ACOG Practice Bulletin #164 on benign breast disorders is a comprehensive summary of various benign and pre-malignant breast pathologies that may cause signs or symptoms prompting a woman to seek guidance from her ob/gyn.1 Evaluation and management of breast complaints is complex. The most obvious clinical challenge is that breast complaints may represent problems that are endocrinologic, dermatologic, musculoskeletal, pharmaceutical or neurologic in origin and not just simply breast-related. Given the broad differential diagnoses that must be considered, it is important to approach any breast complaint in a logical and systematic manner.
The first step is to always get a comprehensive history that includes the 7 dimensions of the current complaint (issues around onset, frequency, quality and quantity of pain/discharge/mass, associated symptoms, prior history of similar complaint and so on). It is also important to get a history of medications (source of galactorrhea), physical activity (trauma or stimulation due to poorly fitted bra), family history (evaluate for genetic risks of breast pathology and possible cancer), reproductive history (contraceptive use, pregnancies, and breastfeeding) and detailed review of systems looking for evidence of endocrine, trauma or other sources of the concern. The physical exam needs to determine if the breast complaint is the primary manifestation of a breast problem (e.g., fibroadenoma) or a secondary manifestation of a more systemic process, such as a pituitary adenoma or autoimmune disease with marked eczema. Findings need to be carefully described and documented for follow-up assessments of growth, change or resolution. Typically, if a finding is bilateral, it is more likely to be physiologically normal or manifestation of a more systemic issue (e.g. prolactinoma or fibrocystic changes). The bulletin helps with this process by presenting clear logical algorithms to guide a provider in a systematic cost-effective process to make a diagnosis.