BREAST PAIN

BREAST PAIN: Excerpt from Differential Diagnosis in Primary Care

Division of the breast anatomically into various components is interesting but not worthwhile in the differential diagnosis of breast pain. It is rather more instructive and practical to use VINDICATE in developing a list of causes of this symptom.

1. V—Vascular infarction in this area is rare, although a pulmonary or myocardial infarction may refer pain to the breast, and congestive heart failure may distend the veins of the breast sufficiently to cause mastitis.
2. I—Inflammation in the form of acute bacterial mastitis occurs in breastfeeding mothers, but it is infrequent. Under other circumstances chronic cystic mastitis is a common cause of unilateral or bilateral breast pain. A breast abscess may develop during lactation. Herpes zoster may affect the skin and nerve roots supplying the breast.
3. N—Neoplasms of the breast, like neoplasms elsewhere, are an unlikely cause of breast pain, but if they infiltrate the skin (i.e., in Paget disease), axillary nerves, or obstruct the ducts they may cause pain.
4. D—Degenerative conditions are rarely a cause of breast pain.
5. I—Intoxication. A number of drugs (e.g., chlorpromazine and ά-methyldopa) may cause gynecomastia and pain. Alcoholism, estrogen, and birth control pills are probably more frequent causes.
6. C—Congenital anomalies are not a significant cause of breast pain.
7. A—Allergic-autoimmune conditions are also unlikely causes of breast pain.
8. T—Trauma from a bite on the breast by a feeding infant is a common cause of acute mastitis and pain. Frequent sexual relations and masturbation of the breasts may induce pain, although some women are reluctant to admit that their breasts have been traumatized this way.
9. E—Endocrine causes of breast pain are numerous. Menstruation, menarche, pregnancy, and menopause are associated with bilateral swollen and painful breasts. Hyperestrinemia from endogenous or exogenous sources is also a frequent cause. Estrogen from birth control pills, estrogen therapy for menopause, and the increase of blood estrogen in chronic liver disease and ovarian tumors are a few of the etiologies in this group. Any pituitary condition associated with an increased output of prolactin may cause swollen, painful, and, of course, lactating breasts. The Chiari–Frommel syndrome is one of these.

BREAST PAIN

Approach to the Diagnosis

The diagnosis of a painful breast is usually made by taking a careful history. What drugs are the patient taking? Associated symptoms and signs (see sections on bloody discharge, page 90 and swelling, page 92) are also important. A culture of the discharge, mammography, and serum, estrogen, and prolactin levels may be important, but referral to an endocrinologist is wise when the history does not provide a simple solution, especially when the pain is bilateral. Biopsy (frozen section) is necessary when tumor is suspected and mammography is equivocal, because faith in mammography has declined somewhat in recent years.

Other Useful Tests

1. CBC (infection)
2. Sedimentation rate (infection)
3. Chest x-ray (metastasis)
4. CT scan of the brain (pituitary adenoma)
5. Sonogram (cyst)
6. Aspiration (cyst)
7. Discontinue suspicious drugs
8. Pregnancy test
9. Surgery consult

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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