13.6 Breast Disorders & Diseases of the Vulva and Vagina
Key Takeaways
- Breast nodules, mastitis and breast-feeding, and other breast disorders including cyclic pain and nipple discharge are enumerated under breast disorders.
- Diseases of the vulva and external genitalia and vaginal disorders other than vulvovaginitis are separately enumerated blueprint subsections.
- A discrete palpable breast mass requires tissue diagnosis even when mammography and ultrasound appear benign.
- Unilateral spontaneous bloody nipple discharge from a single duct requires evaluation, whereas bilateral milky discharge suggests hyperprolactinemia.
- A vulvar lesion that fails to respond to topical therapy requires biopsy, because vulvar carcinoma is frequently misdiagnosed as a benign dermatosis.
1. The Palpable Breast Mass
Triple assessment — clinical examination, imaging and tissue sampling — is the standard, and the governing rule is that a discrete palpable mass requires tissue diagnosis even if imaging is reassuring. Imaging has a false-negative rate, particularly in dense breasts and in some cancers, so negative imaging does not close a palpable finding.
Imaging by age:
| Age | Initial imaging |
|---|---|
| Under 30 | Ultrasound first, with mammography added if findings are suspicious |
| 30 and over | Diagnostic mammography plus ultrasound |
Common benign entities:
- Fibroadenoma — the most common discrete mass in young women; firm, mobile, well-circumscribed, rubbery
- Simple cyst — may fluctuate with the cycle; aspiration is both diagnostic and therapeutic. Non-bloody fluid that fully resolves the mass needs no further workup; bloody fluid, a residual mass, or rapid reaccumulation requires biopsy
- Fat necrosis — after trauma or surgery; may be firm and irregular and mimic malignancy on imaging
Features that raise concern: hard, fixed, irregular, non-mobile; skin dimpling or retraction; peau d'orange; nipple retraction; axillary lymphadenopathy.
Two malignancies that do not present as a lump:
- Inflammatory breast cancer — an erythematous, warm, edematous breast with peau d'orange, frequently misdiagnosed as mastitis. Mastitis in a non-lactating woman, or mastitis that fails to improve after a short antibiotic course, requires imaging and skin punch biopsy.
- Paget disease of the breast — a persistent eczematous, scaling or ulcerated change of the nipple and areola, usually unilateral, associated with underlying carcinoma. It is distinguished from eczema by starting at the nipple and spreading outward and by failing to respond to topical steroids. Persistent unilateral nipple dermatitis requires biopsy.
2. Breast Pain and Nipple Discharge
Mastalgia is usually benign. Cyclic pain, bilateral and worse premenstrually, is hormonal and responds to a supportive bra, reassurance and reduction of caffeine; non-cyclic pain is often musculoskeletal (costochondritis, chest wall). Isolated breast pain is rarely a presentation of cancer, but a focal, persistent, unilateral pain still warrants examination and age-appropriate imaging.
Nipple discharge is triaged by pattern:
| Pattern | Significance |
|---|---|
| Bilateral, milky, expressed | Galactorrhea — check prolactin, thyroid-stimulating hormone, pregnancy test; review drugs (antipsychotics, metoclopramide, opioids) |
| Bilateral, multi-duct, green or yellow | Usually duct ectasia or fibrocystic change; benign |
| Unilateral, spontaneous, single-duct, bloody or serous | Pathologic — requires imaging and duct evaluation |
Intraductal papilloma is the most common cause of pathologic bloody discharge, but ductal carcinoma must be excluded.
3. Mastitis and Breast-Feeding
Lactational mastitis presents with a wedge-shaped area of erythema, tenderness, fever and malaise, usually from Staphylococcus aureus.
The key management points:
- Continue breastfeeding or expressing from the affected breast. Milk stasis perpetuates the infection, and the milk is safe for the infant.
- Antibiotics active against S. aureus (dicloxacillin or cephalexin; consider MRSA coverage where prevalent)
- A fluctuant mass or failure to improve within 48 to 72 hours suggests abscess and requires ultrasound and drainage
- Non-lactational mastitis should raise suspicion for inflammatory carcinoma and for periductal mastitis, which is strongly associated with smoking
Medications and lactation: most common antibiotics, antihypertensives and analgesics are compatible; codeine is avoided because of variable maternal metabolism, and specific compatibility should be checked rather than assumed.
4. Diseases of the Vulva and External Genitalia
A named blueprint subsection. The unifying clinical failure is treating a vulvar lesion empirically for months without a biopsy.
Lichen sclerosus
Ivory-white, atrophic, crinkled or cigarette-paper skin in a figure-of-eight distribution around the vulva and perianal area, with intense pruritus, dyspareunia and progressive architectural loss — resorption of the labia minora, clitoral phimosis and introital narrowing. Most common in postmenopausal women, but occurs at any age.
Two points of high yield:
- Treatment is a high-potency topical corticosteroid such as clobetasol — not a low-potency steroid, and not an antifungal. Treatment relieves symptoms and limits scarring.
- Lichen sclerosus carries an increased risk of vulvar squamous cell carcinoma, so it requires ongoing surveillance, and any thickened, ulcerated or non-responding area must be biopsied.
Other vulvar conditions
| Condition | Features |
|---|---|
| Lichen planus | Erosive, glassy erythema with a white reticular (Wickham) border; may involve the vagina, causing adhesions, and the mouth |
| Lichen simplex chronicus | Thickened, leathery skin from chronic scratching; the itch-scratch cycle |
| Vulvar intraepithelial neoplasia | HPV-associated; multifocal, pigmented or white plaques; requires biopsy |
| Vulvar carcinoma | Persistent ulcer, plaque or mass; often diagnosed late after prolonged empiric therapy |
| Bartholin cyst or abscess | Unilateral posterior introital swelling; abscess requires drainage, and a new Bartholin mass in a woman over 40 warrants biopsy to exclude carcinoma |
| Vulvodynia | Chronic vulvar pain without an identifiable cause; localized provoked vestibulodynia is the most common form |
| Hidradenitis suppurativa | Recurrent painful nodules, sinus tracts and scarring in the groin, axillae and inframammary folds; associated with smoking and obesity |
The operational rule: any vulvar lesion that persists despite appropriate treatment, or that is ulcerated, pigmented, indurated or asymmetric, requires a biopsy.
5. Vaginal Disorders Other Than Vulvovaginitis
A separately enumerated blueprint subsection, indicating that infectious vulvovaginitis is covered elsewhere and this category concerns non-infectious vaginal disease.
Genitourinary syndrome of menopause (atrophic vaginitis)
Estrogen deficiency produces vaginal dryness, burning, dyspareunia, decreased lubrication, and urinary urgency, frequency and recurrent urinary tract infection. Examination shows pale, thin, friable mucosa with loss of rugae and often an elevated vaginal pH.
Treatment: vaginal moisturizers and lubricants first; low-dose vaginal estrogen is highly effective with minimal systemic absorption and does not require a progestin. It can be considered even in many women for whom systemic hormone therapy is inappropriate, though use in survivors of hormone-sensitive breast cancer requires individualized discussion with oncology. Alternatives include vaginal DHEA and oral ospemifene.
A clinical point with real consequences: vaginal estrogen reduces recurrent urinary tract infections in postmenopausal women, and is a preferable strategy to long-term antibiotic prophylaxis.
Other vaginal conditions
- Vaginal atrophy versus lichen sclerosus — atrophy is diffuse and pale with loss of rugae; lichen sclerosus is well-demarcated, white and sclerotic with architectural loss, and it spares the vagina while affecting the vulva and perianal skin.
- Vaginal intraepithelial neoplasia and vaginal carcinoma — uncommon; HPV-associated; suspect with abnormal cytology in a woman who has had a hysterectomy, or with a persistent lesion.
- Desquamative inflammatory vaginitis — purulent discharge with an elevated pH, increased parabasal cells and no identifiable pathogen; responds to topical clindamycin or corticosteroid.
- Vaginal foreign body — a cause of malodorous discharge, particularly a retained tampon; the treatment is removal.
- Pelvic organ prolapse — a sensation of vaginal bulge and pressure; managed with pelvic floor therapy, a pessary, or surgery.
A 44-year-old woman has a 1.5 cm firm, non-tender, mobile mass in the upper outer quadrant of the left breast that she first noticed six weeks ago. Diagnostic mammography and targeted ultrasonography are both reported as showing no suspicious findings. What is the most appropriate next step?
A 63-year-old woman reports two years of vulvar itching and dyspareunia. Examination shows well-demarcated ivory-white atrophic crinkled skin in a figure-of-eight distribution around the vulva and anus, with partial resorption of the labia minora. She has used topical antifungals and low-potency hydrocortisone without benefit. What is the most appropriate management?