CASE


A 35-year-old female reported a 10-year history of intermittent bilateral mastalgia. The patient stated that a cold environment caused "severe" pain in both breasts, but the pain resolved in a warmer environment. Her symptoms, which occurred in the winter and in air-conditioned rooms in the summer, were significant enough to limit her activities in cold environments. She denied pain in the fingers or toes on exposure to cold temperatures. There was no nipple discharge and no history of breast disease or breast surgery. 


The patient was gravida 2, para 0, aborta 2, with no history of breastfeeding. At the time of this visit, she was sexually active but not using any contraception and was seeking information on contraceptive options as well. She was taking no prescription, OTC, or herbal medications. A current smoker (1 pack per day), she had a 17-pack-year history. Her medical history included mild hyperlipidemia and a cholecystectomy 9 years ago. Family history was negative for Raynaud phenomenon and breast cancer. 


Examination The breast examination of this obese white female was normal, with no tenderness to palpation. There was no supraclavicular or axillary lymphadenopathy, masses, or nipple discharge. The remainder of the examination was unremarkable, except for a thyroid nodule, which was later determined to be benign. No tests were performed.


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DISCUSSION


The patient's history and symptoms suggested a diagnosis of primary Raynaud phenomenon (RP) of the breasts. A literature search that included the Internet and PubMed found case reports of RP in the nipples, but only in breastfeeding women.1,2 A provisional diagnosis of primary RP was made.


Raynaud phenomenon is a vaso­spastic ischemic condition, most commonly affecting the digits.3 Classically, the area affected by RP undergoes a sequential color change from white (blanching due to ischemia caused by vasospasm) to blue (cyanosis) to red (rewarming and return of blood flow). This patient did not report any color change, and it was not observed on examination. Maneuvers to induce an attack by cooling the patient are not recommended.4 


Raynaud phenomenon is classified as primary or secondary. Primary RP is characterized by ongoing episodic digital ischemia in the absence of signs or symptoms of underlying connective tissue disease. Primary RP usually affects women between the ages of 15 and 30 years.4 Secondary RP typically appears at a later age. It is most commonly associated with connective tissue, vascular, endocrine, neoplastic, or hematologic disorders.3 In both primary and secondary forms, symptoms are often exacerbated by nicotine, as well as some prescription medications (including beta-blockers and some migraine medications).3 Emotional stressors have been implicated as triggers of RP due to stimulation of the sympathetic nervous system.4


The prevalence of RP varies among different populations and can range from 3% to 20% in women and 3% to 14 % in men.4 Patients in whom primary RP has been diagnosed do not typically experience serious injury. The disease is more of a nuisance than a threat to health. Secondary RP has been used as a marker to indicate an underlying connective tissue disorder. 


Treatment Since the overall mechanism of Raynaud phenomenon has yet to be fully understood, there is no well-defined treatment.3 Conservative approaches include wearing warmer clothing over the affected areas as well as relaxation and stress management techniques. Calcium channel blockers, alpha-blockers, and vasodilators can be utilized. Nifedipine, a calcium channel blocker, is the most commonly described treatment.2-4 Smoking cessation should be recommended because of the association between nicotine and RP.


Outcome Our patient was given a prescription for 30 mg of extended-release nifedipine to be taken once daily. Contraceptive options and smoking cessation were also addressed. Two months later, the patient reported that her symptoms had subsided and she was able to return to normal activities of daily living free from mastalgia. At a wellness visit 1 year later, she said that the prescribed dose of nifedipine had resolved the breast pain, and she was then using nifedipine as needed.


Comment Although primary RP is fairly easy to diagnose when patients report symptoms in the digits, this case reminds us that the disease can manifest in uncommon locations. Strict attention to the history and prescribing an appropriate treatment have allowed this patient to live a normal life free of pain. JAAPA

The authors are affiliated with the Department of Physician Assistant Studies at Idaho State University, Pocatello. Cynthia Bunde is affiliate faculty and practices at the Pocatello Women's Health Clinic; Bernadette Howlett is an associate professor and research coordinator; Nicholas Ogami is a student; Rebecca Hall is a research assistant. The authors have indicated no relationships to disclose relating to the content of this article.


Erich Fogg, PA-C, MMSc, department editor


REFERENCES


1. Lawlor-Smith L, Lawlor-Smith C. Vasospasm of the nipple—a manifestation of Raynaud's phenomenon: case reports. BMJ. 1997;314(7081):644-645.


2. Holmen OL, Backe B. An underdiagnosed cause of nipple pain presented on a camera phone. BMJ. 2009;339:631-632.


3. Adee AC. Managing Raynaud's phenomenon: a practical approach. Am Fam Physician. 1993;47(4):823-829.


4. Wigley FM. Clinical manifestations and diagnosis of the Raynaud phenomenon. UpToDate Web site. http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-the-raynaud-phenomenon?source=search_result&selectedTitle=1~136. Updated January 25, 2011. Accessed December 2, 2011.