Breast Pain and Nipple
Discharge
Philip Turton
Consultant Breast, Oncoplastic, and
Aesthetic Breast Surgeon
Leeds General Infirmary
Mastalgia alone or in combination
with lumpiness
is the commonest reason for
referral to a breast clinic
Pain alone
17%
Lumpiness and pain 33%
Non painful lump
36%
Nipple discharge
5%
Family history
3%
50%
Breast Pain

Theory
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Imbalance of essential fatty acids
Hormonal stimulation
Endogenous sensitivity of some breast lobules
Almost never associated with malignancy
with normal examination
Breast Pain

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Non breast mastalgia should be
differentiated by a good history
Consider: Angina, GS, Cervical
spondylosis, Cervical rib, oesophageal
erosions, lesions and achalasia, rib
fracture, torn/strained muscle, pleuritic
pain, pneumonia, pulmonary lesion, Tietz’s
syndrome
Non-cyclical pain
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Unrelated to the menstrual cycle
Described as tight, burning or sore
Constant or intermittent
Usually affects one breast, in a localized area,
but may spread more diffusely across the
breast
Usually affects postmenopausal women in
their 40s and 50s
Cyclical Breast Pain
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Clearly related to the menstrual cycle
Described as dull, heavy or aching
Often accompanied by breast swelling or lumpiness
Usually affects both breasts, UOQs, +/- radiates to axilla
Intensifies during the two weeks leading up to the start
of your period, then eases up afterward
Usually affects premenopausal women in their 20s and
30s and perimenopausal women in their 40s
Mastalgia: Taking a good history
Age, FH, parity
 Previous history of breast problems: cysts,
pain, biopsies, cancer, surgery (BBA, BBR,
mastopexy)
 Previous breast imaging- what, why and
when
 When was last period?
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Menstrual irregularities
Usage of OCP, depot, mirena coil,
progesterone only pill
Breast Pain

Assess the pain: pain chart if not
straightforward
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Site, type, intensity, duration of symptoms
frequency
previous occurrence
Current impact on QOL
Specific concerns eg cancer
FIGURE 3.1
Back to Chapter 3 thumbnails
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FIGURE 3.2
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Examination

NB: re-examine after next period if
presenting in the week prior to
menstruation
Examination:
Mirror signal manoeuvre!!
Examination:
Mirror signal manoeuvre!!
Examination:
Mirror signal manoeuvre!!
Who can be managed initially in
primary care
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Bilateral symmetrical cyclical pain, which
resolves following menstruation
Recent onset breast pain, with normal
examination in young patient
Male patients with simple tender gynaecomastia
Normal examination and recent normal breast
imaging
If in doubt, please refer
Treatment
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Educate and Reassure
Refit bra if obvious problem/ sports bra
helps in short term
Topical NSAID gel
Avoid caffeine completely
Evening primrose oil: 1gm od or BD for
minimum of 3-months, with good
compliance
If on HRT- reduce
If recently started COCP - reassure
If mirena/prog only pill, consider other
Breast Pain

Who to refer: “anything atypical”
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1. Pain associated with definite signs: eg
dominant or discrete lump, palpable focal
thickening: will have triple assessment
2. Patients who have previously had breast
cancer
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Rib met, lung met, LR
3. Persisting pain, same quadrant for 3months
Mammo + targetted USS

normal or B9 changes carries almost 100%
Hospital Treatment of Severe
Mastalgia
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Tamoxifen 10-20mg OD, 4-months
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Use on days 5 to 21 of cycle most effective
S/E hot flushes, vaginal dryness
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Very rare: DVT
Treatment
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Danazol 100mg tds, 4-months
Inhibits pituitary gonadotrophins (FSH &
LH)
Stimulates androgenic pathways
S/E: acne, oily skin, hirsuitism, weight
gain, voice change, thrombosis
Treatment
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Bromocriptine 2.5mg OD, 4-months
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Stimulates dopamine receptors in the brain
and inhibits release of prolactin
Avoid in post-partum period (MI, CVA, HT)
S/E drowsiness, headache, postural
hypotension, nausea, dizziness, dry mouth,
fibrotic reactions
Treatment
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GnRH analogues,
Decrease FSH/LH (after initial surge)
S/E: Hot flushes, sweating, vaginal
dryness, loss of libido
Breast Pain
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Treatment of non-cyclical breast pain
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Usually as for cyclical
More likely to use oral NSAID early on
Often due to duct ectasia; more common
after menopause
Is there a chance that cancer can be
present?
Rare in absence of palpable thickening, or lump.
 Ensure breast looks & feels normal, and no
obvious palp LN
 Repeat examination after 6-weeks
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Questions?
Nipple Discharge
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Causes
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Physiological
Duct ectasia
Mild inflammation
Post-partum
Papilloma
DCIS, Inv ca
Abscess
Very rare: endocrine cause,
joggers nipple
Papillomas and duct ectasia
commonly arise
in the sub areola segment
Duct ectasia
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An aberration of development & involution
Women >50
Nipple discharge, retraction, doughy
palpable mass
Discharge cheesy/ white
Slit-like nipple retraction
Management conservative or surgical
Surgical = total duct excision
Nipple Discharge
Taking a History
 When
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Spontaneous, or on Squeezing
Frequency & duration
Consistency & quantity: spotting on bra,
or staining through to blouse
Blood stained
Current medication: phenothiazines, haloperidol,
methyldopa
Colour
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Usually always insignificant: multi-duct
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Brown and haem negative
Green
White, creamy
Investigate: single duct
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Brown and haem negative but persistent
Brown and haem positive
Serous
Blood stained
Galactorrhea
NB: Use the
standard
urinalysis
sticks
History
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Associated breast symptoms or signs
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Any lump
Any changes near the NAC
Nipple inversion, nipple eczema
Adjuncts to assess risk
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Parity
FH of breast or ovarian ca
Previous breast problems, abnormal breast biopsies
For galactorrhea: amenorrhea/headache/visual
Examination
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Apart from the nipple discharge,
examination is usually normal
Look for the rarely associated signs of a
sinister cause
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Indrawing, lump, sub-areola thickening
Investigation of new nipple discharge
Advise to cease expression
Mammogram/USS if persists
Review in 2-3 months
If persistent bilateral, do serum
prolactin
Investigate further in breast clinic
Investigation
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Nipple fluid: haem test
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If positive do Hadfields procedure
Nipple fluid: smear onto a slide for cytology
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Epithelium should not be seen ie should be “negative
for epithelial cells”
If positive for epithelial cells indicates higher
possibility of papilloma or DCIS, therefore do
Hadfields procedure to send tissue to pathologist
Investigation
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>35: Mammo and USS of NAC
<35: USS of NAC
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Guided biopsy
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Eg USS guided core or FNAC of ?intraduct papilloma
NB: Any clinically palpable lump must
always be biopsied even if mammo and
USS are normal
Treatment
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Diagnostic Surgery
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Uncommon:
microdochotomy/Ductoscopy
“Hadfield’s Procedure”
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Sub areola excision of the major breast
ducts, which is sent for histology
S/E: nipple sensation, nipple necrosis,
infection
Therapeutic operation
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Where results of Hadfields procedure
show DCIS/Inv ca: Usually
mastectomy & IBR
Treatment of non-significant nipple
discharge
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Advise not to squeeze the nipple to look
for further discharge
If persists and is nuisance can refer for
further investigation
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Would tend to do a therapeutic Hadfields
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Ie the purpose is to stop the discharge with the
operation instead of doing it for diagnostic
assessment alone
Key Points
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Breast Pain:
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Most do not need referring, reassure, educate
Refer: not settling, focal nodularity, lump
Nipple Discharge:
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Most are physiological or duct ectasia
Refer: watery or blood stained
Handouts: please email me on eplt@aol.com
Any breast related queries: philip.turton@leedsth.nhs.uk
NHS secretary: Angela Mathie: 0113 3922250
Spiculate mass right breast
Normal left breast
USS of Right Breast Cancer, and USS core,
confirming needle through lesion
MRI of Right Breast Cancer, revealing multifocality
Biopsy: The Mammotome
Handouts: please email me on eplt@aol.com
Any breast related queries:
philip.turton@leedsth.nhs.uk