SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.
If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.
The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.
This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.
A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.
Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.
It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.
The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”
Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.
Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.