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Mastitis
- Inflammatory breast infection, most commonly associated with lactation, caused by milk stasis with secondary bacterial infection
Clinical Presentation
- Localized breast pain, erythema, warmth, and swelling
- Often unilateral
- Associated fever and malaise
- Most common in breastfeeding women, especially early postpartum
- The question stem will sound like: a breastfeeding patient with fever and a painful red area on one breast
Assessment
- Clinical diagnosis
- No imaging needed initially
- Failure to improve raises concern for breast abscess
Management
- Continue breastfeeding or pumping
- Oral antibiotics targeting Staphylococcus aureus
- Supportive care: NSAIDs, warm compresses
Exam Keys
- Breastfeeding + pain + erythema + fever = mastitis
- Do not stop breastfeeding
- No improvement after 48–72 hours → evaluate for abscess
Breast Abscess
- Localized collection of pus within the breast, most often a complication of unresolved mastitis
Clinical Presentation
- Focal, tender, fluctuant mass with overlying erythema
- Persistent breast pain and swelling
- Fever may persist despite antibiotic therapy
- Usually unilateral
- Most common in lactating women, but can occur in nonlactating patients
- The question stem will sound like: a breastfeeding patient whose breast pain and fever did not improve after antibiotics and now has a painful lump
Labs, Studies, and Imaging
- Breast ultrasound to confirm abscess and guide drainage
- Suspect when no improvement after 48–72 hours of appropriate mastitis treatment
Management
- Drainage (needle aspiration or incision and drainage)
- Antibiotics targeting Staphylococcus aureus
- Continue breastfeeding or pumping if feasible
Exam Keys
- Mastitis that fails to improve → think abscess
- Fluctuant mass suggests abscess, not mastitis
- Antibiotics alone are not sufficient
Galactorrhea
- Inappropriate milk production unrelated to pregnancy or breastfeeding, most often due to elevated prolactin
Clinical Presentation
- Milky nipple discharge, often bilateral
- May be spontaneous or expressed
- Can occur in women or men
- May be associated with amenorrhea, infertility, decreased libido, or headaches
- The question stem will sound like: a nonpregnant patient with milky nipple discharge and menstrual irregularities
Labs, Studies, and Imaging
- Serum prolactin: elevated in prolactinoma, medication-induced causes, or hypothyroidism
- Pregnancy test: always rule out pregnancy first
- TSH: hypothyroidism increases TRH, which stimulates prolactin release
- MRI of the pituitary: indicated when prolactin is elevated to evaluate for prolactinoma
Common Causes
- Prolactinoma
- Medications that block dopamine, such as antipsychotics, antidepressants, and antiemetics
- Hypothyroidism
- Chest wall stimulation or trauma
Management
- Treat the underlying cause
- Dopamine agonists for prolactinoma
- Treat hypothyroidism if present
- Adjust or discontinue offending medications when possible
Exam Keys
- Milky discharge outside lactation = galactorrhea
- Elevated prolactin drives the workup
- Always check TSH and pregnancy test
- High prolactin → pituitary MRI
Gynecomastia
- Benign proliferation of glandular breast tissue in males, caused by an imbalance between estrogen and androgen activity
Clinical Presentation
- Bilateral or unilateral breast enlargement in males
- Rubbery or firm tissue beneath the nipple-areolar complex
- May be tender, especially early
- Can occur in newborns, adolescents, and older men
- The question stem will sound like: a male patient with tender breast enlargement and no discrete mass
Assessment
- Focus on onset, symmetry, and associated symptoms
- Evaluate for systemic causes if atypical or persistent
- Distinguish from pseudogynecomastia (fat deposition only)
Labs, Studies, and Imaging
- Labs if concerning features or unclear cause:
- Testosterone
- Estradiol
- LH and FSH
- TSH
- Imaging only if suspicious for malignancy (hard mass, nipple discharge, skin changes)
Common Causes
- Physiologic (puberty, aging)
- Medications such as spironolactone, antiandrogens, anabolic steroids
- Endocrine disorders (hypogonadism, hyperthyroidism)
- Liver or kidney disease
- Testicular tumors
Management
- Reassurance for physiologic gynecomastia
- Treat underlying cause if identified
- Discontinue offending medications when possible
- Surgical referral for persistent or symptomatic cases
Exam Keys
- Tender glandular tissue under nipple = gynecomastia
- Painless hard mass → think malignancy
- Most cases are benign and self-limited
Fibrocystic Changes
- Benign, hormone-related breast condition caused by cyclic estrogen effects, leading to pain and nodularity
Clinical Presentation
- Bilateral breast pain and tenderness
- Diffuse, lumpy or nodular breasts
- Symptoms worsen premenstrually and improve after menses
- No single dominant mass
- Most common in premenopausal women
- The question stem will sound like: a woman with bilateral breast pain and lumpiness that worsens before her period
Labs, Studies, and Imaging
- Clinical diagnosis in classic presentation
- Imaging if focal mass, atypical features, or diagnostic uncertainty
- Ultrasound preferred in younger women; mammography in older women
Management
- Reassurance
- Supportive care such as NSAIDs and supportive bra
- Symptoms often improve over time
Exam Keys
- Cyclic pain + bilateral nodularity = fibrocystic changes
- Benign condition
- Reassurance is appropriate
Fibroadenoma
- Benign solid breast tumor composed of fibrous and glandular tissue, most common in young women
Clinical Presentation
- Firm, rubbery, well-circumscribed mass
- Freely mobile, often described as “slips under the fingers”
- Usually painless
- Size may increase with pregnancy or estrogen exposure
- Most common in women under 30
- The question stem will sound like: a young woman who notices a painless, mobile breast lump found incidentally on exam
Labs, Studies, and Imaging
- Ultrasound is first-line imaging in younger patients due to dense breast tissue
- Diagnosis often clinical with imaging
- Biopsy if features are atypical or diagnosis is uncertain
Management
- Reassurance and observation if classic presentation
- Surgical excision if enlarging, symptomatic, or diagnostic uncertainty
Exam Keys
- Young patient + mobile, rubbery mass = fibroadenoma
- Benign lesion
- Often managed conservatively
Malignant Breast Neoplasms
Malignant Breast Neoplasms
- Cancerous tumors of the breast with potential for local invasion and metastasis
- Exam focus is recognition and escalation, not cancer subtypes or staging
Clinical Presentation
- Hard, painless, fixed mass
- Usually unilateral
- Irregular borders
- Skin changes such as dimpling, nipple retraction, or peau d’orange
- Possible bloody or serous nipple discharge
- May have axillary lymphadenopathy
- The question stem will sound like: a patient with a firm, painless breast mass and skin or nipple changes
Risk Factors
- Increasing age
- Family history of breast cancer
- Prolonged estrogen exposure (early menarche, late menopause, nulliparity)
- Prior chest radiation
Labs, Studies, and Imaging
- Imaging first, based on age
- Ultrasound in younger patients with dense breast tissue
- Mammography in older patients
- Biopsy required for diagnosis
- Labs do not establish diagnosis
Management
- Prompt referral for biopsy and oncologic management
- Treatment depends on stage and tumor characteristics
- Early detection significantly improves outcomes
Exam Keys
- Painless, hard, fixed mass = malignancy until proven otherwise
- Skin or nipple changes are red flags
- Suspicious mass → image, then biopsy
- Do not reassure
Breast Complaints: Key Differentiators
-
Mastitis vs Breast Abscess
- Diffuse pain, erythema, and fever that improve with antibiotics vs persistent pain with a focal, fluctuant mass requiring drainage
-
Fibroadenoma vs Fibrocystic Changes
- Single, mobile, rubbery mass in a young woman vs bilateral, diffuse nodularity with cyclic pain
-
Benign vs Malignant Breast Mass
- Mobile, well-circumscribed, often tender mass vs hard, painless, fixed mass with irregular borders
-
Galactorrhea vs Pathologic Nipple Discharge
- Milky, bilateral discharge related to prolactin vs bloody or serous, unilateral discharge
-
Gynecomastia vs Male Breast Cancer
- Tender, rubbery tissue beneath the nipple vs hard, painless, fixed mass, often unilateral
-
Infection vs Neoplasm
- Pain, warmth, erythema, fever vs painless, progressively enlarging mass
-
Premenopausal vs Postmenopausal Breast Mass
- More likely benign and hormone-related vs malignancy until proven otherwise
-
Reassurance vs Escalation
- Reassure when findings are mobile, bilateral, cyclic, and tender
- Escalate when findings are hard, fixed, painless, unilateral, or associated with skin dimpling, nipple retraction, bloody discharge, or axillary lymphadenopathy
