Zero To Finals - Womens Health

Question 1

What is a triple assessment when assessing breast lumps?

Answer 1

Triple Assessment
• Triple assessment should be performed for all breast
lumps (refer to breast clinic for them to arrange)
• Examination
• Fine needle aspiration / cytology
• Imaging (mammography >50yrs, ultrasound otherwise)

• Quadruple assessment – both mammography and USS
imaging

Question 2

Breast lump differentials

Answer 2

Breast cancer
Fibroadenoma
Fibrocystic breast changes
Breast cysts
Fat necrosis
Lipoma
Galactocele
Phyllodes tumour
Intraductal Papilloma
Breast abscess
Mastitis

Question 3

Fibroadenoma

Answer 3

Fibroadenoma
Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue.
They are typically small and mobile within the breast tissue.

They are sometimes called a “breast mouse”, as they move around within the breast tissue.
They are more common in younger women, aged between 20 and 40 years.
They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.

Question 4

On examination Fibroadenoma are:

Answer 4

On examination, fibroadenomas are:
® Painless
® Smooth
® Round
® Well circumscribed (well-defined borders)
® Firm
® Mobile (moves freely under the skin and above the chest wall)
® Usually up to 3cm diameter

Question 5

Fibrocystic breast changes

Answer 5

The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled).

◊ These changes fluctuate with the menstrual cycle.

It is a benign (non-cancerous) condition, although it can vary in severity and significantly affect the patient’s quality of life if severe.
It is common in women of menstruating age.
Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.

Question 6

Presentation of Fibrocystic breast changes

Answer 6

Symptoms can affect different areas of the breast, or both breasts, with:
◊ Lumpiness
◊ Breast pain or tenderness (mastalgia)
◊ Fluctuation of breast size
◊ Cobblestone

Question 7

Complication of Fibrocystic breast changes

Answer 7

Harder to identify any pathological changes/ new breast lumps

Question 8

Management of Fibrocystic breast changes

Answer 8

Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:
◊ Wearing a supportive bra
◊ Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
◊ Avoiding caffeine is commonly recommended
◊ Applying heat to the area
◊ Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 9

Breast cysts

Answer 9

Breast Cysts
Breast cysts are benign, individual, fluid-filled lumps.
They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period.
They can be painful and may fluctuate in size over the menstrual cycle.

Question 10

On examination breast cysts are:

Answer 10

On examination, breast cysts are:
– Smooth
– Well-circumscribed
– Mobile
– Possibly fluctuant

Question 11

Management of breast cysts

Answer 11

Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision.
Aspiration can resolve symptoms in patients with pain.
Having a breast cyst may slightly increase the risk of breast cancer.

Question 12

Fat necrosis

Answer 12

Fat Necrosis
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast.
It may be associated with an oil cyst, containing liquid fat.
Fat necrosis is commonly triggered by:
○ Localised trauma
○ Radiotherapy
○ Surgery
○ with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue.
It does not increase the risk of breast cancer.

Question 13

Examination of fat necrosis

Answer 13

On examination, fat necrosis can be:
w Painless
w Firm
w Irregular
w Fixed in local structures
w There may be skin dimpling or nipple inversion

Question 14

Investigations and management of fat necrosis

Answer 14

Ultrasound or mammogram can show a similar appearance to breast cancer.
Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.

After excluding breast cancer, fat necrosis is usually treated conservatively.
It may resolve spontaneously with time.
Surgical excision may be used if required for symptoms.

Question 15

Lipoma

Answer 15

Lipoma
Lipomas are benign tumours of fat (adipose) tissue.
They can occur almost anywhere on the body where there is adipose tissue, including the breasts.

On examination, lipomas are typically:
w Soft
w Painless
w Mobile
w Do not cause skin changes

They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed

Question 16

Galactocele

Answer 16

Galactocele
• Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding.
• They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk.
• They present with a firm, mobile, painless lump, usually beneath the areola.
• They are benign and usually resolve without any treatment.
• It is possible to drain them with a needle.
• Rarely, they can become infected and require antibiotics.

Question 17

Phyllodes tumour

Answer 17

Phyllodes tumour
• Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50.
• They are large and fast-growing.
• They can be benign (~50%), borderline (~25%) or malignant (~25%).
• Malignant phyllodes tumours can metastasise.

• Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.
• Chemotherapy may be used in malignant or metastatic tumours.

Question 18

Types of mastalgia (breast pain)

Answer 18

Breast pain (mastalgia) is common. It can be:
• Cyclical – occurring at specific times of the menstrual cycle
• Non-cyclical – unrelated to the menstrual cycle

Pain is not typically considered a symptom of breast cancer.
After a proper assessment and without other features of breast cancer (e.g., a lump or skin changes), patients with mastalgia can generally be reassured.

Question 19

Cyclical breast pain presentation

Answer 19

Cyclical Breast Pain
○ Cyclical breast pain is more common and is related to hormonal fluctuations during the menstrual cycle.
○ The pain typically occurs during the two weeks before menstruation (the luteal phase) and settles during the menstrual period.
○ There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.

Symptoms are typically:
○ Bilateral and generalised
○ Heaviness
○ Aching

Question 20

Non cyclical breast pain presentation and differentials

Answer 20

Non-Cyclical Breast Pain
Non-cyclical breast pain is more common in women aged 40 – 50 years.
It is more likely to be localised than cyclical breast pain.
Often no cause is found. However, it may be caused by:
Medications
Hormonal
Antidepressants
Antipsychotics
Digoxin
Spironolactone
Metronidazole
Ketoconozaole
Infection (e.g., mastitis)
Pregnancy

The pain may not originate in the breast but instead come from:
§ The chest wall (e.g., costochondritis)
§ The skin (e.g., shingles or post-herpetic neuralgia)

Question 21

How is cyclical breast pain diagnosed?

Answer 21

Diagnosis
A breast pain diary can help diagnose cyclical breast pain.
The three main things to exclude when someone presents with breast pain are:
® Cancer (perform a thorough history and examination)
® Infection (mastitis)
® Pregnancy (perform a pregnancy test)

Question 22

How is cyclical breast pain managed?

Answer 22

Management
Options to manage cyclical breast pain include:
◊ Wearing a supportive bra
◊ Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical) - more usually topical
◊ Avoiding caffeine is commonly recommended
◊ Applying heat to the area
◊ Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 23

Gynaecomastia

Answer 23

Gynaecomastia refers to the enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years). It may also be present in newborns due to circulating maternal hormones, resolving as the maternal hormones are cleared.

Question 24

Causes of gynaecomastia

Answer 24

Gynaecomastia is generally caused by a hormonal imbalance between oestrogen and androgens (e.g., testosterone), with higher oestrogen and lower androgen levels. Raised oestrogen stimulates breast development, whilst androgens have an inhibitory effect on breast development.

Prolactin is a hormone that also stimulates glandular breast tissue development (as well as breast milk production). Therefore, raised prolactin (hyperprolactinaemia) can cause gynaecomastia. It is worth remembering that dopamine has an inhibitory effect on prolactin. Dopamine antagonists (e.g., antipsychotic medications) block dopamine production, which can allow prolactin levels to rise and cause gynaecomastia and galactorrhea (breast milk production).

Gynaecomastia is idiopathic in many cases, meaning no cause is found.

Gynaecomastia may be physiological in adolescents, where there can be proportionally higher oestrogen levels around puberty. This resolves after a few years, as the hormone levels balance.

Question 25

Gynaecomastia causes due to increased oestrogen levels

Answer 25

Gynaecomastia can be caused by conditions that increase oestrogen:
• Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
• Testicular cancer (oestrogen secretion from a Leydig cell tumour)
• Liver cirrhosis and liver failure
• Hyperthyroidism
• Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer

Question 26

Gynaecomastia causes due to reduced testosterone

Answer 26

Gynaecomastia can be caused by conditions that reduce testosterone:
• Testosterone deficiency in older age
• Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
• Klinefelter syndrome (XXY sex chromosomes)
• Orchitis (inflammation of the testicles, e.g., infection with mumps)
• Testicular damage (e.g., secondary to trauma or torsion)

Question 27

What medications can cause gynaecomastia?

Answer 27

There is a long list of medications and drugs that can cause gynaecomastia:
○ Anabolic steroids (raise oestrogen levels)
○ Antipsychotics (increase prolactin levels)
○ Digoxin (stimulates oestrogen receptors)
○ Spironolactone (inhibits testosterone production and blocks testosterone receptors)
○ Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
○ Opiates (e.g., illicit heroin use)
○ Marijuana
○ Alcohol

Question 28

Management of gynaecomastia

Answer 28

Management
Management depends on the underlying cause. Gynaecomastia almost always resolves with time in adolescents. Stopping a causative drug (e.g., anabolic steroids or spironolactone) will usually resolve the symptoms. Patients may be referred to the specialist breast clinic where the cause is unclear or cancer is suspected.

Treatment options in problematic cases (e.g., pain or psychological distress) include:
• Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)
• Surgery

Question 29

Full assessment of presenting gynaecomastia

Answer 29

Assessment
It is important to distinguish between gynaecomastia and breast enlargement due to obesity (pseudogynaecomastia). On palpation, there will be firm tissue behind the areolas in gynaecomastia, representing growth of the gland and duct tissue. This is different to simple adipose (fat) tissue, which is soft and more evenly distributed.
The next step is to try and establish the cause.

The key points to cover in the history are:
• Age of onset, duration and change over time
• Associated sexual dysfunction (indicating low testosterone)
• Any palpable breast lumps or skin changes (exclude breast cancer)
• Associated symptoms that may indicate the cause (e.g., testicular lumps or symptoms of hyperthyroidism)
• Prescription medication (e.g., antipsychotics, spironolactone or GnRH agonists)
• Use of anabolic steroids, illicit drugs or alcohol

The key points to cover in the examination are:
	○ True gynaecomastia versus simple adipose tissue
	○ Unilateral or bilateral
	○ Any palpable lumps, skin changes or lymphadenopathy (exclude breast cancer)
	○ Body mass index (BMI)
	○ Testicular examination (e.g., lumps, atrophy or absence)
	○ Signs of testosterone deficiency (e.g., reduced body and pubic hair)
	○ Signs of liver disease (e.g., jaundice, hepatomegaly, spider naevi and ascites)
	○ Signs of hyperthyroidism (e.g., sweating, tachycardia and weight loss)

Question 30

Investigations for gynaecomastia

Answer 30

Investigations
Investigations will be determined by history and examination findings. Simple gynaecomastia in an otherwise healthy adolescent may be managed with watchful waiting. Unexplained rapid-onset gynaecomastia in a 30 year old male with no apparent cause may require in-depth investigations.

Blood tests:
• Renal profile (U&Es)
• Liver function tests (LFTs)
• Thyroid function tests (TFTs)
• Testosterone
• Sex hormone-binding globulin (SHBG)
• Oestrogen
• Prolactin (hyperprolactinaemia)
• Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
• Alpha-fetoprotein and beta-hCG (testicular cancer)
• Genetic karyotyping (if Klinefelter’s syndrome is suspected)

Imaging:
	○ Breast ultrasound (may help assess the extent of gynaecomastia)
	○ Mammogram (if cancer is suspected)
	○ Biopsy (if cancer is suspected)
	○ Testicular ultrasound (if cancer is suspected)
	○ Chest x-ray (if lung cancer is suspected)

Question 31

Galactorrhoea

Answer 31

Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin.
Prolactin is produced in the anterior pituitary gland. It is also produced in other organs, such as the breast and prostate. Prolactin also regulates aspects of immune function and metabolism.
Dopamine blocks the secretion of prolactin. Therefore, dopamine antagonists (i.e., antipsychotic medications) can result in raised prolactin and galactorrhea. Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to suppress prolactin secretion.

Question 32

Galactorrhea in pregnancy and breast feeding

Answer 32

Pregnancy and Breastfeeding
Milk production may start in small amounts during the second or third trimester of pregnancy, and leaking can occur during that time. Oestrogen and progesterone inhibit the secretion of prolactin. In pregnancy, higher levels of oestrogen and progesterone inhibit breast milk production.
Oxytocin stimulates breast milk excretion. Full milk production starts shortly after birth in response to oxytocin release and a rapid drop in oestrogen and progesterone.
Breast milk production will taper off and stop once breastfeeding stops.

Question 33

Hyperprolactinaemia

Answer 33

Hyperprolactinaemia
Galactorrhoea is usually associated with a raised prolactin level (hyperprolactinaemia).
There is a long list of causes of hyperprolactinaemia, but the key causes to remember are:
• Idiopathic (no cause can be found)
• Prolactinomas (hormone-secreting pituitary tumours)
• Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
• Medications, particularly dopamine antagonists (i.e., antipsychotic medications)

Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
	○ Menstrual irregularities, particularly amenorrhoea (absent periods)
	○ Reduced libido (low sex drive)
	○ Erectile dysfunction (in men)
	○ Gynaecomastia (in men)

Question 34

Non milk discharge causes

Answer 34

Non-Milk Discharge
Other conditions can cause nipple discharge that is not breast milk:
• Mammary duct ectasia
• Duct papilloma
• Pus from a breast abscess

Question 35

How does a prolactinoma cause bitemporal hemianopia?

Answer 35

The optic chiasm sits just above the pituitary gland. The optic chiasm is the point where the optic nerves coming from the eyes cross over to different sides of the head. Only the nerves fibres containing the signal from the outer visual fields cross over, whereas the fibres from the inner visual fields continue on the same side. A pituitary tumour of sufficient size will start to press on the optic chiasm, where the nerves cross, leading to a visual field defect, with loss of vision in the outer visual fields in both eyes (the inner visual fields are spared). This is called bitemporal hemianopia.

TOM TIP: It is worth properly understanding and remembering bitemporal hemianopia, as it is commonly tested in exams. If you find it a bit confusing, there is a Zero to Finals YouTube video explaining it in detail. Remember to examine the visual fields in any patient with symptoms that may be related to a pituitary tumour.

Question 36

Prolactinomas

Answer 36

Prolactinomas
Prolactinomas are tumours of the pituitary gland that secrete excessive prolactin. This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.
Prolactinomas can be:
• Microprolactinomas – smaller than 10 mm
• Macroprolactinomas – larger than 10 mm

Macroadenomas can have adverse effects relating to their size:
	○ Headaches
	○ Bitemporal hemianopia (loss of the outer visual fields in both eyes)

Question 37

Investigations for Galactorrhoea

Answer 37

Investigations
A pregnancy test is essential in women with childbearing potential presenting with breast milk production.
Blood tests include:
• Serum prolactin
• Renal profile (U&Es)
• Liver function tests (LFTs)
• Thyroid function tests (TFTs)

An MRI scan is the investigation of choice for diagnosing pituitary tumours.

Question 38

Management of galactorrhoea

Answer 38

Management
Management is targeted at the underlying cause.

Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms.

Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of hyperprolactinaemia secondary to a prolactinoma. The pituitary gland and tumour are accessed and removed through the nose and sphenoid bone.

Question 39

Mammary duct ectasia

Answer 39

Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.
Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.

Question 40

Presentation of mammary duct ectasia

Answer 40

Presentation
Mammary duct ectasia may present with:
• Nipple discharge (thick and cheesy)
• Tenderness or pain
• Nipple retraction or inversion
• A breast lump (pressure on the lump may produce nipple discharge)

It may be picked up incidentally on a mammogram, leading to further assessment and investigations.

Question 41

Management of mammary duct ectasia

Answer 41

Management
Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.
Management depends on the individual patient:
• Reassurance after excluding cancer may be all that is required
• Symptomatic management of mastalgia (supportive bra and warm compresses)
• Antibiotics if infection is suspected or present
• Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Question 42

Management of mammary duct ectasia

Answer 42

Diagnosis
The initial priority is to exclude breast cancer, as they can present in similar ways. This involves triple assessment with:
• Clinical assessment (history and examination)
• Imaging (ultrasound, mammography and MRI)
• Histology (fine needle aspiration or core biopsy)

Microcalcifications are a key finding to remember on a mammogram, although they are not specific to mammary duct ectasia.
 
Other investigations that may be performed:
	○ Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
	○ Nipple discharge cytology – examining the cells in a sample of the nipple discharge
	○ Ductoscopy – inserting a tiny endoscope (camera) into the duct

Question 43

Intraductal papilloma

Answer 43

An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge.
Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Question 44

Presentation of intraductal papilloma

Answer 44

Presentation
Intraductal papillomas can occur at any age, but most often occur between 35-55 years.
Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.
They may present with:
• Nipple discharge (clear or blood-stained)
• Tenderness or pain
• A palpable lump

Question 45

Assessment and diagnosis of intraductal papilloma

Answer 45

Diagnosis
Patients require triple assessment with:
• Clinical assessment (history and examination)
• Imaging (ultrasound, mammography and MRI)
• Histology (usually by core biopsy or vacuum-assisted biopsy)

Ductography may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Question 46

Management of intraductal papilloma

Answer 46

Management
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Question 47

Mastitis

Answer 47

• Mastitis refers to inflammation of breast tissue and is a common complication of breastfeeding.
• It can occur with or without associated infection.
• Mastitis can be caused by an obstruction in the ducts and accumulation of milk.
• Regularly expressing breast milk can help prevent this from occurring.
• Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation.
○ The most common bacterial cause is Staphylococcus aureus.

Question 48

Presentation of mastitis

Answer 48

Presentation
Mastitis presents with:
• Breast pain and tenderness (unilateral)
• Erythema in a focal area of breast tissue
• Local warmth and inflammation
• Nipple discharge
• Fever

Question 49

Risk factors that can lead to mastitis

Answer 49

Risk Factors
• Problems with attachment of infant during breast feeding
• Reduced number of feeds/duration of feeds, leading to milk accumulation. This may be due to:
○ Partial bottle feeding
○ Changes in regime
○ Rapid weaning
○ Painful breasts
○ Preferred breast leading to milk accumulation in the other
• Pressure on the breast - tight clothing, seat belt, sleeping in prone position
• Nipple fissures, cracks and sores
• Trauma to breasts
• Blocked milk ducts
• Smoking

Question 50

Conservative management of non infective mastitis

Answer 50

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage.
• Heat packs, warm showers and simple analgesia can help symptoms.

Question 51

Management of infective mastitis

Answer 51

When conservative management is not effective, or infection is suspected (e.g., they have a fever), antibiotics should be started.
• Flucloxacillin is the first line, or erythromycin when allergic to penicillin.
• A sample of milk can be sent to the lab for culture and sensitivities.
• Fluconazole may be used for suspected candidal infections.

Question 52

Should women continue breast feeding with mastitis?

Answer 52

Women should be encouraged to continue breastfeeding, even when an infection is suspected.
• It will not harm the baby and will help to clear the mastitis by encouraging flow.
• Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast.

Question 53

Rare complication of mastitis

Answer 53

A breast abscess is a rare complication if mastitis is not adequately treated.
• This may need surgical incision and drainage.

Question 54

Candida of the nipple

Answer 54

Candida of the Nipple
Candidal infection of the nipple can occur, often after a course of antibiotics.
This can lead to recurrent mastitis, as it causes cracked skin on the nipple that creates an entrance for infection.
It is associated with oral thrush and candidal nappy rash in the infant.

Candida infection of the nipple may present with:
○ Sore nipples bilaterally, particularly after feeding
○ Nipple tenderness and itching
○ Cracked, flaky or shiny areola
○ Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Both the mother and baby need treatment, or it will reoccur. Treatment is with:
○ Topical miconazole 2% to the nipple, after each breastfeed
○ Treatment for the baby (e.g., oral miconazole gel or nystatin)

Question 55

Breast abscess

Answer 55

A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
• Lactational abscess (associated with breastfeeding)
• Non-lactational abscess (unrelated to breastfeeding)

Pus is a thick fluid produced by inflammation. It contains dead white blood cells of the immune system and other waste from the fight against the infection. When pus becomes trapped in a specific area and cannot drain, an abscess will form and gradually increase in size.
Mastitis refers to inflammation of breast tissue. Often this is related to breastfeeding (lactational mastitis), although it can be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. Mastitis caused by infection may precede the development of an abscess.
Smoking is a key risk factor for infective mastitis and breast abscesses. Damage to the nipple (e.g., nipple eczema, candidal infection or piercings) provides bacteria entry. Underlying breast disease (e.g., cancer) can affect the drainage of the breast, predisposing to infection.

Question 56

Common causative bacteria of breast abscess

Answer 56

Causes
The most common causative bacteria are:
• Staphylococcus aureus (the most common)
• Streptococcal species
• Enterococcal species
• Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Question 57

What antiobitoics are effective against gram positive and negative bacteria breast abscess

Answer 57

TOM TIP: It is worth becoming familiar with the effective antibiotics against different classes of bacteria.

Staph aureus, streptococcal and enterococcal bacteria are gram positive, meaning that penicillins are likely to be effective. Flucloxacillin, in particular, is used against staph aureus skin infections (this association is worth remembering).

However, anaerobic bacteria can also cause breast abscesses, and simple penicillins (e.g., amoxicillin or flucloxacillin) do not cover anaerobic bacteria. Co-amoxiclav (amoxicillin plus clavulanic acid) covers anaerobes. Metronidazole gives excellent anaerobic cover (also worth remembering), so it can also be added to the mix.

Question 58

Presentation of a breast abscess

Answer 58

Presentation
The presentation of mastitis or breast abscesses is usually acute, meaning the onset is within a few days.
Mastitis with infection in the breast tissue presents with breast changes of:
• Nipple changes
• Purulent nipple discharge (pus from the nipple)
• Localised pain
• Tenderness
• Warmth
• Erythema (redness)
• Hardening of the skin or breast tissue
• Swelling

The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast. Fluctuance refers to being able to move fluid around within the lump using pressure during palpation. Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid.

There may be generalised symptoms of infection, such as:
○ Muscle aches
○ Fatigue
○ Fever
○ Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion)

Question 59

Management of non-lactational mastitis

Answer 59

Management of non-lactational mastitis involves:
• Analgesia
• Antibiotics
• Treatment for the underlying cause (e.g., eczema or candidal infection)

Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either:
	○ Co-amoxiclav
	○ Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)

Question 60

Management of a breast abscess

Answer 60

Management of a breast abscess requires:
§ Referral to the on-call surgical team in the hospital for management
§ Antibiotics
§ Ultrasound (confirm the diagnosis and exclude other pathology)
§ Drainage (needle aspiration or surgical incision and drainage)
§ Microscopy, culture and sensitivities of the drained fluid

Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.