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Vasospasm of the nipple–a manifestation of Raynaud's phenomenon: case reports

^a PO Box 1297, Aldinga Beach, SA 5173, Australia, ^b 194a Chandlers Hill Rd, Happy Valley, SA 5159

Correspondence to: Carolyn Lawlor-Smith

	Introduction

Top Introduction Subjects and methods Comment References

Raynaud's phenomenon was first described by Maurice Raynaud in 1862. It is defined as intermittent ischaemia affecting the acral parts of the body, most commonly the fingers or toes. It is much more prevalent in women, with a female to male ratio of 9:1.¹ It is common in healthy women of childbearing age, affecting up to 22% of healthy women in the 21-50 year age group.²Nipple pain is the most common symptom in breastfeeding women and is the second most common reason given for abandoning breastfeeding, exceeded only by perceived low milk supply.³ We report on five women with Raynaud's phenomenon affecting their nipples.

	Subjects and methods

Top Introduction Subjects and methods Comment References

Five breastfeeding patients presented to us in 1994-5 with signs and symptoms suggesting a diagnosis of Raynaud's phenomenon affecting their nipples (table 1). The major presenting complaint of each of the five women was severe, debilitating nipple pain. Three of the patients had had identical pain when breastfeeding a previous child. One had abandoned breastfeeding at six weeks because of pain; the others had continued breastfeeding for 14 and for 7 months in spite of pain.

In each of these women, blanching of the nipple occurred not only during and immediately after feeds but also between feeds. Exposure to cold precipitated nipple blanching and pain in all patients. Two patients showed the classical triphasic colour change of Raynaud's phenomenon (white, blue and red ) in their nipples, and three showed biphasic colour change (white and blue).

Two of the patients gave a history of Raynaud's phenomenon before their first pregnancy, affecting not only fingers and toes but also their nipples. Two gave a family history of Raynaud's phenomenon affecting a parent. None of the patients had any symptoms or signs to suggest a diagnosis of secondary Raynaud's phenomenon. None of the patients smoked. Four of the five patients reported nipple trauma (ulceration, cracking, and blistering) which proved difficult to heal.

The most common cause of nipple pain is poor positioning of the baby at the breast and/or poor attachment of the baby to the breast.⁴ Poor positioning and attachment can also give rise to blanching of the nipple secondary to compression. All five patients were reviewed by at least one lactation consultant for optimal positioning and attachment of the baby to the breast. The patients' breasts and nipples and their babies' mouths were examined for any abnormalities that may have given rise to nipple pain or trauma. On the basis of presenting symptoms and signs and an absence of any other diagnosable cause for nipple pain, a diagnosis of Raynaud's phenomenon was made in all five women.

	Comment

Top Introduction Subjects and methods Comment References

The concept of Raynaud's phenomenon occurring at sites other than the digits is not new. Vasospasm affecting coronary, gastrointestinal, genitourinary, and placental vasculature has been described in patients with Raynaud's phenomenon.⁵ Breastfeeding may increase the risk of nipple vasospasm because the nipples are exposed and subject to mechanical stimulation during the breastfeeding process. Raynaud's phenomenon in breastfeeding women poses the dual problems of distressing pain in the patient combined with an increased risk of failure of breastfeeding.

	Acknowledgements

Funding: No additional funding.

Conflict of interest: None.

	References

Top Introduction Subjects and methods Comment References

1. Belch JJF. Management of Raynaud's phenomenon. Ther Update 1990;6:253-60.
2. Olsen N, Nielsen SL. Prevalence of primary Raynaud's phenomenon in young females. Scand J Clin Lab Invest 1978;37:761-4.
3. Sloper KS, Elsden E, Baum JD. Increasing breastfeeding in a community. Arch Dis Child 1977;52:700-2.
4. Woolridge MW. Aetiology of sore nipples. Midwifery 1986;2:172-6. [Medline]
5. Belch JJF. Raynaud's phenomenon. Curr Opin Rheumatol 1991;3:960-6. [Medline]

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