Breast Masses and Other Breast Complaints During Lactation
by Anne Eglash MD, IBCLC, FABM
Some breast masses are specific to lactation, such as abscesses. Other masses, like fibroadenomas, might appear or grow during lactation but are not necessarily lactation specific. Breastfeeding women may develop other breast symptoms such as nipple growths, skin changes, or nipple bleeding, and it can be challenging to determine if these changes are lactation-related.
The Academy of Breastfeeding Medicine’s protocol on breast masses and other breast complaints defines and describes various breast masses, nipple lesions, and reasons for breast pain and nipple bleeding. It also recommends diagnostic and treatment options for the most common breast masses diagnosed during lactation.
- Core biopsies are preferred over fine needle biopsies for masses during lactation that require further workup.
- A milk fistula is a relatively common risk of a core biopsy.
- A breast MRI is more sensitive (easier to see abnormalities) during lactation than a mammogram.
- The ‘rusty pipe syndrome’ is a self-limited duration of bleeding (brown or bright red blood) from the nipples that should, by definition, resolve within the first 2 weeks of lactation.
- Paget’s disease of the breast often presents as an eczema-like lesion on the nipple.
- Lactating adenomas should be removed.
- Galactoceles are milk retention cysts that should never be aspirated.
- Lactiferous sinuses are present behind the areola.
See the Answer
Breastfeeding women may develop breast masses or complaints at any point during lactation. Symptoms may be related to lactation, such as a lactating adenoma, or may be due to a condition that coincidentally has manifested during the postpartum period. Understanding the importance of appropriate workup and imaging, as well as indications for referral to breast surgery, is essential to establishing a diagnosis and avoiding delay in care. Breast symptoms require evaluation by physicians and/or lactation consultants and may also require diagnostic breast imaging and/or biopsy. The American College of Radiology (ACR) released new guidelines in 2018 regarding breast imaging of pregnant and lactating women.1 These guidelines state that all breast imaging studies and biopsies are safe for women to undergo while breastfeeding, and also provide recommendations for maximizing examination sensitivity and minimizing biopsy-related complications in this patient population. When approaching a breastfeeding woman with breast symptomatology, it is helpful for providers to frame the workup based on the presence or absence of a palpable mass on examination (Fig 1). Some conditions always present as a mass, whereas others rarely have a palpable finding. However, several conditions have variable presentations and may manifest as a mass and/or another sign/symptom such as nipple discharge (Fig. 2). Quality of evidence is based on the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence2 (levels I–IV) and is noted in parentheses.
Full disclosure- I am a co-author on this protocol.
Core biopsies of masses are recommended over fine needle biopsies, and the risk of a milk fistula is considered rare. Ultrasonography and mammography are more sensitive radiologic tools to evaluate breast masses during lactation as compared with breast MRIs.
Lactating adenomas can grow rapidly during lactation, but are considered non-cancerous and lactation specific. Once diagnosed via biopsy, they can be observed during lactation because they are expected to resolve after weaning. Galactoceles are cysts that tend to be painless, unless they are quite large. Aspiration of milk from the cyst typically confirms the diagnosis. These can be left alone, or aspirated several more times for comfort as needed.
This protocol is a succinct comprehensive guide to share with physicians and other providers who care for breastfeeding mothers, particularly those providers who work in emergency medicine, urgent care, general surgery, family medicine, internal medicine, and radiology.
The protocol also debunks several unsubstantiated beliefs, such as there being a significant risk of milk fistula after a core biopsy, the need for ‘ductograms’ for nipple bleeding, the lack of lactiferous sinuses, the need to wean prior to mammography, or the need to surgically open and pack breast abscesses as the routine initial intervention.