Breast Health Figure 2: Evaluation of Woman with Nipple Discharge Exam: mass identified
Follow Figure 1 to evaluate mass
Exam: skin lesion causing discharge
Consider skin biopsy Imaging:
negative, benign or probable benign
Woman
presents with nipple discharge
History:
spontaneous unilateral discharge, clear or bloody colour Exam:
reproducible and uniductal
Breast imaging (mammo + US or US only if age <30)
Imaging:
suspicious or highly suspicious mass identified
History and exam: bilateral milky discharge Pregnancy test
hCG negative: galactorrhoea workup (see text)
History and exam: discharge expressed only, yellow, green, grey or black colour
US = ultrasound.
routinely. If the discharge is spontaneous, uniductal and clear, serous or sanguinous, the woman should have diagnostic imaging including mammography and retroareolar ultrasound.31
If the imaging identifies a
breast mass, it should be biopsied (image-guided core biopsy). If no lesion is seen on imaging, the work-up should proceed to excision of the involved duct, which is both diagnostic and therapeutic. In some centers, ductography is performed prior to duct excision to evaluate for filling defects, which may help to delineate the depth of the lesion. Terminal duct excision can be both diagnostic and therapeutic for women with uniductal discharge.
Breast Pain
Mastalgia, or breast pain, is a common complaint that frequently leads to evaluation. Mastalgia was the primary indication for 47 % of breast-related visits in a 10-year study of women enrolled in a health maintenance organization.32
Breast pain can be categorized into three divisions: cyclical mastalgia, non-cyclical mastalgia and extra-mammary pain. The former two entities represent true breast pain and the latter may mimic breast pain but stems from another source (e.g. musculoskeletal pain or chest wall). The history should focus on the timing (particularly relative to menses in the reproductive age woman), frequency, severity, location of the pain, and use and effectiveness of medications.
It is important to explore the reason the woman is bringing this to the doctor’s attention, e.g. is the pain significantly affecting her life, or is she seeking reassurance due to fear that a serious, pathologic process may be occurring. Many women report the symptom due to fear of cancer. As with all breast-related evaluations, it is important to assess the woman’s breast cancer risk based on her age, reproductive and family histories.
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The breast exam should focus on identifying discrete breast masses or asymmetries. If a mass is palpable on exam, it should be evaluated in the usual manner (see Figure 1). The chest wall should be examined independently especially at common locations of chest wall pain (e.g., costochondral junction or along the insertion/origin of the pectoralis muscle) to exclude chest wall as a source. A good history will also help the physician to identify the rare cardiac, lung or gastrointestinal problems that may be experienced as breast pain.
Imaging is not generally indicated in women with breast pain without abnormal findings on breast exam, though it could be considered in the woman with focal, non-cyclic mastalgia. Though breast cancer is rarely identified in the patient presenting with mastalgia alone, breast cancer-related mastalgia is more likely to be unilateral, focal, intense, non-cyclic, and persistent or progressive. Reassurance and routine follow-up is the most appropriate management for women with cyclic mastalgia and a normal breast exam. The majority of women will not desire any treatment beyond this.
Women who desire for treatment may benefit from conservative, non-prescription measures. Evening primrose oil (EPO), containing the presumed active ingredient gamma-linolenic acid (GLA), has been the subject of many studies, some of which have demonstrated a reduction in mastalgia, greater for cyclic versus non-cyclic. If EPO is to be used, the recommended dosage would be 2,000–3,000 mg GLA in divided doses daily.33
Recommend avoidance of nipple stimulation or expression
Reassure:
routine surveillance recommended
Biopsy
imaging-detected lesion
Excise involved duct
Other supplements being investigated include Vitex agnus-castus (chaste tree berry) and soy preparations, but evidence is limited at this time. Non-steroidal anti-inflammatory drugs (NSAIDs), both oral and topical regimens, have demonstrated efficacy in small, uncontrolled studies of women with mastalgia. Timing NSAID use to begin prior to the onset of pain based on the woman’s menstrual cycle would be appropriate. Frequently, dietary changes are recommended but few are supported by the available
US OBSTETRICS & GYNECOLOGY
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