Painful Breasts Flashcards
What is cyclical breast pain?
Linked to changing hormone levels during the menstrual cycle and tends to affect women before menopause. It is often described as a heaviness affecting one or both breasts and may radiate to the axilla or down the arms - tends to be worse in the luteal (later part) phase of the cycle. Cyclical breast pain usually settles down by itself in about 20-30% of women and tend to stop after menopause.
What is non-cyclical breast pain?
Consists of pain originating in the breast that is unrelated to the menstrual cycle and pain from an extramammary cause that is referred to the breast e.g. costochondritis. Causes are often unclear but pain tends to settle by itself in about 50%.
Describe lactational mastitis
Inflammatory condition of the interlobular connective tissue that affects 10% of breastfeeding women. The main underlying cause is milk stasis caused by overproduction or insufficient removal of milk. It may be infectious (retrograde spread of commensal organisms via a milk duct or a traumatised nipple) or non-infectious.
What factors predispose to lactational mastitis?
- Use of dummy/bottle (may result in poor attachment to the breast and a reduction in frequency and duration of breastfeeding)
- Nulliparity (no children)
- Baby not attaching well to the breast
- Tight bra
What are the features of a breast abscess?
- Can be a complication of mastitis - indicated if they develop a focal lump and systemic symptoms
- Seen on USS - collection of fluid
- Overlying skin thickening and surrounding oedema
What is the treatment for a breast abscess?
- US guided drainage of the abscess can be done under LA in the breast unit - if it yields 15ml of pus send to microbiology. Recovery is quick so mother + baby not separated for long.
- Start flucloxacillin (abx of choice in pregnancy and suitable in breastfeeding)
What is the most common cause of lactational mastitis?
Staphylococcus aureus
What is the treatment for mastitis?
- Continue breast feeding - patient should be encouraged to keep the breast empty to avoid milk stasis, if it is too painful to continue breastfeeding then may express milk until the pain eases
- Start flucloxacillin
- Safety net
How do you treat non-cyclical breast pain?
- Diet/lifestyle changes
- Well fitting bra
- Topical NSAIDs
- If triggered by contraceptives, stop them/change to a different pill
- Consider hormone suppressing drugs if pain severe/prolonged
How do you treat cyclical breast pain?
- 1st line is refitting bras and topical NSAIDs gel
- Hormone suppressing drugs like danazol and tamoxifen may be considered in severe, prolonged breast pain that hasn’t improved with standard treatment
- SSRIs are a recognised cause of breast pain
What clinical changes happen to the breasts in pregnancy?
Clinically the breasts will feel larger, firmer and more nodular and there may be increased alveolar and nipple pigmentation and Montgomery’s tubercles may become more prominent.
What scan changes happen to the breasts in pregnancy?
- Mammography: increased breast size and density, may help to ask the patient to breastfeed/express milk before a mammogram is performed to decrease the density of the engorged breast
- Ultrasound: the combination of glandular enlargement and engorgement of breast tissue results in increased echogenicity of the breast parenchyma. Duct dilatation and hypervascularity of the breast tissue may also be observed.
What is the histology of lactating breasts?
- Progressive enlargement of the lobules with increasing luminal distension in the latter stages of pregnancy
- Cells are expanded by secretions and have a clear appearance
What are risk factors for non-lactational breast abscesses?
- Smoking
- Diabetes
- Immunocompromised
What is an important diagnosis not to miss?
Inflammatory breast cancer - this is a rare form in which cancer cells grow along the lymph vessels causing the breast to become inflamed and swollen. It can mimic mastitis and breast abscesses - it is often painless.
