Practice Lesson of the Week

An underdiagnosed cause of nipple pain presented on a camera phone

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b2553 (Published 22 July 2009) Cite this as: BMJ 2009;339:b2553
  1. O L Holmen, foundation house officer 1,
  2. B Backe, professor in obstetrics2
  1. 1Department of Obstetrics and Gynecology, St Olav’s University Hospital, Trondheim, Norway
  2. 2Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim
  1. Correspondence to: O L Holmen oddgeir.lingaas.holmen{at}gmail.com
  • Accepted 14 October 2008

Ordinary camera phones deliver high quality photographs, which can help doctors make uncommon diagnoses

Raynaud’s phenomenon of the nipple is a possible diagnosis in lactating women with severe nipple pain. It is characterised by vasospasm of the arterioles causing intermittent ischaemia, which is manifested as pallor, followed by cyanosis as the venous blood is deoxygenated, and then erythema when reflex vasodilatation occurs. Because symptoms do not appear straight after delivery, mothers may seek the help of their GPs rather than of hospital clinicians. It is important, therefore, to educate primary healthcare workers about severe nipple pain, especially since prompt recognition and treatment allow mothers to continue breastfeeding.

Case report

A 25 year old woman sought antenatal obstetric care early in the second trimester of her first pregnancy, reporting frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.

She described how the pain altered in tandem with a triphasic colour change of the nipples: first white combined with a tingling pain (“tightening a vice screw”), then blue with a burning pain (“pouring acid”), and finally a red phase combined with numbness as the pain decreased. The nipples would stay sore for some time afterwards. She presented three photographs from her camera phone depicting the colour changes of a typical episode (figure).

Vasospasm of the arterioles manifesting …

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