging reveals suspicious findings 8

Common Pitfalls to Avoid

• Do not dismiss new unilateral nipple inversion as benign without proper evaluation, as this can be a sign of underlying breast cancer. 1
• Do not order imaging for congenital bilateral inverted nipples in the absence of other concerning features, as this represents unnecessary testing. 1
• Do not recommend surgical correction as first-line treatment when breastfeeding preservation is desired, as non-surgical methods preserve lactiferous ducts. 7, 6
• Do not confuse physiologic nipple characteristics (bilateral, longstanding) with pathologic changes (new, unilateral, associated with mass or discharge). 1, 4