Womens Health

Breast Problems: Appearance, Pain, Discharge, Mammogram-U/S

m Woman's Diagnostic Cyber
Frederick R. Jelovsek MD

Get The Facts About Breast Lumps and Pain



Nipple retraction

I know I should see a doctor but I am scared. I have a nipple that regularly retracts, including the areola. At random the nipple sinks in as you watch it and it is very painful. There is no history of any problems in my family nor have I had any problems. I am 30 years old. Any ideas before I find out the expected?

I suspect you are afraid because you think this may be a sign of breast cancer. Most cases of nipple retraction are almost always a benign muscle retraction of the nipple to touch or cold. Some are due to fibrous tissue. Some are due to a benign condition called mammary duct ectasia. Occasionally it turns out to be associated with breast cancer. This is less likely at your age but because it is possible you have to go and get it examined. Pain is usually against breast cancer (10%) but sometimes it can be associated. I've included an abstract below which I hope reassures you more than frightens you. You must have it evaluated by your doctor but most likely it will turn out to be benign.

*****

Mastalgia; is this commonly associated with operable breast cancer?

Ann R Coll Surg Engl 1986 Sep;68(5):262-263

Smallwood JA, Kye DA, Taylor I

A detailed analysis by questionnaire of breast pain in 460 newly referred patients at a specialized breast clinic revealed that only 1.5% of patients with pain had an early breast cancer. Of all 44 cancers 8 were painful but only 4 considered early. All these had nipple retraction. We conclude that although breast pain is rarely associated with cancer, localized pain must be fully investigated to exclude this diagnosis.


Thinking about breast reduction, can I still nurse?

I am thinking about a breast reduction, because I think that it may be the reason I have so many back problems. I am only 23 years old, and I am worried that doing something like that may prevent me from being able to nurse when I have children. Do I have anything to worry about?

With the techniques that most plastic surgeons are using now you should be able to breast feed at a later date. I've included an abstract below about this.

*****

[Breast feeding after breast reduction].

[Article in French]
Ann Chir 1992;46(9):826-829

Caouette-Laberge L, Duranceau LA
Service de Chirurgie Plastique, Hopital Sainte-Justice, Montreal, Quebec, Canada.

Few authors have addressed the feasibility of breast-feeding after a reduction mammoplasty. Nowadays, the majority of plastic surgeons perform breast reductions with techniques preserving the continuity of the nipple-areola complex with the retained breast tissue. These pedicle techniques should permit lactation as opposed to the free nipple grafting technique used earlier. To find out how many women nurse their children after a reduction mammoplasty, we reviewed 806 charts to identify 243 women having had a pedicle technique breast reduction, between 1967-1987, at the age of 15 to 35 years. These women were contacted and 98 of them were reached. Eighteen women had become pregnant after their surgery. They agreed to answer a questionnaire regarding their decision to nurse their children, the duration of breast-feeding and the difficulties encountered. Eight of eighteen mothers (45%) nursed their children up to 32 weeks (mean 11 weeks). Among them, 3 nursed for less than 3 weeks and 5 nursed from 3 to 32 weeks (mean 20 weeks). Only one mother had to supplement nursing with formula. Two mothers used mixed formula and breast-feeding when they returned to work. Ten of eighteen mothers (55%) did not breast-feed for the following reasons: 6 by personal choice, 2 due to premature delivery, one was advised that nursing was not feasible and one had no lactation. We believe that the nursing capacity of the breast is preserved after a breast reduction and that women should be encouraged to nurse their children.



Excess breast enlargement at puberty

I have a 14 year old daughter whose breasts are becoming extremely large. We are having trouble finding bras and comfortable clothes for her and she is starting to become self conscious. This growth has only taken about 8 months and seems to be continuing. I have not taken her to see a doctor about this. We didn't have any concern about her development for awhile because larger breasts are common in our family. Even though the speed of her growth seemed fast, it was only about two months ago that we started to think her development was abnormal. We have discussed plastic surgery, but have decided against it for now. I would like to know how to proceed. Does this fast growth mean that she will stop developing early? Is is better to have a breast reduction early or wait a while?

What you are describing is probably menarchal hypertrophy of the breast. See Menarchal hypertrophy of the breast

As far as I know there is no treatment for it other than reduction surgery. I would probably wait about 2 years after there is no further change in breast size.

While there is no known medical treatment, you might discuss with your gynecologist about putting your daughter on a progestin only or a progestin dominant birth control pill. In theory the progestin may block the receptors in the breast that are sensitive to estrogen. I can't think of an adverse effect of the pills on this. While most 14 year olds are not on birth control pills, some are and they don't seem to have any long term problems with it.



Accessory nipple causes embarrassment

I am a 22 year old female. I have an accessory nipple that is causing me so much embarrassment. I want to have it removed, but I don't know who I should consult first. Please help.

Usually general surgeons or plastic surgeons are the ones who remove these. It's a cosmetic rather than an indicated medical procedure so you can make an appointment with those physicians directly without a referral. Also, since you will probably have to pay for the removal, you might inquire at the time of appointment to talk to the billing person as to how much it's likely to cost and payment options.



Accessory nipple in 4 month infant

My 4 month old appears to have polythelia, an accessory nipple, very small and faint, but definite. Can you give me any information about this?

Polythelia (extra nipples) and polymastia (extra glandular breast tissue) are common developmental abnormalities of the breast and nipple which usually present as small lesions along the mammary line, an embryologic line that extends bilaterally from the axillary regions (armpit) to the inguinal ligaments (groin) and into the vulvar area in females. They are usually benign skin birth defects that are left alone until after puberty.

In most patients I see, extra nipples look like skin moles that women say have been there "as long as I can remember". Infrequently there can be some associated, extra breast glandular tissue development when she undergoes normal breast development at puberty. Again this isn't usually a problem because the amount of glandular tissue is usually very minimal. If it does become a cosmetic problem for her in later life, which in most cases it does not, she can choose to have it removed as a simple, outpatient procedure.

I was not aware of any other conditions or anomalies associated with polythelia so I did a literature search. Apparently there is a low incidence of some association with underlying kidney and urinary tract defects. See abstract below. Keep in mind that the one study only found about 8% of patients with polythelia/polymastia having any renal/urinary defects. You should mention this to your pediatrician to be sure he or she is aware of it.

Urbani CE, Betti R

Accessory mammary tissue associated with congenital and hereditary nephrourinary malformations.

Int J Dermatol 1996 May;35(5):349-352

Dermatology Service, Hospital San Raffaele Resnati, Milan, Italy.

BACKGROUND AND OBJECTIVES. The association between polythelia (supernumerary nipple) and kidney and urinary tract malformations (KUTM) is controversial. Some authors reported this association in newborns and infants. Case-control studies dealing with adult subjects are not found in the literature. The purpose of this study is to determine the frequency of the association between accessory mammary tissue (AMT) and congenital and hereditary nephrourinary defects in an adult population compared to a control group.

METHODS. The study was performed in 146 white patients (123 men, 23 women) with AMT out of 2645 subjects consecutively referred to us for physical examination. The following investigations were undertaken: ultrasonographic examination of the abdomen and the kidneys, ECG, echocardiogram, roentgenogram of the vertebral column, urinalysis, and other laboratory tests. A sex and age-matched control group without any evidence of AMT or lateral displacement of the nipples underwent the same examinations.

RESULTS. Kidney and urinary tract malformations were detected in 11 patients with AMT (nine men, two women) and in one control. These data indicate a significantly higher frequency of KUTM in the AMT-affected patients compared to controls (7.53% vs. 0.68%).



Blue veins on breasts (non pregnant)

What besides pregnancy can cause blue veins to appear on a woman's breasts? There are not sticking out of the skin like varicose veins, but look like blue lines on them. I am 20 years old, quite fair skinned and on the pill (Alesse®). I had some normal breast enlargement from the pill. Should I be concerned?

Has there been any discharge from the breasts? Are there any abnormal lumps or bumps? Does this occur in one or both breasts?

In response to your questions I have no discharge and no really unusual bumps, although my breasts are "lumpy" by nature and have been from day one on the pill. The veins are on both breasts, but one seems to be worse than the other and the enlargement from the pill did make my left breast a little bit bigger than the right.

The veins are most likely due to the breast enlargement that you got with the pills. Anytime an organ system or tissue enlarges, more arterial and venous blood supply is formed. Some women just show it more than others. Your breasts must be sensitive to the estrogen in the pills. This is more common in women under 20 but can happen any age. This is of no concern unless the increase in breast size bothers you. You are on a low dose pill but a different formulation might help. If you try a different formulation, I would suggest one that has a higher progestin potency, e.g., Demulen®, because the progestin may counteract the estrogen's effect on enlarging the breast. There is no scientific evidence that I know of that this will work, but it shouldn't make things worse.


Mondor's disease - thrombophlebitis of the breast

I have a diagnosis of Mondor's syndrome which is an inflammatory condition of the breast. I cannot find any information that is helpful on the web. Can you help?

Mondor's disease of the breast is a superficial thrombophlebitis of the veins of the breast. Usually it is associated with a history of trauma to the breast. Sometimes it can be associated with breast cancer such as an inflammatory carcinoma of the breast. Your doctors will want to follow you closely with mammograms over time. I've included below some abstracts including one in which this was caused by jellyfish stings!

It is a very rare disease; I have never seen it. I don't think you will find any support groups. Maybe that's a service we could organize here at Woman's Diagnostic Cyber, i.e., postings of women with some of the rarer or unusual women's diseases who are looking for others with those same problems.

*****

Mondor's disease and breast cancer.

Cancer 1992 May 1;69(9):2267-2270

Catania S, Zurrida S, Veronesi P, Galimberti V, Bono A, Pluchinotta A
Second Division of Surgery, Ospedale Vittore Buzzi, Milan, Italy.

Mondor's disease or thrombophlebitis of the subcutaneous veins of the chest region is an uncommon condition and is rarely associated with breast cancer. From January 1980 to June 1990, 63 cases of Mondor's disease were diagnosed (57 women and 6 men). In 31 patients, no apparent cause was determined (primary disease), whereas in 32 cases, the disease was secondary because the etiopathogenesis could be discerned. The identified potential causes were three cases of myentasis (all in men), eight cases of accidental local trauma (seven in women), seven cases of iatrogenic origin (three surgical breast biopsies, one skin biopsy, one needle biopsy, one mastectomy, and one reconstruction operation), six cases of inflammatory process, and eight cases associated with breast cancer (all females). Three of the tumors were less than 1 cm in diameter. The authors performed conservative surgery in four patients and demolitive in the other four. In this series, the incidence of breast cancer in association with Mondor's disease was the highest yet reported (12.7%). It was concluded that Mondor's disease may at times be caused by breast carcinoma. This association is by no means exceptional and implies that mammography should always be performed for Mondor's disease, even when the results of a physical examination are negative.

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Mondor's disease as first thrombotic event in hereditary protein C deficiency and anticardiolipin antibodies.

Neth J Med 1997 Feb;50(2):85-87

Wester JP, Kuenen BC, Meuwissen OJ, de Maat CE
Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, Netherlands.

A 45-year-old Caucasian woman presented with superficial thrombophlebitis of the right arm and right anterior thoracic wall after bilateral breast surgery followed by spontaneous left anterior thoracic vein thrombophlebitis 3 months later. Besides breast surgery and use of oral contraceptives, hereditary protein C deficiency and anticardiolipin antibodies were found as causes for this bilateral Mondor's disease.

*****

Mondor's disease.
J Natl Med Assoc 1996 Jun;88(6):359-363

Pugh CM, DeWitty RL
Department of Surgery, Howard University Hospital, Washington, DC 20060, USA.

Mondor's disease, better known as superficial thrombophlebitis of the breast, is an uncommon disorder. Trauma and surgical biopsies head the top of the list of known causes. Over the past 25 to 30 years, various authors have proposed some new etiologies; however, the clinical course of the disease remains unchanged. This article describes three patients who presented for office visits and were diagnosed as having Mondor's disease. Although Mondor's disease is not a precancerous lesion, patients with atypical clinical courses should undergo close follow-up.

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Mondor's disease and aesthetic breast surgery: report of case secondary to mastopexy with augmentation.

Aesthetic Plast Surg 1995 May;19(3):251-252

Marin-Bertolin S, Gonzalez-Martinez R, Velasco-Pastor M, Gil-Mateo MD, Amorrortu-Velayos J
Department of Plastic and Reconstructive Surgery, Valencia University General Hospital, Spain.

Although the etiology of Mondor's disease remains obscure, trauma of some form is the most commonly cited cause. Surgical trauma has frequently been quoted, but references in the literature specifically implicating aesthetic breast surgery are scarce. In this article, we report a case of Mondor's disease secondary to mastopexy with concomitant augmentation mammaplasty.

*****

[Rare venous pathology: Mondor's disease].
[Article in Italian]
Minerva Chir 1994 Nov;49(11):1179-1180

Fornero G, Rosato L, Ginardi A
Reparto di Chirurgia Generale, Regione Piemonte--USSL n. 40 Ospedale di Ivrea, Torino.

A case of Mondor's disease is described. They remark etiopathogenesis and clinical signs of this rare disease that affects thoraco-epigastric vein or one of its confluents. They point to the benignity of the disease that tends to evolve to a spontaneous healing in a few weeks. Authors confirm the advisability of performing appropriate exams to exclude malignancies of the breast.

*****

[Mondor's disease: our experience].
[Article in Italian]
G Chir 1994 Aug;15(8-9):355-357

Decembrini P, Mobili M, Attardo S, Paolucci G, Del Papa M, Troiani F, Braccioni U
Divisione di Chirurgia Generale, Ospedale Civile, Civitanova Marche MC.

Mondor's disease is commonly described as thrombophlebitis of the subcutaneous veins of the chest. It is a relatively uncommon syndrome, generally considered of trivial importance for its poor symptoms: local pain, rarely fever. Recovery is obtained in one or two months with adequate medical treatment. Common causes are traumas, surgery, stress, breast phlogosis; however, some Authors still consider the syndrome as a sinchronous breast cancer "marker".

*****

Mondor's disease of the breast resulting from jellyfish sting.

Med J Aust 1992 Dec 7;157(11-12):836-837

Ingram DM, Sheiner HJ, Ginsberg AM
Queen Elizabeth II Medical Centre, Nedlands, Wa.
OBJECTIVE: To present two cases of Mondor's disease of the breast resulting from jellyfish stings in Western Australia.
CLINICAL FEATURES: A 30-year-old Caucasian woman presented with a palpable thickened cord in her right breast. The straightness of the cord suggested a thrombosed lymphatic. A 50-year-old Caucasian woman presented with an obvious palpable cord extending most of the length of her left breast. Mammography demonstrated no abnormality. Both women reported having been stung by jellyfish a month earlier.
INTERVENTION AND OUTCOME: As Mondor's disease is a benign, self-limiting disease, the patients were reassured and reviewed routinely. In each case, the condition settled spontaneously over a period of several weeks.
CONCLUSION: Jellyfish stings should be recognised as an unusual variant of the numerous causes which have been described for Mondor's disease.



What determines breast size and shape?

What determines the shape of the nipple and breast? Is there anything you can do to alter it (with or without going to a doctor??)

The breast changes in size and shape due to estrogen after menarche. By about age 18 in most women the breasts are at their adult size and shape. Pregnancy, menopause, and of course weight gain or loss can alter size.

I'm not sure there is much that can change things other than what you may already be aware of, i.e., failing to wear support bras may result in breasts becoming lower and lengthening. Theoretically, tightly binding the breasts in conjunction with weight loss and exercise may cause the breasts to lose more fat than the rest of the body and thus become proportionately smaller. I don't think you can change the nipples and areolas short of surgical procedures.



One breast slightly larger than the other

I am 15 years old. About a year ago, I noticed my right breast was slightly larger than my left one. I didn't think much of it. However, in the past year the right breast has become a lot larger than the left. The nipple also seems to be large and abnormal. This worries me greatly. What is causing this and what can I do? it.

Breast growth in young women can be at a variable rate. Although initial breast growth (breast budding) is the first sign of puberty (avg. age 10.8 +- 1.1), completion of growth is often the last step in puberty (on average 4.5 +-2.04 after the initial breast development or 2.3 years +- 1.5 after onset of menses.

By these numbers you can gauge how many more years the breasts may continue to grow. The tables do not tell you, however, that it is very common for the breasts to grow at different rates and there can be large discrepancies during this growth period. Eventually the slower growing breast catches up but many women will continue to have some inequality in size. The question becomes how much. Most often any remaining inequality is insignificant and is not noticeable by anyone other than the woman herself. However, it is not uncommon to have a difference of as much as one cup size. Most plastic surgeons do not recommend any treatment unless there is at least a two cup size difference. But because this may take care of itself, you need to wait at least until about 6 years after the onset of your menses before deciding to have any corrective action taken.

 

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