Breast Health in Lactating Women
Anne M. Montgomery, MD, IBCLC
from Breastfeeding Abstracts, May 2001, Volume 20, Number 4, pp. 27-28.
Lactating women may develop breast conditions related to lactation, but they also remain susceptible to conditions found in non-lactating women. With delayed childbearing and reproductive technology, more women in their forties—and even fifties—may be lactating, increasing the likelihood that screening for breast cancer will need to occur before a woman finishes breastfeeding.
Superficial infections of the breast may include staphylococcus, streptococcus, candida, and herpes viruses. S. aureus infection should be suspected when there are significant cracks or fissures of the nipple; systemic antibacterial treatment should be considered to avoid progression to mastitis.1 Topical treatment frequently suffices for treatment of minor superficial infections. Recurrent bacterial infections may indicate that mother or baby is a carrier; topical treatment of the nares with muciprocin ointment may eradicate the carrier state.2, 3 With candida, both mother and baby should be treated simultaneously to avoid reinfection. Yeast infection of ducts has been suspected in cases of deep, shooting breast pain, and may respond to systemic antifungals such as fluconazole.
Herpetic lesions on the breast may have been transmitted from the baby’s mouth or from contact with another source of infection. If the baby is beyond the newborn period, breastfeeding may continue unless the lesions are on the nipple or areola. If so, the baby should feed only on the contralateral side until the lesions have dried.3 The lesions should be covered if possible. Good attention to hand-washing and avoiding kissing when oral lesions are present can help prevent spread.
Bacterial mastitis occurs in about 2.5 percent of nursing mothers, most commonly occurring between 2 and 5 weeks post-delivery. It can be prevented by good breast hygiene and hand-washing, and by regular emptying of the breast. If a specific area of the breast does not drain well, manual expression of the milk from that duct may help avoid milk stasis. Treatment for bacterial mastitis includes adequate breast emptying, rest, hydration, and antibiotic therapy directed at the most common organisms (S. aureus, coagulase-negative staphylococcus, streptococci, E. coli). Adequate treatment is essential in order to avoid development of breast abscess. Breastfeeding should continue, as the baby is the most efficient remover of milk; there is no significant risk to the baby from the infection or from the common antibacterial therapies.2, 3, 4
Breast abscesses may be simple or complex. They require surgical drainage. Breastfeeding may continue as long as the incision is away from the nipple and does not interfere with latch-on.2, 4
Chronic inflammation of the breast may lead to plasma cell mastitis. This condition, most commonly seen in multiparous women or women with long nursing histories, results from chronic inspissation of secretions into connective tissue, with development of sterile, granulomatous inflammation. The resulting fibrosis and nipple retraction may mimic malignancy.4
Eczema, psoriasis, seborrheic dermatitis, contact dermatitis, and neurodermatitis may occur on the skin of the breast or areola.
Breastfeeding may cause irritation of the nipple and areolar skin leading to outbreaks of these dermatoses in susceptible women. Topical agents can lead to contact dermatitis. Maternal allergy to foods or cow’s milk or soy formula consumed by the nursling and still in the mouth during breastfeeding can also contribute.
Treatment with careful hygiene, gentle washing after feeding, adequate drying, and topical corticosteroids may relieve the symptoms. Steroid creams should be gently wiped from the nipple to avoid excessive exposure for the baby. Persistent inflammatory lesions may be superinfected with bacteria or yeast, or may represent inflammatory cancer.2
Other benign conditions of the breast
Nipple bleeding and blood in the milk are very common, especially among primiparas during pregnancy and early breastfeeding. This is likely due to the increased vascularity of the breast. If the bloody discharge resolves spontaneously, it is most likely benign. If there is persistent bleeding from a single duct, a ductogram may reveal a papilloma. Bleeding associated with a mass needs to be evaluated for the possibility of malignancy. In general, there is no contraindication to continuing to breastfeed despite the presence of blood in the milk.1, 2, 3
Vasospasm of the nipple (Raynaud’s phenomenon) has been reported. This may manifest as blanching and pain of the nipple, either spontaneously or after nursing. This may or may not be associated with other manifestations of Raynaud’s phenomenon or rheumatologic disease. Avoiding nipple trauma and keeping the nipple warm can prevent some of the occurrences. Calcium channel blockers may be used in severe cases.2
Cyclic nipple and/or breast pain may occur when women resume ovulating. Nipple tenderness around the time of ovulation and breast pain during the luteal phase occur commonly. If nipple and breast pain occur without other explanation and the woman is not menstruating, the possibility of pregnancy should be considered.
Breast cancer screening
Breast cancer has been thought to have a poor prognosis when found in pregnant or lactating women, but most likely this is because of delay in diagnosis of aggressive disease. Many breast cancers diagnosed in pregnant and breastfeeding women have been found as a result of self breast exam. A baseline exam at the first prenatal visit and subsequent periodic exams, ideally by the same examiner, can allow early detection of suspicious masses.7 Pregnant and lactating women should follow guidelines for breast cancer screening for their age and risk status.
Mammography in lactating women, as in younger women, may be less sensitive due to increased breast density. One recent report, however, indicates that an individual woman’s breast density may not change significantly with pregnancy or lactation.7 There is no clear evidence that mammography in premenopausal women decreases the risk of death from breast cancer. If a mammogram is indicated for breast cancer screening, the woman should empty her breasts as completely as possible just prior to the mammogram. Women may develop new micro-calcifications after weaning. These have a benign, diffuse pattern and may be followed for stability. However, for high-risk women, a stereotactic biopsy should be considered. The radiologist should be told of the woman’s lactation history.7
Mammography, combined with self-exam and periodic clinical breast exam, should continue during pregnancy and lactation as per published guidelines. While breastfeeding may provide some protection against the development of breast cancer, most breast cancers found during pregnancy and lactation actually had their beginnings years earlier. Even though breasts may be denser, women and health practitioners do find new, persistent masses that require close observation and further evaluation.
Evaluation of breast masses in lactating women
All breast masses in all women need to be evaluated and explained. In lactating women, a breast mass has an approximately 10 percent likelihood of being malignant, although this figure may be higher in older lactating women. Fortunately, most breast masses can be evaluated without excisional biopsy. Ultrasound examination may identify cystic masses. These may represent fibrocystic fluid or galactoceles. Aspiration may allow diagnosis and resolution of the cyst.4
Solid masses require further evaluation. Benign masses include lipomas, fibroadenomas, lobular hyperplasia, and inflammatory lesions. In most cases, a benign diagnosis can be established by fine-needle aspiration (FNA) performed by an experienced practitioner. The pathologist should be informed that the sample comes from a lactating breast. If the FNA results are unequivocally benign, excisional biopsy is not required. The mass should be closely followed and re-evaluated after weaning. If the FNA results are equivocal or suspicious, the woman should undergo an excisional biopsy.7 There is an increased risk of milk fistula and post-biopsy infection in lactating women, so many surgeons recommend weaning prior to biopsy. If the mother accepts these risks she may continue to breastfeed, although she should nurse the baby and/or express as much milk as possible just prior to the surgery.7
Breast cancer treatment in lactating women usually requires weaning. Because premenopausal breast cancer is an aggressive disease, most women are treated with radiation and chemotherapy. Antimetabolite and anti-estrogen therapy are contraindications to breastfeeding.2 Emotional support should be provided for the mother and family as they face the cancer and also grieve premature weaning.
Pregnancy and lactation after treatment for breast cancer remain somewhat controversial, and recommendations may depend on the estrogen- and progesterone-receptor status of the original tumor. In most cases, women who do become pregnant after breast cancer treatment may be encouraged to breastfeed. They should be monitored for adequate milk production from post-surgical or post-radiation breasts.2, 3
Anne Montgomery, MD, IBCLC, is a board-certified family physician who practices at Group Health Cooperative of Puget Sound in Olympia, Washington. She also has a private lactation practice, Olympia Breastfeeding Medicine. She is Clinical Associate Professor of Family Medicine at the University of Washington, a member of the Board of Directors of the Academy of Breastfeeding Medicine, an LLL Medical Associate, and an accredited LLL Leader.
1. Livingstone, V. and L. J. Stringer. The treatment of Staphylococcus aureus infected sore nipples: A randomized comparative study. J Hum Lact 1999; 15(3):241-46.
2. Lawrence, R. A. and R. M. Lawrence. Medical complications of the mother. Chapter 15 in Breastfeeding: A Guide for the Medical Profession, 5th ed. St. Louis: Mosby, 1999.
3. Riordan, J. and K. G. Auerbach. Breast-related problems. Chapter 15 in Breastfeeding and Human Lactation, 2nd ed. Sudbury, MA: Jones and Bartlett, 1999.
4. Olsen, C. A. and R. E. Gordon. Breast disorders in nursing mothers. Am Fam Physician 1990; 41(5):1509-16.
5. Sorosky, J. I. and C. E. H. Scott-Conner. Breast disease complicating pregnancy. Obstet Gynecol Clinics North Am 1998; 25(2):353-63.
6. Lawlor-Smith, L. and C. Lawlor-Smith. Vasospasm of the nipple—a manifestation of Raynaud’s phenomenon: Case reports. Br Med J 1997; 314:644-45.
7. Scott-Conner, C. E. H. and S. J. Schorr. The diagnosis and management of breast problems during pregnancy and lactation. Am J Surgery 1995; 170:401-5.
8. Swinford, A. E., D. D. Adler, and K. A. Garver. Mammography appearance the breasts during pregnancy and lactation: False assumptions. Acad Radiol 1998; 5(7):467-72.
9. Stucker, D. T., D. M. Ikeda, A. R. Hartman et.al. New bilateral microcalcifica-tions at mammography in a postlactational woman: Case report. Radiology 2000; 217(1):247-50.
10. Gupta, R. K., A. G. R. McHutchinson, C. S. Dowle, and J. S. Simpson. Fine-needle aspiration cytodiagnosis of breast masses in pregnant and lactating women and its impact on management. Diagnostic Cytopathology 1993; 9(2):156-59.