Breast Pain

Synonym: Mastalgia

This is a common presentation in general practice, usually in women aged 30-50 years. In a series presenting to a UK breast pain clinic, most patients were found to have cyclical breast pain (54%). Other presentations were trigger zone pain (localised single tender area in the breast - 14%) or continuous pain (8%). Tietze's disease (5%), spinal root pain (4%), duct ectasia (4%) and psychological depression (2%) account for most others. Approximately 10% were undiagnosed.

Symptoms

These range from mild discomfort to severe tenderness and pain. Establish whether the pain is cyclical, (i.e. worse in the luteal phase, but may persist throughout) or whether it has no relationship to menstrual cycle. Mild premenstrual breast discomfort lasting for 1 to 4 days can be considered "normal."

Noncyclic mastalgia is less common, typically in women >40 years, and sometimes associated with a fibroadenoma or cyst.

Signs

Palpation may demonstrate an abnormality. Commonly it reveals coarse nodular areas resembling bundles of string in the breast, but check carefully for any discrete lump.

Chronic pelvic pain, premenstrual syndrome, fibrocystic breast disease, and caffeine intake.

• Cyclical breast pain
• Non-cyclical breast pain
• Musculoskeletal - tender costochondral junctions - Tietze's syndrome, cervical and thoracic spondylosis, thoracic outlet syndrome
• Medication (e.g. contraceptive pill)
• Bornholm disease
• Lung disease
• Gall stones

Refer if a lump present. Ultrasonography of the breast and mammography in patients with breast pain is of little diagnostic value in the absence of physical signs, but they are still sometimes performed to reassure the patient and the physician.⁴

Cyclical

Non-drug management

• Reassurance that the pain is not due to breast cancer and an explanation as to its hormonal nature may be all the management that some women require.
• Reduction of dietary fat may be helpful.
• Although there is little evidence to support its use, some women find a soft support sleep bra helpful at night.

Drug management

• Topical diclofenac - there is widespread consensus that topical NSAIDs are effective and well tolerated.⁵
• Simple non-opioid analgesia can be helpful for mild discomfort.
• Changing from the contraceptive pill to a mechanical method is sometimes helpful if symptoms are severe.
• Danazol is licensed for severe pain and tenderness in benign fibrocystic breast disease which has not responded to other treatment. GPs inexperienced in its use may wish to refer to a consultant before prescribing. Adverse effects (commonly nausea, dizziness, rash, backache) can be minimised by reducing the dose of danazol to 100mg from initial starting dose of 300mg daily, and restricting treatment to two weeks preceding menstruation. Non-hormonal contraception is essential as danazol has androgenic effects in the fetus.⁶
• Tamoxifen is effective and one trial suggested its benefits lasted longer than that of danazol.⁷ However, it is not licensed for mastalgia in the UK. There is a consensus to limit its use to no more than 6 months under expert supervision due to high incidence of adverse effects (commonly hot flushes, vaginal discharge, gastro-intestinal symptoms). Non-hormonal contraception is required during use because of potential teratogenicity. There is a risk of thromboembolism but there is no long-term evidence to suggest this is a significant adverse effect at a dose of 10 mg given from days 10 to 25, which is the standard dose for mastalgia and lower than the dose used for breast cancer.⁸
• Goserelin injections are occasionally used for severe refractory mastalgia. The incidence of side effects (mainly vaginal dryness, hot flushes, decreased libido, oily skin or hair, decreased breast size, irritability) can be reduced by using tibolone or hormone replacement therapy.^8,9
• Bromocriptine is now rarely used because frequent and intolerable adverse effects (mainly nausea, dizziness, postural hypotension, constipation). At therapeutic dose. In one large trial, the overall withdrawal rate was 29%.¹⁰

Non-cyclical^3,5

• Chest wall pain often responds to non-steroidal anti-inflammatories (NSAIDs). Referred pain should be appropriately treated.
• Trigger spots sometimes respond to infiltration with local anaesthetic and steroid injection.
• For true diffuse breast pain a support bra, oral or topical NSAIDs may be helpful.