Doctor’s Corner
WE started the focus on breast problems last week.
Cyclical and non-cyclical breast pain was described, including a look at some of the important implications of breast pain.
Different causes of breast lumps were also discussed.
This article will continue to reveal more causes of breast pain and lumps, including causes of discharge from the nipples, breast trauma and infection.
In the following articles, the issue of breast-feeding will be covered before we look at breast cancer.
Nipple discharge is a common problem that can force patients to seek help from their doctor.
Nipple discharges are commoner in women over 35 years. In younger women they are associated with oral contraceptives.
There are three common causes: mammary duct ectasia, duct papilloma and galactorrhoea.
The cause of mammary duct ectasia, as with many breast disorders, is an exaggeration of the normal cyclical changes — a wear and tear process.
The breast, among other constituents such as fat, is made up of a network of ducts, which are bodily tubes that carry secretions such as breast milk from glands.
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The ducts adjacent to the nipple can become filled with these breast secretions, making them engorged and dilated, causing blockage and allowing infection to set in, with pus being discharged.
Discharge from the nipple can range from milky to dirty green and is often, but not always, on both breasts.
Occasionally, it is associated with pain, usually cyclical.
(Remember, we said cyclical pain is breast pain that is related to menstrual periods. Cyclical pain is usually in the early phase of the cycle, with intensity gradually worsening to reach a peak just before menstruation, easing with the start of the period).
The infection that sets in from the blockage in ducts causes pain and swelling of the breast and therefore the feeling of a lump.
So infection is yet another cause of lumps in the breast.
Long-standing (chronic) inflammation is often associated with nipple retraction, which gives it the appearance of the feared breast cancer.
The discharge in an infected breast does not necessarily come out through the nipple only, but also in the margins of the darker area surrounding the nipple called the areola. The discharge comes out through small openings called sinuses.
Patients above 35 years of age can go for mammography to establish the general state of the breast.
Mammography is a photograph of the breasts made by X-rays, and is of little value in woman under 35 years of age because the breasts are frequently too dense for small lumps to be seen.
A small sample (swab) of the discharge may be taken by your doctor for laboratory assessment.
If both these investigations find nothing abnormal, then nothing needs to be done because everything will be fine.
In situations where discharge is troublesome and is persisting then the doctor may advise a small operation that involves cutting out part of the duct system, but this is not commonly done.
Another common cause of nipple discharge is an abnormal, non-cancerous tissue mass (tumour) called a duct papilloma, which is a wart-like tumour.
This is a very uncommon condition associated with a bloodstained discharge usually from one nipple.
The duct papilloma is not a cancer, but the presence of a cancer should always be excluded especially when blood-staining of the discharge is present.
But do not be alarmed because the majority turn out not to be cancers.
However, in spite of not finding a cancer, it may be necessary at times to remove the small part of the duct system.
Galactorrhoea is a common condition in which there is a spontaneous flow of milk from the nipples that follows breast-feeding and is caused by a persistently high level of a certain hormone called prolactin. We will discuss this in detail when we look at aspects of breast-feeding.
Trauma to the breasts is relatively rare although sexual encounters and love bites may be responsible for injury.
A blunt impact, including a fist punch to the breast, can interfere with blood supply to the area and, together with an accumulation of blood due to the bleeding, can disrupt blood supply and result in the “death” of cells in the area including fat cells.
This can also result in a hard, painful lump in the breast. The accumulation of blood (haematoma) can also provide a medium for infection to set in.
Infection is common in the breast. The two common causes are lactational breast abscess and peri-ductal mastitis.
Lactation is the natural process of secretion and yielding of milk from the mammary glands of the breast.
The condition called lactational breast abscess is a complication of lactation and breast-feeding.
There is a bacteria that is involved almost all the time, commonly found on the skin called staphylococcus aureus.
It is believed that the bacteria enter into the breast through cracks in the nipple during feeding.
A segment of the breast becomes inflamed. The mother may have noticed obvious cracks in the nipple although this is unusual.
The pain in lactational breast abscess can be so severe that sleep can be lost.
When the doctor takes a look, a tender segment of the breast may be found, perhaps with evidence of nipple damage.
The swelling may feel soft (fluctuant) or hard depending on how much pus has accumulated inside.
If detected early and treated with appropriate antibiotics and anti-inflammatory drugs, it will easily clear.
Feeding from the affected side will need to be stopped and the milk expressed from the healthy segments so that it does not accumulate and cause complications as described above.
The doctor may also decide to drain out the pus using a needle and syringe to relieve the pain and reduce the swelling.
The pus will be sent to the laboratory for investigation.
The other common infection of breasts is called periductal mastitis, meaning inflammation around the ducts in the breasts.
It affects young women in their 30s and is associated with smoking and the infection can result from trauma or other infections already existent in the body or surface of the skin.
There may also be swelling like any other inflammatory condition which can be treated with antibiotics and anti-inflammatory drugs.
So other than the conditions we mentioned in the last article that cause pain and breast lumps, we have seen in this article that there are many more causes.