Mastalgia or Breast Pain
Mastalgia is a term that refers to painful breast and is broadly of 2 types.
This type of breast pain appears to vary with your menstrual cycle and usually affects both breasts. The upper, outer areas of the breast and commonly affected. The pain is usually worse in the few days before the period, improving thereafter.
Simple measures that may help cyclical mastalgia include:
Reduce consumption of caffeine in tea coffee and sodas.
Wear a comfortable, support bra.
Apply warm or cool compresses when the breasts are painful.
Try vitamin E, evening primrose oil or GLA
If your mastalgia is severe and lifestyle limiting, you may be prescribed some additional medications.
This pain is usually localized to one specific part or parts of the breast and does not appear to vary with the menstrual cycle. This type of breast pain should be evaluated by a breast surgeon. Cysts and inflammation can cause this type of pain. Occasionally pain may arise from the rib cage or nerve root. If your pain is associated with redness, fevers, skin changes, swelling or other concerns, you should seek urgent attention.
Breast Feeding Problems
Swollen painful Breasts are common 2-5 days after delivery. Massaging and emptying the breasts with each feed, using a breast pump, cool compresses and occasional pain reliever medications can be used to treat engorgement. If a certain area of the breast feels persistently firm or painful or the skin appears warm and red, you should seek urgent attention. Aggressive massage and heat application should be avoided.
Cracked nipples are common during breastfeeding and can arise from poor latching and infant positioning, high intensity use of breast pump, trauma from baby’s teeth etc. These pose a risk for introducing infections into the breast. Avoiding soap to prevent drying, using purified lanolin creams, air drying the nipples, using nipple shields are measures that can be used to prevent cracked nipples.
Mastitis ( Inflammation of the Breast )
Breast Infections are common during breastfeeding. Bacteria from the baby’s mouth infect breast tissue through cracked nipples. Poor latching and incomplete emptying of the breasts during feeds, increases this risk. Symptoms of mastitis can include fevers, redness, warmth and pain. This should be recognised and treated early to prevent abscess formation.
Breast Abscesses ( Pus collections in the Breast )
Once a pus collection develops in the breast, it rarely improves with antibiotics alone and often needs a drainage procedure. This can be done one of two ways.
A)Percutaneous Abscess Aspiration:
Using ultrasound guidance, we can aspirate the abscess with a needle to remove the pus. This sample is also sent for culture to guide further antibiotic therapy. Multiple such aspirations may be required in some cases.
B) Surgical Incision and Drainage:
This procedure is usually done in the operating room under short general anesthesia. Usually the incision is placed in a way that can allow the mother to continue breast-feeding after the surgery. Daily dressing changes may be needed after this procedure to allow complete wound healing.
Recurring Breast Abscesses
Idiopathic Granulomatous Mastitis (IGM)
IGM is a recurring inflammatory condition of the breast, often presenting as recurring mastitis, abscess, sinuses and fistulae.
The exact cause is unknown and is not due to bacterial infection. It is often seen in young women who have had a prior pregnancy and is believed to be an auto-immune condition. The condition is often misdiagnosed and treated with repeated surgery which leads to loss of breast volume, scarring and deformity of the breast.
Zuska’s Disease (ZD)
ZD is an inflammatory condition specifically affecting the nipple. It presents as abscesses sinuses and fistulae around the nipple. Smoking is a common risk factor for the condition. Changes in the lining of the nipple ducts cause plugging, thick yellow discharge and infection around the nipple. The condition is not associated with pregnancy or breast feeding. It is treated with repeated courses of antibiotics and surgery for removal of sinuses and affected ducts.
Breast Tuberculosis (TB)
Tuberculosis of the Breast is a common condition in India. It causes “cold abscesses” that are typically not warm or painful. It can also present as sinus and fistulae of the breast that drain pus for prolonged periods of time. It can be diagnosed on core needle biopsy but more often than not is picked up after surgery. It needs to be distinguished from granulomatous mastitis as the two conditions are often confused with each-other. The condition does not respond to usual antibiotics and needs to be treated with anti-tubercular therapy for 6 months or more.
Milky discharge from the nipple in a woman who is not pregnant or breast feeding is called galactorrhea. It is often caused by hormonal disturbances or endocrine problems rather than intrinsic problems of the breast itself. To work-up galactorrhea we usually start with a complete review of medications you may be taking. Common medicines that can cause galactorrhea include some antacids, antidepressants, antipsychotics, anti-hypertensive and estrogen containing drugs. A hormonal workup may include measuring blood levels of Prolactin and Thyroid hormones. Rarely galactorrhea may be caused by a tumor in the pituitary gland and hence a complete workup should be done by seeing a breast specialist.
A papilloma often presents as abnormal nipple discharge. Discharge is often seen coming from a single milk duct and is usually bloody or watery. Papilloma can be single of multiple wart-like growths arising from the lining of the ducts. They do not usually present as a lump or swelling and are often missed on mammography and ultrasound. Treatment of a papilloma involves removal of the involved duct system for complete pathological evaluation and treatment. Sometimes a papilloma is associated with atypia or DCIS (ductal carcinoma insitu) and hence a complete removal of the papilloma and involved duct is advised. The surgery can usually be done as a short-stay or day-care procedure and the scar around the areola usually becomes invisible in a few months.
Duct ectasia is caused by thickening of the walls of the milk duct. The milk ducts get plugged and widen. These findings are commonly noted on ultrasound especially in the elderly and often do not need surgery or other treatment. In some patients, especially diabetics and smokers, the condition can cause repeated infections or ‘chronic periductal mastitis’.
Breast Cysts and Fibroadenomas
Breast Cysts are fluid-filled sacs and are not growths or tumors. They do not increase your risk of breast cancer. They can be seen at any age but are more common in young women. ‘Simple cysts’ usually do not need any treatment. ‘Complex cysts’ or cysts that are large and painful are usually aspirated with a small needle to remove the fluid. This fluid can be tested with cytology if it appears bloody. Rarely a type of breast tumor called ‘encysted papillary carcinoma’ can present as a complex cyst.
Fibroadenoma is a commonly found benign or non-cancerous growth. Fibroadenomas are often multiple. They are usually diagnosed with an ultrasound a confirmatory needle biopsy. Not all fibroadenomas needed treatment. Usually once they are larger than 2-3 cm they tend to cause pain and discomfort and can be surgically removed. The surgery can usually be done as a short-stay or day-care procedure. The scar is hidden around the areola or the fold below the breast so that it becomes invisible in a few months.
Fibroadenoma that grow rapidly or recur in the same area after surgery can in-fact be a different type of breast tumor called “Phyllodes tumor”. These should be treated by a breast surgeon who has expertise treatment of the condition.