Guidelines 2016 – Breast Pain

Nov 20, 2019 admin PHỤ KHOA 0

Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Breast Pain
N64.4 Mastodynia 

I.  DEFINITION

  1. Background
    1. Breast pain is the most common symptom among women seeking consultation.
    2. Breast pain alone is rarely the presenting symptom in women diagnosed with breast
    3. However, up to 7% of women with newly diagnosed breast cancer presented with breast pain as their only
  2. Cyclic breast pain
    1. Begins during luteal phase and resolves with menses
    2. Usually bilateral with no focal concern
    3. Most common in younger women
  3. noncyclic breast pain
    1. does not correlate with menstrual cycle
    2. May be unilateral or focal
    3. More common in women ages 40 to 50
  4. referred pain
    1. referred pain from sites outside the breast

II.  ETIOLOGY

  1. Cyclic breast pain
    1. Fibrocystic breast tissue (dense, cystic tissue)
    2. Hormonal fluctuations associated with the menstrual cycle
  2. noncyclic breast pain
    1. Breast mass
    2. Breast cyst
    3. Mastitis
    4. Weight gain
    5. trauma (hematoma or fat necrosis may be present)
    6. Caffeine (controversial)
    7. exogenous hormone use
    8. dermal lesions
    9. Pregnancy
  3. extramammary (referred) pain
    1. Musculoskeletal
      1. Chest wall muscle pain (recent trauma; overuse from repetitive movement)
      2. Costochondritis
      3. rib pain
    2. nerve pain
    3. Cardiopulmonary origins (especially on left side)

III.  HISTORY

  1. What the patient may present with
    1. Pain
    2. Lump
    3. swelling
    4. redness—bruised area that does not resolve
    5. discharge from nipple
    6. nipple retraction
    7. Change in appearance of skin and areola
    8. dimpling, scaliness
  2. additional information to be considered
    1. is the pain unilateral or bilateral?
    2. is the pain focal or diffused?
    3. does the pain correlate with the menstrual cycle?
    4. is the woman perimenopausal?
    5. does she feel a mass?
    6. erythema, warmth, swelling, fever
    7. Was there any recent trauma?
    8. Has the woman gained weight?
    9. exogenous hormone use
    10. recent pregnancy or nursing

IV. PHYSICAL EXAM (SEE BREAST MASS, PHYSICAL EXAMINATION, IV) 

V. LABORATORY EXAMINATION

  1. diagnostic mammogram (if older than 30)
  2. targeted ultrasound of area of concern if pain is focal
  3. if discharge is present, guaiac test all discharge for occult

VI. DIFFERENTIAL DIAGNOSIS (SEE BREAST PAIN, ETIOLOGY, II) 

VII.  TREATMENT

  1. if clinical or imaging findings are suspicious, refer to a breast specialist.
  2. if a large cyst is seen, refer to a breast specialist for
  3. if mastitis is present
    1. trial of antibiotics
    2. refer for incision and drainage if necessary
    3. Ultrasound for evaluation of potential fluid collection to be aspirated
    4. Cultures should be sent if infection is suspected.
  4. if clinical exam and imaging are negative, offer reassurance (likeli- hood of malignancy is low).
  5. For women with a negative workup, recommend
    1. nonsteroidal anti-inflammatory drugs (nsaids)
    2. Well-fitting bra (sports bra; wearing at night may be helpful)
    3. eliminate caffeine (may be placebo but helps with some women)
    4. Weight reduction
    5. reduce/eliminate exogenous hormones
    6. Vitamin e and evening primrose oil (inconclusive; likely placebo)
    7. Medical treatment (danazol, tamoxifen) can be considered for severe persistent pain that interferes with daily activities but should be offered only under the guidance of a breast

VIII.  COMPLICATIONS

  1. anxiety related to breast pain
  2. Pain may have an impact on daily
  3. evaluation may result in identification of a suspicious

IX.  CONSULTATION/REFERRAL

  1. if clinical or imaging findings are suspicious, refer to breast specialist
  2. if a large cyst is seen, refer to breast specialist for aspiration to reduce discomfort
  3. all mastitis/cellulitis that do not resolve
  4. Mastitis/cellulitis that is severe or extensive at presentation
  5. referral to plastic surgery for women with large breasts who are considering reduction
  6. When in doubt, refer to a breast specialist

X.  FOLLOW-UP

  1. reevaluate the patient after next menstrual cycle (or in 6 weeks for postmenopausal women) to confirm stability of exam findings and discuss benefit of relief
    1. refer patients who have a change in their clinical
    2. refer patients with significant persistent pain to breast specialist for further
  2. Continue to follow all mastitis/cellulitis to refer patients who do not respond quickly to antibiotics or who have extensive infection at presentation.

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