Management of Breast Mass in Patient with Subdermal Contraceptive Implant
The breast mass requires immediate evaluation with breast ultrasound as the initial imaging modality, regardless of the patient's age, to exclude malignancy and guide further management. The cramps and breast tenderness are likely side effects of the contraceptive implant itself, but the breast mass is a separate clinical finding that demands urgent diagnostic workup.
Critical Distinction: Implant Location vs. Breast Pathology
The subdermal contraceptive implant is placed in the upper arm, not the breast 1, 2, 3. The breast mass you describe is therefore unrelated to the implant location and represents a distinct breast finding requiring standard breast evaluation protocols.
Immediate Diagnostic Approach for the Breast Mass
Initial Imaging Selection
Breast ultrasound is the initial examination of choice for evaluating a palpable breast mass, as it can identify fluid collections or solid masses and provides image guidance for diagnostic procedures 4. Ultrasound demonstrates:
- 84% sensitivity for detecting effusions 4
- 46% sensitivity for detecting masses with 100% specificity 4
- Superior ability to distinguish solid from cystic lesions 5
Age-Based Imaging Algorithm
For patients under 30 years:
- Targeted ultrasound alone is appropriate as the initial study 6, 7
- Ultrasound has 100% sensitivity and negative predictive value in this age group 6
- Avoids unnecessary radiation exposure 6
For patients 30-39 years:
- Ultrasound remains the primary modality 7
- Diagnostic mammography ± digital breast tomosynthesis (DBT) may be added if ultrasound is equivocal 7
For patients ≥40 years:
- Diagnostic mammography or DBT plus targeted ultrasound is recommended 7
- Combined imaging has 97.4-100% negative predictive value 7
Management Based on Imaging Results
If Benign Findings (BI-RADS 1-2)
- Simple cysts correlating with the palpable mass may be aspirated if symptomatic 7
- Approximately 20% of focal breast symptoms have identifiable benign causes 6
- Proceed with symptomatic treatment for breast tenderness 7
If Suspicious Findings (BI-RADS 4-5)
- Core needle biopsy is mandatory 7
- While cancer risk with isolated symptoms is low (0-3%), any suspicious mass requires tissue diagnosis 7, 5
If Ultrasound is Equivocal
- MRI with and without contrast may be considered as a second-line study 4
- MRI shows 82% sensitivity for effusions and 50% for masses 4
Addressing the Contraceptive Implant Side Effects
Expected Side Effects
The cramps and breast tenderness are common side effects of levonorgestrel subdermal implants 2, 3:
- Menstrual abnormalities affect most users at some time during therapy 2
- Breast tenderness is a recognized adverse effect 2
- These symptoms alone do not indicate implant removal unless severely bothersome 2
Management of Implant-Related Symptoms
- NSAIDs (ibuprofen or naproxen) for pain management 6, 8, 7
- Well-fitting supportive bra 6, 7
- Ice or heat application as needed 8, 7
- Reassurance that symptoms often improve with continued use 2
Critical Pitfalls to Avoid
Do not attribute the breast mass to the contraceptive implant. The implant is in the arm, not the breast, and any breast mass requires standard oncologic evaluation 1, 2, 3.
Do not delay imaging based on patient age. While cancer risk is lower in younger women, any palpable breast mass warrants imaging evaluation 5.
Do not assume pain or tenderness indicates benign disease. While the risk of malignancy with isolated pain is low (0-3%), certain cancers can present with pain 7, 5.