Benign breast disease can present as a lump, pain, nipple discharge and skin changes. Exclusion and referral in the presence of a discrete lump always takes precedence.
The most common cause of benign breast lumps is fibrocystic disease. The lumps are rubbery and ill-defined commonly found on the upper outer sections of the breast. They tend to be common during the reproductive years and uncommon in those under 25.
If the nodularity is symmetrical and non-discrete then a review in six weeks asynchronous to the menstrual cycle is indicated. Where nodularity is asymmetrical and is associated with increased genetic risk a referral is required.
Breast cysts can also present as lumps. They have a typical fluid-filled, tense consistency. Clinical examination is not sufficient to exclude malignant disease and referral will be required.
Cystic lumps developing in the subareolar area after lactation has stopped are likely to be galactocoeles. Common complications are mastitis and abscess. Where resolution does not occur referral for a biopsy is required. Mastitis, not in the context of breast-feeding, should arouse suspicion of an underlying cause.
Physiological states that cause breast pain are pregnancy, breast feeding and puberty and require nothing more than reassurance. Other causes of pain include drugs (for digoxin and spironolactone) and shingles.
Where pain and a lump are present, the management of the lump takes precedence. Where there is no specific cause and in the absence of a discrete lump, mastalgia may be divided into cyclical and non-cyclical. A pain chart can be used to help patients keep a diary of the pain to help distinguish between the two.
Cyclical mastalgia usually occurs midcycle onwards, affects the upper outer areas of the breast and is relieved by menstruation. The pain is variable. When it is mild, reassurance and an explanation of the hormonal aetiology will suffice. If severe, a reduction in dietary fat and a trial of mechanical contraception rather than hormonal may help. Continuing and intractable or severe pain needs referral.
Discharge and skin changes
In those aged under 50, if the discharge is clear and of small volume this simply requires reassurance. Where the volume is large or the discharge is unilateral, blood stained or persistent an urgent referral is indicated. Discharges in those aged 50 and over should always be referred urgently.
Galactorrhoea outside the context of pregnancy or lactation can be secondary to drugs (for example, contraceptives, tricyclics and metoclopramide) or a prolactinoma. Cessation of the medication and a measurement of blood prolactin levels will guide management.
Changes in texture of the breast skin, ulceration skin tags, skin distortion, recent nipple retraction and persistent or unilateral nipple eczema are indications for urgent referral.
Dr Hashmi is a GP and a part-time tutor at St George’s Hospital, London
- Examination and referral of a presence of a discrete lump is imperative.
- Breast pain is uncommonly associated with cancer.
- Galactorrhoea in elderly patients should be investigated.
- All breast skin changes need urgent referral.