Breast Pain & Discharge

Breast Pain & Discharge: Excerpt from In a Page: Signs and Symptoms

Breast pain (or mastalgia) is a common complaint that can often be diagnosed by a careful history and physical examination. Pain and tenderness may be normal during early pregnancy and before menses. Breast discharge, however, is rarely normal except in pregnant or lactating women, and it generally requires a full workup.

Differential Diagnosis

Breast pain

• Fibrocystic change
  –Most common benign breast condition
  –Clinically present in 50% and histologically in 90% of women
• Mastitis
  –Associated with lactation
• Extramammary causes of pain (e.g., cervical radiculitis, costochondritis, herpes zoster, angina)
• Breast cancer
  –Occurs in 1/9 women (lifetime risk)
• Cyst
• Breast abscess
• Unilateral or bilateral gynecomastia
• Phylloides tumor
• Intraductal papilloma
• Fat necrosis
• Trauma
• Fibroadenoma
• Lipoma
• Pregnancy
  Breast discharge
• Duct ectasia
• Galactorrhea
• Mondor's disease
• Chronic nipple stimulation
• Pregnancy
• Hypothyroidism
• Sarcoidosis
• Systemic lupus erythematosus
• Cirrhosis or other hepatic disease
• Breast cancer
  –Occurs in 1/9 women (lifetime risk)
• Intraductal papilloma
• Fibrocystic change
• Medications (e.g., phenothiazines, metoclopramide, tricyclic antidepressants, reserpine, opiates, cimetidine, androgens)
• Hypothalamic and pituitary abnormalities (e.g., prolactinoma, acromegaly, empty sella syndrome)
• Pseudocyesis

Workup and Diagnosis

• History includes past medical history, duration and pattern of pain and/or discharge, family history of breast or gynecologic cancer, and menstrual/pregnancy history

• Breast exam 7–9 days after menstrual flow
  –Fibrocystic areas: Slightly irregular, mobile, bilateral, upper outer quadrant; compression causes tenderness
  –Breast cancer: Solitary, irregular, or stellate; hard, nontender, fixed; not clearly delineated from surrounding tissue, ± lymphadenopathy
  –Mastitis: Inflamed, edematous, erythematous, indurated, tender areas, axillary lymphadenopathy
  –Nipple discharge: Bloody or serosanguinous discharge is suspicious for cancer; oral contraceptives, estrogens, or elevated prolactin levels may result in clear, serous, or milky discharge
• Diagnostic mammogram is indicated in patients >30 years old who present with solitary or dominant mass or asymmetric thickening
  –Compare with prior mammograms if possible
• Ultrasound is used to distinguish solid versus cystic
• Fine-needle aspiration, breast biopsy, cytologic exam of discharge, ductogram and/or galactogram may be indicated
• Endocrine evaluation may include prolactin levels, TSH, FSH, and LH

Treatment

• Fibrocystic changes
  –Caffeine avoidance is often effective in decreasing pain
  –Aspirate cysts or medical therapies (e.g., danazol, oral contraceptives, tamoxifen, bromocriptine, evening primrose oil, GnRH agonists, vitamin E) for pain relief
  –Routine follow up is sufficient unless cytologic atypia is present

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Breast Cancer

• Back to disease: Breast Cancer: Introduction
• Next Book Extract About Breast Cancer: BREAST DISCHARGE (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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