1. Palpable masses
2. Spontaneous nipple discharge
3. Skin or nipple changes
4. Breast pain

Palpable masses
If the woman comes to the health care provider with a suspected mass or if a mass is detected on clinical breast examination (CBE), a thorough history and workup are indicated. The most common breast problems causing palpable masses are fibroadenomas, cysts, fibrocystic changes, and breast cancer. The prevalence of these diseases varies significantly by age.

In women under 25 the most likely cause of a breast symptom is a mass. The most likely cause of such a mass is a fibroadenoma, a benign tumor composed of fibrous tissue. The prevalence of fibroadenoma in adolescents with palpable masses is estimated at 70% to 80%. Therefore in this group the diagnosis is often easy to make. Fibroadenomas are extremely mobile, smooth, firm, and usually non tender (Osuch). Referral to a breast surgeon for excisional biopsy is recommended if the mass is palpable, increasing in size, or psychologically disturbing to the woman (American College of Obstetricians and Gynecologists).

During pregnancy and lactation, increased vascularity can produce bloody nipple discharge. This is usually self-limited, but breast feeding may continue in this setting. In addition, fibroadenomas may become larger during this period. Breast cancer incidence is not different during this time, but workup of a mass should not include mammography because of the radiation risk to the fetus.

During mature reproductive age (25 to 40) the breast undergoes cyclic changes in response to ovarian hormonal fluctuations. This may produce nodularity and tenderness, especially in the week before menses. This condition, termed fibrocystic change, is extremely common. In women in this age group, over 50% of masses are due to fibrocystic changes, approximately 25% are fibroadenomas, 10% are cysts, and 10% result from breast cancer (Osuch).

From age 35 to 55, the breasts undergo involution of normal breast tissue, causing formation of cysts, fibrocystic changes, and other inflammatory conditions. These changes and the increasing incidence of breast cancer make differentiating benign from malignant masses difficult in this age group. Cysts increase in prevalence as menopause nears. The incidence of breast cancer in this group of women with palpable masses is an estimated 35%, while fibrocystic changes and cysts account for 55% of masses (Osuch).

In women aged 55 and over, breast cancer accounts for the majority of masses. The development of benign breast lumps in postmenopausal women is relatively rare. Therefore any mass in a postmenopausal woman is suggestive of cancer until proven otherwise (Cady, PHS document).

Spontaneous nipple discharge
Most nonspontaneous nipple discharge is normal. Spontaneous nipple discharge is not normal and should be further considered. To detect spontaneous nipple discharge, ask the woman if she has noticed discharge on her undergarments or in her bedclothes. Next determine whether the discharge is unilateral or bilateral and from a single duct or many ducts. Bilateral milky discharge from multiple ducts usually has a systemic cause such as pregnancy, pituitary adenoma or other endocrinopathy, or drugs (Osuch). If the discharge is not milky but is also from multiple ducts, consider duct ectasia. This is a condition that occurs in perimenopausal and postmenopausal women. The woman may have a tender, hard mass close to the areola, often associated with a thick, greenish discharge. Pathologic evaluation shows dilated terminal collecting ducts filled with inspissated material. This is often followed clinically unless symptoms are unpleasant or uncomfortable. At that point, referral to a surgeon for possible removal of the subareolar duct system is appropriate.

Unilateral, spontaneous discharge from a single duct should be referred to a surgeon for further evaluation. The differential diagnosis includes intraductal papilloma, fibrocystic change, duct ectasia, and breast cancer. The majority of these discharges result from an intraductal papilloma, a benign condition. However, characteristics of the discharge (such as bloody or watery) cannot differentiate among these conditions, and surgical evaluation is necessary (Osuch). All women with spontaneous nipple discharge should have bilateral mammography even though the yield is relatively low. Cytologic evaluation of discharge is generally not useful.

Skin or nipple changes
Skin erythema may be caused by mastitis. This is most common in breast-feeding women but may also occur in nonlactating women. Inflammatory carcinoma and periductal mastitis are two important causes of nonlactational mastitis. Periductal mastitis is often due to duct ectasia and colonization of inspissated material, and it can lead to chronic abscess formation (Osuch). Inflammatory carcinoma causes erythema and breast thickening by lymphatic obstruction and has a poor prognosis. Diagnosis requires skin biopsy. Skin dimpling may suggest an underlying cancer, and women should be referred to a surgeon for further evaluation.

Nipple retraction can be caused by benign or malignant conditions. Even if the findings of CBE and mammography are normal, women with nipple retraction should be referred to a surgeon. Nipple scaling can be a sign of Paget’s disease of the nipple. This is in situ cancer of the nipple associated with in situ or invasive breast cancer. If the nipple is not involved, Paget’s disease is less likely, but if symptoms do not resolve within a short time, women should be referred to a surgeon.

Breast pain
Breast pain is a common complaint. Although breast cancer presenting solely as breast pain is uncommon, this symptom should be taken seriously, with a thorough history and CBE. Questions about whether pregnancy is likely, whether the pain varies with menstrual cycle, whether it is bilateral or focal, and whether it is related to hormone use should be asked. If CBE does reveal a mass, an appropriate workup should be performed. If CBE does not reveal a mass, mammography should be performed only if appropriate for screening purposes. Yield of mammography is low if the only symptom is breast pain. If breast cancer is ruled out (no mass, screening mammogram normal in age-appropriate women), the woman should be reassured. Most breast pain is self-limited and related to fibrocystic changes. Women should be counseled to try an antiinflammatory medication and a more supportive brassiere. In addition, reducing foods high in methylxanthines (caffeine, chocolate) may be helpful. If the woman is receiving HRT, decreasing the dose of estrogen may reduce breast pain (Osuch).