Additional Material

Additional Information on  Anatomy and Physiology of Normal Breasts

Breast Development

  • 4-6 weeks in utero
    • Breast development begins
  • 8 months in utero
    • Nipples appear
  • 34 weeks in utero
    • Breast bud appears
  • 8-13 years
    • Onset of pubertal breast development
      • Adipose tissue and ductal tissue grow from estrogen
      • Progesterone initiates lobular growth and alveolar budding 
      • Breasts usually develop over a 2-4 year span


De Silva NK, 2012

Additional Information on Extramammary Breast Pain

Pain originating in areas other than breasts caused by:

  • Musculoskeletal pain
  • Cardiac pain
  • Gastrointestinal pain
  • Tietze Syndrome
  • Shingles
  • Medications:
    • Digoxin
    • Spironolactone
    • Chlorpromazine


Chase C, et al., 2011

Additional Information on Mastalgia

Breast Exam

  • Entire breast area should be examined (lymph nodes, cervical and thoracic spine, chest wall, and arm pits)
  • Patient should be in supine position to determine if pain is extramammary or breast pain 
  • If breast mass is felt during the examination – refer for radiographic  work
Illustration showing directions to palpate breasts with fingertips during self exam.
Image provided courtesy of A.D.A.M


Rodden AM, 2009

Mastalgia Diagnosis

Diagnosis and Discussion of Mastalgia
Diagnosis Discussion
Breast Pain Diary
  • Pain diary helps clinician make appropriate diagnosis 
  • Patients keep track of pain rating, when pain occurs, activity performed when pain occurred, and relation to menstrual cycle occurrence
Urine Pregnancy Test
  • Pregnancy can cause breast pain. Pregnancy test will help rule out pregnancy
Breast Exam
  • A clinical breast exam will help determine if the pain is in the breast or Extramammary 
  • Breast exam will allow physician to feel for unusual lumps and to determine if imaging is necessary
  • If patient is >30 years of age, clinician may recommend mammogram or ultrasound


Rodden AM, 2009

Comparison of Effectiveness of Centchroman and Danazol for Mastalgia 

Bar chart showing percent decrease in mastalgia pain when using Danazol compared to Centchroman.
Mastalgia pain decrease when using Danazol compared to Centchroman

Additional Information on Age Related Breast Pain

Adolescents – Benign Breast Disease

Risk factors for developing benign breast disease from adolescent health:

  • Thin – More adipose in childhood (OR, 0.91; P=.04) associated with lower risk of developing Benign Breast Disease (BBD)
  • Tall – Girls with rapid height growth were most at risk (OR, 2.12; P=.09)
  • Rapid growing – Girls with history of maternal breast cancer and rapid growth had higher risk of developing BBD (OR, 1.47; P= .02)

Study Design

  • 9-15 year old females completed annual questionnaires from 1996-2001, 2003, 2005, and 2007 about menarche, height, weight 
  • On the 2005-2007 surveys, 6899 females (ages 18-27) reported if a healthcare provider ever diagnosed them with Benign Breast Disease (n=147) and if it was confirmed through a biopsy (n=67) 
  • Based on the results from the questionnaires, risk factors were identified for developing benign breast disease

Berkey CS, et al., 2011

Adolescents - Mastalgia

Mastalgia is common in adolescents.

  • Conduct a history and physical examination
  • Because mastalgia can be a symptom of pregnancy, a pregnancy test should be administered
  • Conduct nutritional history for potential aggravating agents

Greydanus DE, et al., 2006; De Silva NK, 2012

Cyclic Breast Pain

Cyclical Breast Pain may cause:

  • Absence from school or work, sports, etc.
  • Interrupt sleep
  • Increase pain during sexual activity


Chase C, et al., 2011

American Women Experiencing Cyclic Breast Pain

Bar chart of American women experiencing cyclic breast pain. Out of 1171 healthy premenopausal women (under 55 years old), 58% experienced mild discomfort, 48% had breast pain that interfered in usual sexual activity, 37% had breast pain that interfered in physical acitivty, 12% had breast pain that interfered in social activities, 11% had experienced moderate to severe cyclic breast pain, and 8% had breast pain that interfered in school activiities.
Adapted from Benign Breast Disease in Women,  Santen RJ, 2000;  Ader DN, et al., 2001

Cyclic Breast Pain - Menopause

Prevalence of breast discomfort: 

  • 21% lower in late perimenopause compared with early perimenopause 
  • Breast tenderness shown as an adverse effect of menopausal hormone therapy 
  • Change in sex steroid levels may influence breast discomfort 
    • As evidenced by prevalent breast tenderness during premenopausal compared to the decline of prevalence in menopause 
    • However, prevalence and causes for breast pain in postmenopausal women is not well-understood
  • ~40% of women experience cyclic mastalgia during premenopausal years 
  • Cyclic pain may worsen during perimenopause 
    • This may be due to hormones surging and dropping erratically 
  • Cyclic pain may continue into menopause 
    • especially for those using oral contraceptives or hormonal therapy 
  • Although cyclic pain is often resolved during menopause, women may still experience breast tenderness and pain


Breast pain, 2005; Rosolowich et al., 2006; Chase C, et al., 2011

Additional Information- Benefits of Lactation

Benefits for breastfeeding:

  • Decreases childhood infection incidence
  • Lower sudden infant death syndrome
  • Lower post-neonatal mortality rates
  • Reduced childhood obesity incidence
  • Reduced childhood diabetes
  • Reduced certain childhood cancers
  • Can help to lower postpartum bleeding and reduce the risk of breast and ovarian cancer


Breastfeeding, 2015; Eidelman AL & Schanler RJ, 2012; Lessen R & Kavanagh K, 2015; Spatz DL & Lessen R, 2011; Steube A, 2016

U.S. Women Exclusively Breastfeeding

Bar chart illustrating number of US women who exclusively breastfeed at different ages for their infants.
Number of US women exclusively breastfeeding


Dennis CL et al., 2014

Additional Information on Pain During Breastfeeding

Sore Nipples

Breastfeeding Mothers with Sore Nipples
% of Breastfeeding Mothers Description
34%-96% Nipple pain and trauma caused from breastfeeding
29%-76% Traumatic nipples (visible skin breakdown)
80%-90% Mild nipple pain (of breastfeeding women)
26% Nipple pain develop into nipple fissures


Shanazi M, et al., 2015; Kent JC, et al., 2015

Traumatic Nipples and Sore Nipples

Due to Nipple Trauma (Traumatic Nipples):

  • The greatest nipple pain intensity seems to happen between 3-7 days postpartum for most women
  • Can cause psychological distress 
  • Can interfere with:
    • Sleep
    • Activities 
    • Mood
    • Mother/child bonding 
  • May lead to deprivation of breast milk 
  • If traumatic nipples occur early can lead to cessation of breastfeeding
  • Untreated nipple pain can develop into nipple fissures 
  • Nipple fissures increase the risk for bacterial infections 
    • Latch needs to be improved to reduce trauma and promote healing 
  • If sore nipples occur early can lead to cessation of breastfeeding 
  • Too little supply of milk can cause pain due to overlong nursing periods. 
    • A low milk supply can result from nipple pain
      • inhibition of milk ejection from pain and not removing milk properly when infant has ankloglossia or cleft palate

Shanazi M, et al., 2015; Kent JC, et al., 2015

Commonality of Attributed Nipple Pain

N = 264 cases

Commonality of Attributed Nipple Pain
Attributed Cause n
Incorrect positioning and attachment 238
Ankyloglossia 177
Insufficient milk supply 104
Palatal anomaly 117
Flat or inverted nipples 32
Vasopasm 14
Mastitis 32
Confirmed infection 69
C. albicans 7
S. aureus 56
Other bacteria 6

Kent JC, et al., 2015

Etiology for Nipple Pain

  • Positioning of infant/ Poor attachment/ Pumping with incorrect shield size
  • Flat or inverted nipples
  • Infant sucking action
  • Infant ankyloglossia
  • Infant palatal
  • Infant suction
  • Milk blisters
  • Infections
  • Eczema/Psoriasis/Dermatitis
  • Pregnancy
  • Raynaud’s Phenomenon
  • Lack of nipple exposure to light and air
  • Frequency and duration of feedings


Kent JC, et al., 2015; Dennis CL, et al., 2014

Treatments for Sore Nipples

From the Breast Feeding Centre of Western Australia:

Correct Positioning and attachment

  • Most common recommendation 
  • When corrected early, breastfeeding duration is prolonged and sore nipple prevalence is reduced

Improving Latch

  • Infants between 4 days- 12 months old, this has been proven to resolve breast pain in 65% of cases

Nipple Shields

  • Short-term remedy for premature infants 
  • Helps with mothers who have flat/inverted nipples.
  • Helps decrease intense suction
  • Should not be used too long

Anhydrous Lanolin/Vitamin A Ointments

Remedy for nipple pain caused by friction

Frentomy for Ankyloglossia

  • Effective for pain relief and to increase milk transfer 
  • Points to consider: Infant with tongue tie may have already developed and learned usual tongue mechanics which means fixing the tongue tie may not immediately relieve pain in the mother’s nipple.

Warm Compress

  • Helps with milk blisters


  • For breast pain caused by infection or Candida infection

Avoiding Irritants/Topical Corticosteroid Ointment

  • Remedy for Dermatitis and Psoriasis of the nipple
  • Points to consider: Topical steroids can be harmful for present trauma/fissures 
    • Can delay healing

Warmth/ Avoidance of Vasoconstrictors/Prescriptions for Nifedipine

  • Remedy for Raynaud’s Phenomenon.

Herbal Treatment: Lanolin

  • Gives moisture to nipples 
  • Penetrates skin to help facilitate absorption of medicines
  • Can absorb up to 30% of water 
  • Use of Lanolin associated with an increase in the rate of infection 
    • Could be a result of hand hygiene when applying lanolin to the nipples

Herbal Treatment: Dexphanthenol

  • Part of B complex vitamins 
  • Works a moisturizer to help keep skin hydrated by reducing water loss through the epidermis and can help to reduce nipple pain

Herbal Treatment: Peppermint

  • Has been shown to decrease pain and increase healing in nipple trauma 
  • Can help to increase tissue flexibility and prevent fissures 
  • An effective treatment of traumatic nipples for patients interested in using herbal medications

Kent JC, et al. , 2015; Berens PD, 2015

Shanazi M, et al., 2015; Kent JC, et al., 2015

Treatment Considerations for Sore Nipples

  • There is no sufficient evidence showing glycerin gel dressings, breast shells with lanolin, lanolin alone, or all-purpose nipple ointment (APNO) significantly improve maternal perceptions of nipple pain
  • APNO has not been found to be superior to lanolin in treating nipple pain 
  • A separate study failed to find a difference in pain between groups at 1 week of treatment for women using either APNO or lanolin
  • Not enough evidence to recommend a specific treatment for painful nipples 
  • Some studies suggest applying nothing or expressed breast milk for early breast discomfort may be just as or more beneficial in the short term than applying ointment such as lanolin 
  • Regardless of treatment, nipple pain in most women seemed to reduce to mild levels 7-10 days after giving birth


Dennis CL, et al., 2014; Dennis CL, et al., 2012; Berens PD, 2015

Pumping Breast Milk with a Nipple Shield That Is Too Small

Raynaud’s of the Nipple

Noticeable whiteness of nipple immediately after breastfeeding, then turning red or purple.

Image showing Raynaud's of the nipple, with an orange-looking areola and purple nipple
Raynaud's of the nipple. © Holmen, OL  & Backe, B (2009)

Treatment Option

Use of Nifedipine

  • 10 mgs three times per day
  • Or sustained released capsule of 30 mgs per day

Wu M, Chason R, Wong M, 2012

Yeast and Cracking


Image showing yeast around the nipple
Yeast around nipple. Image compliments of Dr. Diane Spatz.


Image showing cracking of the nipple
Cracking of the nipple. Image compliments of Dr. Diane Spatz.

Plugged Ducts/Engorgement

  • Engorgement, plugged ducts, and mastitis are common causes of pain and may lead to cessation of breastfeeding 
    • Cessation can be permanent or temporary
Illustration showing the milk glands of a normal breast compared to an engorged breast.
Non-lactating vs  engorged breast

Engorgement can happen:

  • When milk first "comes in" to the breasts, during the first few days after birth.
  • When a regular breast-feeding routine is interrupted and the mother cannot nurse or pump as much as usual.
  • If the baby suddenly stops breast-feeding.
  • When the baby's breast-feeding suddenly drops, either when the baby is starting or increasing solid foods or when the baby is ill with a poor appetite.

Engorged breasts:

  • Are swollen, firm, and painful. If severely engorged, they are very swollen, hard, shiny, warm, and slightly lumpy to the touch.
  • May have flattened-out nipples. The dark areola may be very hard. This makes it difficult for the baby to latch on.
  • Can cause a slight fever of around 100F.
  • Can cause slightly swollen and tender lymph nodes in the armpits.

Data from the Infant Feeding Practices Survey in 2008 showed that 36.6% of women reported feeling their breasts were overly full within the 1st 2 weeks of postpartum breastfeeding.


Witt AM, et al., 2016; Berens PD, 2015

Treatment for Plugged Ducts/Engorgement

  • Therapeutic Breast Massage in Lactation (TBML)
    • Can help to empty the breast, which can help to reduce pain and resolve symptoms 
    • Provides immediate significant pain relief
    • Reduces engorgement severity, provides immediate size reduction, and sometimes can provide complete resolution for plugged ducts 
    • Mother’s reported they were able to use TBML technique on their own after learning and receiving this treatment at a medical office
    • This provides evidence that TBML can be taught and used outside of medical offices
  • Cabbage Leaves
    • Some studies have shown this treatment reduces pain, but there has been no statistical evidence to show these interventions improved symptoms better than routine care
  • Cold Pack
    • Some studies have shown this treatment reduces pain, but there has been no statistical evidence to show these interventions improved symptoms better than routine care
  • Manual Expression
  • Pumping Before
  • Reverse Pressure Softening of the Areola

Witt AM, et al., 2016; Berens PD, 2015

Alternative Pain Treatment for Plugged Ducts/Engorgement

  • Oxytocin
  • Breast ultrasound

Berens PD, 2015

Proper Attachment and Latch

  • Frequent Nursing: Breastfeed on demand. 
  • Application of Warmth: For only a few minutes at a time, apply warmth to the breasts by standing in a warm shower, applying warm washcloths, or by dipping the breasts in a bowl of warm water and allow some milk to flow out. Shower water should not spray directly on the engorged breasts. Application of warmth should not be done for longer than a few minutes because it may worsen swelling and inflammation caused by the engorgement.
Image showing proper attachment and latch of a baby to the mother's nipple.
Image compliments of Dr. Diane Spatz.

Breast Massage

Before nursing, gently massage the breast toward the nipple and allow some milk to flow out to soften the nipple for easier latch. During nursing, gently compress and massage the breast to stimulate the letdown of milk.

Illustration showing various motions to massage the breast to help with letdown of milk and easier latch.
Image provided courtesy of Breast Health Project

Treatment Considerations of Plugged Ducts/Engorgement

  • Receive consultation from an experienced lactation expert 
  • Extreme engorgement can lead to improper infant latch which can lead to pain
  • Symptoms tend to improve over time regardless of the remedy or routine care 
  • Studies show that further scientific investigation on painful engorgement is necessary

Zhao C, et al., 2014; Berens PD, 2015

Additional Information on Treatment Considerations of Lactation Pain

Important considerations: 

  • important to specifically measure mothers thoughts on breastfeeding
  • Example: Edinburg Postpartum Depression Scale (EDPS) to identify mother’s frustration and possible related depression 
    • Women with pain had a much higher likelihood of having a score on the EDPS consistent with depression (38%) compared to those without pain (14%)

Likelihood of Experiencing Depression From Breast Pain Based on Edinburgh Postnatal Depression Scale (EDPS)

Likelihood of Experiencing Depression From Breast Pain Based on Edinburgh Postnatal Depression Scale (EDPS)
Pain Likelihood of having score consistent with depression based on EDPS
High pain 38%
Reduced pain 16%
Without pain 14%


Berens PD, 2015

Additional Information on Short Frenulum

Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound

Patients and methods:

Twenty-four mother-infant dyads (infant age: 33 +/- 28 days) that were experiencing persistent breastfeeding difficulties despite receiving professional advice were recruited. Submental ultrasound scans (Acuson XP10) of the oral cavity were performed both before and >or=7 days after frenulotomy. Milk transfer, pain, and LATCH (latch, audible swallowing, type of nipple, comfort, and hold) scores were recorded before and after frenulotomy. Infant milk intake was measured by using the test-weigh method.


Image showing pre-frenotomy
Pre-frenotomy. Image compliments of Dr. Diane Spatz


Image showing post-frenotomy
Post-frenotomy. Image compliments of Dr. Diane Spatz

Additional Information on Mastitis

Symptoms of mastitis:

  • Breast pain
  • Swelling
  • Redness
  • Fever
  • Enlargement
  • Changed nipple sensation
  • Discharge
  • Itching
  • Tenderness
  • And/or a breast lump
Illustration shows a breast with a printed list of symptoms of mastitis: breast pain, swelling, redness, fever, enlargement, changed nipple sensation, discharge, itching, tenderness, and/or a breast lump.
Symptoms of mastitis

Treatment of Mastitis

  • Breast Drain
    • Early mastitis may be managed by draining the breast 
    • Make sure affected breast is appropriately drained
    • Infected breast should remain drained to manage infection (if there is an infection)
  • Antibiotics
    • Early infection may resolve itself through breast drainage, but if not, antibiotics should be considered
    • If high fever is present or symptoms do not resolve in 12-24 hours then antibiotics are recommended 
    • Dicloxicillin or cephalosporin are used because the most commonly found organisms are streptococcus and staphylococcus 
    • Typically taken for 10-14 days
  • Frequent breastfeeding and rest
    • Components of management 
    • Feedings should take place on affected breast to allow for a drained breast, unless pain prohibits 
    • If pain prohibits feeding on affected breast, start with other breast and move to affected breast once pain has decreased 
    • If feeding is terminated or pain prohibits any type of breastfeeding, pumping should take place on affected breast to drain breast 
    • Bed rest and increase fluids can help
  • Pain Medication
    • Ibuprofen can be considered for pain 
    • Ibuprofen may aid in reducing inflammation in breast
  • Prevention of Recurrence
    • Investigate risk predisposing factors such as nipple trauma, poor breast drainage, breast mass 
    • If none of these are relative, it is important to look into hygiene and care of pump as possible risk factors
  • Milk Culture
    • May be requested for  recurrent episodes of mastitis 
    • mastitis that does not relieve in 48 hours of antibiotic therapy.
    • Instance with premature or ill infant 
    • Infants in the NICU 
    • Infant on immunosuppression 
    •  Exclusively pumping mothers who would not have had infant at breast for source of infection
    • When choosing antibiotics that may be less likely to treat suspected organisms due to an allergy 
    • High rate of resistance in the community or recent hospitalization
  • Infant
    • If mother suffers from nipple trauma or fissures, consider observing latch, feeding, positioning, and observe infant’s tongue for tongue tie
  • Imaging
    • Not usually used for mastitis
    • However, if antibiotics fail or if there is a breast mass, ultrasound may be used to evaluate for breast abscess 
    • Mammography may be used during acute infection 
    • However, may be misleading due to inflammatory changes 
    • Treat the infection. Pursue mammography after resolving infection, if one


Adapted from Berens PD, 2015

Additional Information on Benign Disease Related

Infectious Inflammation

  • Staphylococcus
    • Most common etiological agent of mastitis
  • Staphylococcus aureus
    • Related to acute mastitis cases 
      • More commonly found than Candida when fissures on nipples are present
  • Staphylococcus epidermidis
    • Can cause nipple pain, breast engorgement
      • But is usually misdiagnosed as “noninfectious” or “mammary candidiasis”
  • Total bacteria and Staphylococcus loads have been correlated with pain perception in women’s breast 
    • Decreasing breastmilk microbiota directly relates to pain symptoms


Maldonado-Lobon JA, et al., 2015

Additional Information on Postmastectomy Pain Syndrome (PMPS)

Treatment Related Risk Factors

  • More extensive surgery in the axilla 
  • Radiation therapy 
  • Tumor localization in the upper lateral quarter 
  • Radiotherapy
  • Tumor diameter 
  • Tumor grade
  • Estrogen and progesterone receptor status 
  • Amount of removed sentinel node
  • Amount of removed lymph node
  • Lymphedema
  • Preoperative neoadjuvant  Chemotherapy 
  • Postoperative chemotherapy
  • Postoperative hormone therapy 
  • Adjuvant treatment
  • Surgery type 
  • Analgesic treatment


Andersen KG,et a., 2015; Beyaz SG,et al., 2016; Caviggioli, F, et al., 2016

Etiology of Chronic Pain

  • Chemotherapy agents can play, as role as: Taxanes, platinum agents, and vinca alkaloids are neurotoxic
  • Endocrine therapy may prompt musculoskeletal pain and arthralgia
  • Infections, seroma, and hematoma may aid in the development of persistent pain altering physiological scarring


Caviggioli F,  et al., 2016

Areas of Pain and Discomfort Among Breast Cancer Survivors

N = 147

Bar chart illustrating areas of pain and pain severity for women with Postmastectomy Pain Syndrome (PMPS)
Areas of Pain and Discomfort Among Breast Cancer Survivors


Bosompra K, et al., 2002

Frozen Shoulder

  • Temporary loss of range of motion in the shoulder 
  • Typically occurs when the shoulder has been immobilized for a long period of time (i.e. surgery)
  • A shoulder becomes frozen when:  the shoulder is immobile, the capsule surrounding the glenohumeral joint (the main ball and socket of the shoulder) thickens and contracts causing it to stiffen 
  • The shoulder may remain immobile to avoid pain. 
  • The less the shoulder is moved the more likely it is that the capsule will contract and stiffen

Typical Candidates for Frozen Shoulder

  • Typically occurs when individuals who undergo surgery and do not receive exercise therapy following their procedure

Treatment for Frozen Shoulder

  • Visit expert or clinical for physical exam
  • May receive x-ray/MRI to rule out other possible conditions
  • Anti-inflammatory medications may be prescribed 
  • Most important treatment is physical therapy to stretch the joint capsule 

How to release a frozen shoulder, 2004

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