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Breast Pain or Tenderness

 

Breast pain, otherwise known as mastalgia/mastodynia, is one of the most common breast symptoms experienced by women; up to two-thirds will get it at some point in their lives. Woman experiencing breast pain often describe it as mild to moderate pain; very few experience symptoms worse than this. Only about half of patients with breast pain seek medical advice, therefore thorough assessment and diagnosis is important as there can be a lot of anxiety associated with breast pain, even though there is often no sinister cause for the pain.

 

Breast pain is uncommon in men, although it may be experienced by those who develop gynaecomastia (breast enlargement due to abnormal development of large mammary glands in males) secondary to medication, hormonal factors, cirrhosis and other conditions.

 

Clinical Examination and Assessment

 

History

 

When a patient presents with breast pain, a focussed history should be taken. An adaptation to the acronym SOCRATES is useful in remembering what to establish in a breast pain history:

 

 

It is important to ask about medication history and their reproductive, family and past medical history. The affect the breast pain is having on the patients life should be assessed as it may be interfering with their quality of life, particularly regarding work, exercise and relationships.

 

Examination

 

The patient should be assessed for any non-breast pathology before a full breast examination is carried out. It may be worthwhile examining for other causes of pain, particularly the cervical and thoracic spine, chest wall, shoulders, upper extremities, heart, lungs and abdomen. It is important to exclude pregnancy, malignancy and infection. Malignancy may be suspected if there is a persisting discrete lump or a lump that enlarges, is fixed and hard or is present in a woman who has previously had breast cancer. Any skin or nipple changes may also be suspicious. Any suspected malignancy should be referred urgently. An infection may be suggested by localised breast swelling, redness, warmth and pain, with associated systemic symptoms such as fever or flu-like illness.

 

It may be worthwhile asking the patient to complete a daily pain score recorded on a visual analogue scale for a couple of months so any variation throughout the menstrual cycle can be noted. This will help in classifying the type of breast pain and may be useful in measuring the effectiveness of treatment. Ultrasound or mammography is of little value in the absence of physical signs.

 

Classification

 

Most women would accept that pain lasting one to four days is a normal part of the menstrual cycle. Breast pain lasting longer than this can be divided into cyclical and non-cyclical breast pain.

 

1. Cyclical Breast Pain

 

Cyclical breast pain has a clear relationship with the menstrual cycle – pain tends to increase from the mid-cycle onwards, therefore it does not occur in postmenopausal women or males. Two-thirds of women, who experience breast pain, have cyclical breast pain and patients are often young with an average age of 34 years. Cyclical breast pain is defined as more severe pain than ‘normal’ lasting for more than 7 days per month; pain may be present throughout the rest of the menstrual cycle but to a lesser degree. Patients often report years of symptoms although occasionally it can improve or resolve spontaneously.

 

Cyclical breast pain classically affects the outer, upper quadrant of the breasts and it can radiate to the upper arm and axilla. Most patients are affected bilaterally. The breasts may become tender, with generalised swelling and lumpiness (although any discrete lump should be investigated further). The pain is often relieved by menstruation and symptoms subside completely following the menopause.

 

Treatment of Cyclical Breast Pain

 

1. First Line

 

The most important first line treatment is to reassure the patient that there is no serious underlying pathology and explain the nature of cyclical breast pain; this may be the only treatment required in up to 85% of the patients. Many patients that present with breast pain are worried about breast cancer but the risk of this is low if breast pain is the only symptom. Other first line treatments to consider are:

 

  • A better fitting bra during the day
  • A soft support bra at night
  • Oral paracetamol and/or ibuprofen, as required
  • Topical non-steroidal anti-inflammatory (NSAIDs) drugs, as required

 

NSAIDs are known to be effective and well tolerated by most patients. The options above are very patient dependent. In general, first line treatment should be continued for 6 months before second line treatment is considered.

 

There are other causes of breast pain including medications, particularly hormonal medications such as hormone replacement therapy (HRT) and the contraceptive pill. It may be helpful to change from the contraceptive pill to a mechanical method if symptoms are severe, but medication alterations are not usually recommended. Some women have suggested that the pain decreases with continued use of the same medications. Other drugs that may contribute to breast pain include antidepressants, antipsychotics and anxiolytics, anti-hypertensives and cardiac medication and antimicrobials.

 

Some women have found that reducing saturated fat intake can lead to some improvement although this is not routinely recommended. There is no evidence to suggest that other medications such as evening primrose oil are effective in reducing breast pain, particularly when their risks are taken into account.

 

2. Second Line

 

If pain is severe enough to affect the patients’ quality of life and it has not responded to any first line treatment, it may be advisable to refer the patient to a specialist for other treatments. The other options available include:

 

  • Danazol (anti-gonadotrophin) which is licensed for severe pain and tenderness in benign fibrocystic breast disease
  • Tamoxifen (an oestrogen-receptor antagonist) which has proven to be effective and a trial suggested its benefits lasted longer than that of Danazol. However, it is not licensed for breast pain in the UK and its use should be limited to less than 6 months due to the high incidence of adverse side effects
  • Bromocriptine which is rarely used now due to frequent and intolerable adverse effects

 

2. Non-cyclical Breast Pain

 

Non-cyclical breast pain is not linked to the menstrual cycle; it can be constant or intermittent. A third of women who experience breast pain have non-cyclical breast pain. It tends to be unilateral and localised within a quadrant of the breast. Most arise due to unknown reasons but some can be explained by the following:

 

  • Pregnancy
  • Mastitis
  • Breast abscess
  • Breast cysts
  • Diffuse breast pain
  • Trigger spots
  • Fibroadenosis
  • Fibrocystic breast disease
  • Trauma
  • Benign tumours
  • Carcinoma

 

Non-cyclical breast pain tends to occur in older women with an average age of 43 years – many women are postmenopausal. Each patient’s symptoms will vary according to the cause of the pain. In some cases it may be possible to find localised areas of tenderness, otherwise known as trigger spots.

 

Breast Infections/Mastitis

 

Breast infections, otherwise known as mastitis, are fairly common in women who are breast-feeding, typically occurring within the first few weeks. They are the result of introduction of bacteria, usually Staphylococcus aureus from the infant’s mouth and/or throat and affects between 2-33% of breastfeeding women. The ducts that carry the breast milk can become blocked and inflamed, or alternatively, mastitis can occur if you suddenly stop breastfeeding and the breasts become engorged with milk. Breast infections can lead to abscesses within the breast.

 

Usually only one quadrant is affected in a single breast. The patient may present with a red, swollen and hot breast that is tender to touch and/or with a systemic fever or flu-like illness. The infection may be accompanied by purulent discharge and axillary lymphadenopathy.

 

Treatment of Non-Cyclical Breast Pain

 

Treatment of non-cyclical breast pain is dependent on its cause. Referred pain should be appropriately investigated and treated but the majority of non-cyclical breast pain would benefit from the same treatment and advice used for cyclical breast pain, particularly wearing a firm support bra and the use of NSAIDs when required.

 

3. Extramammary (non-breast) Pain

 

Extramammary breast pain does not arise from the breast but from the chest wall causing tender costochondral junctions (Tietze’s syndrome) or from other non-breast areas including:

 

  • Cervical and thoracic spondylosis
  • Lung disease
  • Gallstones
  • Exogenous oestrogens (HRT, oral contraceptive pill)
  • Thoracic outlet syndrome

 

Treatment of Extramammary Breast Pain

 

Treatment of extramammary breast pain is also dependent on its cause. Pain from the chest wall may benefit from treatment with NSAIDs or an injection of steroid and local anaesthetic into the local areas.

 

Guide to Diagnosing Breast Pain

Summary

 

In summary, breast pain can be categorised into cyclical, non-cyclical and extramammary. Cyclical breast pain is related to the menstrual cycle, affects younger women and both breasts. Non-cyclical breast pain has many causes, particularly pregnancy, mastitis and fibrocystic breast disease. Extramammary breast pain is not from the breast but from the chest wall or other non-breast areas. The treatment of breast pain is aimed at the cause, but the same advice applies to all three classifications of breast pain: a firm support bra during the day, a soft support bra during the night and NSAIDs in tablets or gel form when required.

 

References

 

 

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