Benign Breast Conditions NURS 541: Women’s Healthcare – Diagnosis and Management

Benign Breast Conditions Most common breast conditions Mastalgia Nipple discharge Benign breast masses Sensitive topic for women! Fears and concerns re: breast cancer first and foremost

Mastalgia Etiologies Benign in >90% of cases of breast pain Classified as cyclic (~70%) and non-cyclic (~30%) Etiologies Menstrual cycle hormone changes Hormonal contraception methods, hormone replacement Other medications (antidepressants, digoxin, methyldopa, spironolactone, oxymetholone, chlorpromazine) Fibrocystic breast changes

Mastalgia History Diagnostic testing Differential diagnosis Cyclic or non-cyclic Pregnancy test! Timing and character Mammogram if indicated, to rule out malignancy Unilateral or bilateral Differential diagnosis Quality of pain Physical exam Chest wall abnormalities Costochondritis Comprehensive breast exam Pleuritis Exam of chest wall Mastitis Shingles

Mastalgia Management Non-pharmacologic measures Pharmacologic measures Reassurance!! Reduction in caffeine, fat (mixed evidence) Wearing a supportive, well-fitting bra (strong evidence) Pharmacologic measures Changing hormonal method, dose, route Danazol, tamoxifen, bromocriptine effective (Danazol only FDA approved treatment for mastalgia) Significant side effects may outweight benefits Evening primrose oil, Agnus castus, isoflavones (mixed evidence)

Nipple Discharge Classified as: Etiologies Normal lactation Milky discharge unrelated to childbearing Non-milky discharge (pathologic discharge) Etiologies Pregnancy/lactation Galactorrhea Intraductal papilloma Mammary duct ectasia Cancer

Nipple Discharge History Diagnostic testing Exam Unilateral or bilateral Spontaneous, bilateral, milky discharge: Duration, timing Pregnancy test Character of discharge Serum prolactin, TSH Spontaneous or expressed Brain MRI if prolactin One or more ducts Spontaneous, unilateral, uniductal discharge: Other breast symptoms Exam Mammogram or ultrasound Expressed only Comprehensive breast exam None needed If discharge is spontaneous, bilateral, do pregnancy test, prolactin, TSH If discharge is spontaneous, unilateral,uniductal or associated with mass, do mammogram or ultrasound If discharge is expressed only, non-milky, encourage limited breast contact and reassess in 3-4 months

Nipple Discharge Differential diagnosis Management Sexual stimulation Infection, abscess Paget’s disease Management Reassurance if lactation, colostrum, physiologic causes Galactorrhea Depends on cause – pituitary tumor, hypothyroidism Medication management would require long term treatment Surgical modalities for intraductal papilloma, ectasia

Benign Breast Masses Common types of benign breast masses Fibroadenomas Non-tender, encapsulated, round, moveable, firm Often seen in younger women, decreasing with age Cysts Fluid-filled, soft, moveable Often seen with women 30-50 years old Lipomas Fatty tissue Increasing incidence with age Fat necroses Result of trauma to the breast (surgical or external force)

Benign Breast Masses Common types of benign breast masses (continued) Phyllodes tumors Large, fast-growing, firm, palpable mass From periductal stromal cells (may be benign or malignant) Hamartomas Glandular tissue, fat, fibrous tissue Seen in older women Galactoceles Milk-filled cysts, from duct dilation Occur during or after lactation

Benign Breast Masses History Diagnostic testing Physical exam Onset, duration Age < 30: ultrasound Other breast symptoms Age ≥ 30: mammogram Menstrual/medical/family history If mass suspicious for malignancy, order both Biopsy Physical exam Differential diagnosis Comprehensive breast exam Fibrocystic changes Describe mass Tender, moveable, skin changes Infection/abscess Malignancy Lymphadenopathy

Benign Breast Masses Management Fibroadenomas, cysts, lipomas Expectant management – monitor for changes Phyllodes tumors Excisional biopsy recommended Hamartomas Biopsy needed for diagnosis, expectant management Galactocele Aspiration for diagnosis and treatment

Special Considerations Breast cancer is the fear for women presenting with breast concerns Primary objective is to rule out breast cancer Secondary objective is to assess, identify concern, and provide guidance for women with benign breast conditions Breast cancer topic covered in another module