Patient education: Common breast problems (Beyond the Basics)

COMMON BREAST PROBLEMS OVERVIEW — Breast problems, such as breast lumps, breast pain or tenderness, nipple discharge or inversion, and changes in the skin of the breast, are common in women of all ages, from adolescents to older women. While it can be frightening to discover a new breast problem, most breast problems are not caused by breast cancer.

This topic will review some of the most common breast problems, including those that you or your healthcare provider may find. This article will also review how common breast problems are evaluated and treated.

More detailed information about common breast problems is available separately. (See "Overview of benign breast diseases" and "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass".)

BREAST LUMP — You or your healthcare provider may find a breast lump by looking at or feeling your breast. It is difficult to determine by examination alone if a lump is caused by breast cancer. Although most breast lumps in women age 20 to 50 are not cancerous, all new breast lumps should be evaluated by a healthcare provider to determine if further testing is needed.

Evaluation — After a breast examination, the best test for evaluating a breast lump depends, in part, upon your age.

Women under age 30 — If you are under 30 years and you find a lump before your menstrual period, you may be advised to have a repeat breast examination after your period has ended. In this age group, breast lumps are often caused by hormonal changes and will resolve after your menstrual cycle.

If the lump does not go away when your period is over, you will likely need further testing with a breast ultrasound or needle aspiration biopsy to determine whether the lump is fluid filled or solid. Mammograms are not usually performed in women under 30 years old, although a mammogram may be needed if the ultrasound does not provide enough information.

Women age 30 and older — Women who are age 30 or older who find a new breast lump will need a diagnostic mammogram and usually an ultrasound as well. During a diagnostic mammogram, a mammography technician works with a radiologist to study the area that feels or appears abnormal. Often, a mammogram of the other breast is done for comparison. If the lump appears suspicious on the mammogram and/or the ultrasound, a breast biopsy is usually recommended. (See "Breast imaging for cancer screening: Mammography and ultrasonography".)

Ultrasound and needle aspiration — Ultrasound of the breast may be recommended to determine whether a lump is fluid filled or solid. Needle aspiration (using a needle and syringe to withdraw fluid) is another option.

●Fluid-filled cysts are not usually caused by cancer and only require treatment if they cause discomfort. Treatment for a fluid-filled cyst, if necessary, usually includes draining the fluid with a needle.

●Women with a solid or "complex" (fluid and solid) breast nodule are usually advised to have a biopsy. (See 'Breast biopsy' below.)

Breast biopsy — A breast biopsy is often recommended to further evaluate a new breast lump. A breast ultrasound, mammogram, or needle aspiration may be recommended before a biopsy. (See 'Breast lump' above.)

If your healthcare provider can feel the lump, they can often biopsy the area with a needle right in the office. This may involve removing some cells (fine needle aspiration) or a small sample of tissue (core needle biopsy).

If the abnormality cannot be easily felt but is visible on the ultrasound, a needle biopsy can be done under ultrasound guidance. This involves placing a needle in the abnormal area and removing a sample of tissue, which is later examined with a microscope.

If the abnormality can be seen only on the mammogram, there are two ways to biopsy the area:

●A needle biopsy may be done in radiology with local anesthesia using mammographic guidance (called stereotactic biopsy).

●Occasionally, biopsies must be done surgically instead. In this case, the radiologist will work with the surgeon to mark the abnormal area with a thin wire, radioactive or magnetic seed, or another method prior to surgery. After the radiologist places the seed or wire, the surgeon can use it to guide removal of the proper area. Surgical biopsy is usually recommended only if the biopsy cannot be obtained with less invasive methods.

ABNORMAL MAMMOGRAM — Having an abnormal screening (initial) mammogram can cause concern. Fortunately, most women with abnormal mammograms do not have breast cancer. An abnormal mammogram may be due to a mass, a collection of calcium deposits (called calcifications), or other factors. Sometimes, normal breast structures can overlap in a way that can look abnormal even if nothing is really there.

If you have an abnormal screening mammogram, the next step depends on the type of abnormality found.

●If the abnormality is likely benign (not cancerous), you may be advised to have a follow-up mammogram in six months.

●If the mammogram shows an area that is abnormal, the next step is to have additional imaging, such as a diagnostic mammogram. During a diagnostic mammogram, a mammography technician works with a radiologist to study the area that feels or appears abnormal. Different angles can be used, and the picture can be magnified and/or targeted to a particular area of interest. The radiologist can usually review the mammogram immediately and discuss the results with you. In some cases, an ultrasound may be performed to better define the abnormality.

In many cases, the diagnostic mammogram shows that the abnormality is benign (not cancerous), and no further testing is needed. However, if the diagnostic mammogram is indeterminate or suspicious for cancer, a breast biopsy is recommended. (See 'Breast biopsy' above.)

●Occasionally, other types of breast imaging, such as magnetic resonance imaging (MRI), may be required to further evaluate the abnormality found on mammogram.

BREAST PAIN OR TENDERNESS — The most common type of breast pain is caused by the hormones that control the menstrual period. These hormonal changes can cause pain in both breasts several days before the menstrual period begins. Because the pain can come and go with the menstrual cycle, it is called "cyclical" breast pain. Cyclical breast pain is not usually caused by breast cancer or other serious breast problems. Breast pain in the perimenopausal years may also be related to hormonal changes.

Less commonly, a woman can have breast pain that does not come and go with the menstrual cycle (also called noncyclical breast pain). This type of pain is not related to the menstrual cycle and might occur in only one breast or one area of the breast. Noncyclical breast pain is usually caused by a problem outside the breast, such as muscle or connective tissue strain, skin injury, spinal conditions, or problems in another organ system (eg, heart burn, chest pain). Noncyclical breast pain is caused by breast cancer in only a very small percentage of women. (See "Breast pain".)

If you are worried about breast pain, speak to your healthcare provider to determine if you need further testing. If testing shows no signs of a serious problem, you can try one or more of the following treatments:

●Pain relief medicines, such as acetaminophen (Tylenol and others) or ibuprofen (Advil, Motrin, and others). Women with very severe breast pain are sometimes treated with a prescription medicine.

●Decrease the dose or stop taking medicines that contain estrogen (after a discussion with your healthcare provider).

●Wear a well-fitted support or sports bra.

●Consider making changes to your diet. Elimination of caffeine and a low-fat, high-complex-carbohydrate diet is helpful for some women. Dietary supplements such as vitamin E and evening primrose oil have also been suggested for breast pain; however, there is no proof that these are effective. (See "Breast pain".)

NIPPLE DISCHARGE — Having a milky-colored discharge (also called galactorrhea) from both nipples is common, especially during the first year or two after giving birth. Nipple discharge from both breasts can also occur in women with an underactive thyroid (hypothyroidism), as a side effect of certain medications, or because of a growth in the pituitary (a part of the brain), causing an increase in a hormone called prolactin. (See "Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics)" and "Patient education: High prolactin levels and prolactinomas (Beyond the Basics)".)

As with other ducts in the body, breast ducts make and carry secretions. Many women can express (squeeze out) a small amount of yellowish, greenish, or brownish discharge. This is often called "physiologic" discharge and is not a cause for concern. Physiologic discharge is not bloody.

Spontaneous nipple discharge (discharge that occurs without squeezing) or nipple discharge that is clear (not yellow or straw colored) or bloody may be caused by an abnormal growth within the breast or, less commonly, by breast cancer.

Any woman with nipple discharge should be evaluated by a healthcare provider. A mammogram, breast ultrasound, breast MRI scan, and/or examination of the breast ducts (ductogram, also called galactogram) may be recommended in some cases. (See "Nipple discharge".)

INVERTED NIPPLES — Many women are born with nipples that naturally invert (pull in) at times and evert (poke out) at other times (sometimes called "bifid," "cleft," or "slit-like" nipples). Other women find that this happens after breast feeding. Nipple inversion of this type is not cause for concern.

If your nipples have always been everted, however, and begin to invert for no obvious reason, this should be evaluated by your healthcare provider. Most causes of nipple inversion are not a cause for concern, but occasionally this is the first sign of a breast cancer. New nipple inversion is usually evaluated with a breast examination and mammogram as a first step.

BREAST SKIN CHANGES — Skin problems can develop on or near the breast, some of which cause itching, scaling or crusting, dimpling, swelling, redness, or changes in skin color. While most of these changes are not caused by a serious breast problem, it is important to be evaluated if a skin problem on your breast does not resolve within a few days.

More serious causes of skin changes on the breast can include less common forms of breast cancer, such as Paget disease or inflammatory breast cancer. Other, more common skin problems, such as rashes, moles, cysts, or skin infections, can occur on the skin of the breast as well. (See "Patient education: Locally advanced and inflammatory breast cancer (Beyond the Basics)" and "Nonlactational mastitis in adults" and "Paget disease of the breast (PDB)".)

The evaluation of breast skin changes usually includes a breast examination and may include a mammogram. A skin biopsy may be needed to confirm the diagnosis.

WHEN TO SEEK HELP — If you find a new breast problem, you should make an appointment with your primary care or gynecologic healthcare provider within a few weeks. Although breast problems are not usually an emergency, delaying the evaluation for months can potentially allow the problem to worsen.

In some cases, this evaluation will be all that is needed. In other cases, you may be referred for further testing or evaluation with a breast surgeon.

If your initial evaluation shows no sign of a problem but you remain concerned, talk to your healthcare provider. Further testing, follow-up over time, or referral to a breast specialist may be recommended.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Common breast problems (The Basics)
Patient education: Breast cancer screening (The Basics)
Patient education: Inflammatory breast cancer (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Breast cancer screening (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass
Screening for breast cancer: Strategies and recommendations