Breast Pain and Nipple Discharge

1
Breast Pain and Nipple Discharge
Philip Turton Consultant Breast, Oncoplastic,
and Aesthetic Breast Surgeon Leeds General
Infirmary
2
Mastalgia alone or in combination with
lumpinessis the commonest reason for referral to
a breast clinic
Pain alone 17 Lumpiness and pain
33 Non painful lump 36 Nipple discharge
5 Family history 3
50
3
Breast Pain

• Theory
• Imbalance of essential fatty acids
• Hormonal stimulation
• Endogenous sensitivity of some breast lobules
• Almost never associated with malignancy with
  normal examination

4
Breast Pain

• Non breast mastalgia should be differentiated by
  a good history
• Consider Angina, GS, Cervical spondylosis,
  Cervical rib, oesophageal erosions, lesions and
  achalasia, rib fracture, torn/strained muscle,
  pleuritic pain, pneumonia, pulmonary lesion,
  Tietzs syndrome

5
Non-cyclical pain

• Unrelated to the menstrual cycle
• Described as tight, burning or sore
• Constant or intermittent
• Usually affects one breast, in a localized area,
  but may spread more diffusely across the breast
• Usually affects postmenopausal women in their 40s
  and 50s

6
Cyclical Breast Pain

• Clearly related to the menstrual cycle
• Described as dull, heavy or aching
• Often accompanied by breast swelling or lumpiness
  
• Usually affects both breasts, UOQs, /- radiates
  to axilla
• Intensifies during the two weeks leading up to
  the start of your period, then eases up afterward
  
• Usually affects premenopausal women in their 20s
  and 30s and perimenopausal women in their 40s

7
Mastalgia Taking a good history

• Age, FH, parity
• Previous history of breast problems cysts, pain,
  biopsies, cancer, surgery (BBA, BBR, mastopexy)
• Previous breast imaging- what, why and when
• When was last period?
• Menstrual irregularities
• Usage of OCP, depot, mirena coil, progesterone
  only pill

8
Breast Pain

• Assess the pain pain chart if not
  straightforward
• Site, type, intensity, duration of symptoms
• frequency
• previous occurrence
• Current impact on QOL
• Specific concerns eg cancer

9
FIGURE 3.1
FIGURE 3.1
Back to Contents
Back to Chapter 3 thumbnails
10
FIGURE 3.2
FIGURE 3.2
Back to Contents
Back to Chapter 3 thumbnails
11
Examination

• NB re-examine after next period if presenting in
  the week prior to menstruation

12
ExaminationMirror signal manoeuvre!!
13
(No Transcript)
14
ExaminationMirror signal manoeuvre!!
15
ExaminationMirror signal manoeuvre!!
16
Who can be managed initially in primary care

• Bilateral symmetrical cyclical pain, which
  resolves following menstruation
• Recent onset breast pain, with normal examination
  in young patient
• Male patients with simple tender gynaecomastia
• Normal examination and recent normal breast
  imaging
• If in doubt, please refer

17
Treatment

• Educate and Reassure
• Refit bra if obvious problem/ sports bra helps in
  short term
• Topical NSAID gel
• Avoid caffeine completely
• Evening primrose oil 1gm od or BD for minimum of
  3-months, with good compliance
• If on HRT- reduce
• If recently started COCP - reassure
• If mirena/prog only pill, consider other

18
Breast Pain

• Who to refer anything atypical
• 1. Pain associated with definite signs eg
  dominant or discrete lump, palpable focal
  thickening will have triple assessment
• 2. Patients who have previously had breast cancer
• Rib met, lung met, LR
• 3. Persisting pain, same quadrant for 3-months
• Mammo targetted USS
• normal or B9 changes carries almost 100 negative
  predictive value. Core of any focal area but is
  uncommon

19
Hospital Treatment of Severe Mastalgia

• Tamoxifen 10-20mg OD, 4-months
• Use on days 5 to 21 of cycle most effective
• S/E hot flushes, vaginal dryness
• Very rare DVT

20
Treatment

• Danazol 100mg tds, 4-months
• Inhibits pituitary gonadotrophins (FSH LH)
• Stimulates androgenic pathways
• S/E acne, oily skin, hirsuitism, weight gain,
  voice change, thrombosis

21
Treatment

• Bromocriptine 2.5mg OD, 4-months
• Stimulates dopamine receptors in the brain and
  inhibits release of prolactin
• Avoid in post-partum period (MI, CVA, HT)
• S/E drowsiness, headache, postural hypotension,
  nausea, dizziness, dry mouth, fibrotic reactions

22
Treatment

• GnRH analogues,
• Decrease FSH/LH (after initial surge)
• S/E Hot flushes, sweating, vaginal dryness, loss
  of libido

23
Breast Pain

• Treatment of non-cyclical breast pain
• Usually as for cyclical
• More likely to use oral NSAID early on
• Often due to duct ectasia more common after
  menopause
• Is there a chance that cancer can be present?
• Rare in absence of palpable thickening, or lump.
• Ensure breast looks feels normal, and no
  obvious palp LN
• Repeat examination after 6-weeks

24
Questions?
25
Nipple Discharge

• Causes
• Physiological
• Duct ectasia
• Mild inflammation
• Post-partum
• Papilloma
• DCIS, Inv ca
• Abscess
• Very rare endocrine cause, joggers nipple

Papillomas and duct ectasia commonly arise in the
sub areola segment
26
Duct ectasia

• An aberration of development involution
• Women gt50
• Nipple discharge, retraction, doughy palpable
  mass
• Discharge cheesy/ white
• Slit-like nipple retraction
• Management conservative or surgical
• Surgical total duct excision

27
Nipple Discharge

• Taking a History
• When
• Spontaneous, or on Squeezing
• Frequency duration
• Consistency quantity spotting on bra, or
  staining through to blouse
• Blood stained
• Current medication phenothiazines, haloperidol,
  methyldopa

28
Colour

• Usually always insignificant multi-duct
• Brown and haem negative
• Green
• White, creamy
• Investigate single duct
• Brown and haem negative but persistent
• Brown and haem positive
• Serous
• Blood stained
• Galactorrhea

NB Use the standard urinalysis sticks
29
History

• Associated breast symptoms or signs
• Any lump
• Any changes near the NAC
• Nipple inversion, nipple eczema
• Adjuncts to assess risk
• Parity
• FH of breast or ovarian ca
• Previous breast problems, abnormal breast
  biopsies
• For galactorrhea amenorrhea/headache/visual

30
Examination

• Apart from the nipple discharge, examination is
  usually normal
• Look for the rarely associated signs of a
  sinister cause
• Indrawing, lump, sub-areola thickening

31
Investigation of new nipple discharge
Advise to cease expression Mammogram/USS if
persists Review in 2-3 months If persistent
bilateral, do serum prolactin
Investigate further in breast clinic
32
Investigation

• Nipple fluid haem test
• If positive do Hadfields procedure
• Nipple fluid smear onto a slide for cytology-
• Epithelium should not be seen ie should be
  negative for epithelial cells
• If positive for epithelial cells indicates higher
  possibility of papilloma or DCIS, therefore do
  Hadfields procedure to send tissue to pathologist

33
Investigation

• gt35 Mammo and USS of NAC
• lt35 USS of NAC
• Guided biopsy
• Eg USS guided core or FNAC of ?intraduct
  papilloma
• NB Any clinically palpable lump must always be
  biopsied even if mammo and USS are normal

34
Treatment

• Diagnostic Surgery
• Uncommon microdochotomy/Ductoscopy
• Hadfields Procedure
• Sub areola excision of the major breast ducts,
  which is sent for histology
• S/E nipple sensation, nipple necrosis, infection
• Therapeutic operation
• Where results of Hadfields procedure show
  DCIS/Inv ca Usually mastectomy IBR

35
Treatment of non-significant nipple discharge

• Advise not to squeeze the nipple to look for
  further discharge
• If persists and is nuisance can refer for further
  investigation
• Would tend to do a therapeutic Hadfields
• Ie the purpose is to stop the discharge with the
  operation instead of doing it for diagnostic
  assessment alone

36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Key Points

• Breast Pain
• Most do not need referring, reassure, educate
• Refer not settling, focal nodularity, lump
• Nipple Discharge
• Most are physiological or duct ectasia
• Refer watery or blood stained

Handouts please email me on eplt_at_aol.com Any
breast related queries philip.turton_at_leedsth.nhs.
uk NHS secretary Angela Mathie 0113 3922250
40
Normal left breast
Spiculate mass right breast
41
USS of Right Breast Cancer, and USS
core, confirming needle through lesion
42
MRI of Right Breast Cancer, revealing
multifocality
43
(No Transcript)
44
(No Transcript)
45
Biopsy The Mammotome
46
(No Transcript)
47
(No Transcript)
48
Handouts please email me on eplt_at_aol.com Any
breast related queries philip.turton_at_leedsth.nhs
.uk