Breast Pain

Synonyms: mastalgia, mastodynia

Pain is one of the most common breast symptoms experienced by women and management requires careful assessment and diagnosis. There is often understandable anxiety associated with the symptom, particularly about breast cancer. This concern is the primary reason most women seek medical evaluation.¹ The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low and suitable reassurance can usually be given.¹

Breast pain is uncommon in men. Pain and tenderness may occur in men who develop gynaecomastia secondary to medication, hormonal factors, cirrhosis and other conditions.¹ Cyclical breast pain is clearly only confined to women but both non-cyclical breast pain and extramammary pain can occur in men. The assessment of these types of pain is similar for men and women.

Breast pain is typically approached according to its classification as:

• Cyclical breast pain - breast pain that has a clear relationship to the menstrual cycle and the most common type of breast pain.
• Non-cyclical breast pain - may be constant or intermittent but is not associated with the menstrual cycle.
• Extramammary (non-breast) pain - is interpreted as having a cause within the breast but arises from elsewhere (chest wall or other sources).

The classification is important because the assessment and response to treatment is different for the different types of breast pain.

• Only about half of patients with breast pain seek medical advice.¹
• This is a common presentation in general practice, usually in women aged 30-50 years.
• In patients attending for breast problems in specialist clinics and general practice, breast pain is given as the reason for attendance in about half of patients.¹
• 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 syndrome (5%), spinal root pain (4%), duct ectasia (4%) and psychological depression (2%) account for most others. Approximately 10% were undiagnosed.²

Symptoms

The history should be directed toward identifying and characterising breast-related symptoms.
Establish:

• Quality and severity of pain (ranges from mild discomfort to severe tenderness and pain).
• Site of pain.
• Any relationship to activity.
• Presence of other breast symptoms (lumps, discharge).
• Relationship to menstrual cycle. 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.
• Medication history.
• Reproductive, medical and family history.

Normal or physiological breast pain

• Mild premenstrual breast discomfort lasting for 1 to 4 days can be considered "normal".
• In order of decreasing frequency, premenstrual breast symptoms are tenderness, swelling, pain and lumpiness.

Cyclical breast pain

• Women who experience more severe and prolonged pain are considered to have cyclic mastalgia.
• Research studies use methods to measure the severity and duration of pain. Cyclic mastalgia is taken to be more severe pain lasting for more than 7 days per month.
• About 10 to 20% of women will meet the criteria for cyclic mastalgia.¹
• Pain may be present to a lesser degree during the entire cycle (with premenstrual intensification).
• The pain is typically in the upper outer breast area. It often radiates to the upper arm and axilla.
• Most cyclic mastalgia is diffuse and bilateral (may be more severe in one breast).
• Pain is described as "dull", "heavy" or "aching".
• It is important to ask about medical history and any associated problems. Such problems are common and disruptive. Likely findings include:
  • Sleep problems.
  • Work, school and social disruption.
  • Previous investigations (including mammography and breast biopsy) are more likely and often under age 35.¹

Non-cyclical breast pain

• It is less common and typically accounts for approximately 31% of women seen in breast pain clinics.¹
• It tends to be unilateral and localised within a quadrant of the breast.
• Non-cyclic breast pain presents later (fourth or fifth decade). Many women are postmenopausal at onset of symptoms.
• Most noncyclic breast pain arises for unknown reasons.
• It is more likely to have an anatomical rather than hormonal cause (with the exception of breast pain associated with medication).
• A minority of non-cyclical breast pain is explained by pregnancy, mastitis, trauma, thrombophlebitis, breast cysts, benign tumours or cancer.¹
• A wide range of drugs have been associated with breast pain. Between 16% and 32% of women report breast pain with oestrogen and combined hormonal therapies.¹ Other drugs associated with breast pain include antidepressants (including venlafaxine and mirtazapine), cardiovascular drugs (including digoxin and spironolactone) and other drugs including metronidazole and cimetidine.¹

Extramammary pain

Extramammary pain due to various conditions may present as breast pain. There are many such conditions but most common are costochondritis and other chest wall syndromes.

Signs

• Clinical breast examination requires careful inspection and palpation of each breast (including nipple and areolar), together with examination of the regional lymph nodes.
• 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.
• It may be appropriate to examine other potential causes of the pain. Examination of the cervical and thoracic spine, chest wall, shoulders, upper extremities, heart, lungs and abdomen may help further diagnostic evaluation.

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

• Breast-related:
  • Cyclical breast pain
  • Non-cyclical breast pain
  • Mastitis
  • Breast trauma
  • Thrombophlebitis/Mondor's syndrome
  • Breast cysts
  • Benign breast tumours
  • Breast cancer
• Musculoskeletal:
  • Chest wall pain
  • Costochondritis/Tietze's syndrome
  • Chest wall trauma and/or rib fracture
  • Fibromyalgia
  • Cervical and thoracic spondylosis/radiculopathy
  • Shoulder pain
  • Herpes zoster
  • Thoracic outlet syndrome
  • Bornholm disease
• Miscellaneous causes:
  • Coronary artery disease/angina
  • Pericarditis
  • Pulmonary embolus
  • Pleurisy
  • Gastroesophageal reflux
  • Peptic ulcer disease
  • Cholelithiasis/cholecystitis
  • Sickle cell anaemia
  • Psychological
  • Pregnancy
• Medication, e.g. contraceptive pill

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.⁵

Management will depend on the cause but a variety of measures which have been routinely recommended by some in the past should no longer be so recommended.

Cyclical breast pain⁶

First-line 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.
• A better-fitting bra and simple analgesia is the first line of treatment. Simple non-opioid analgesia can be helpful for mild discomfort.
• Topical diclofenac may be helpful. There is some consensus that topical NSAIDs are effective and well tolerated.⁷
• Changing from the contraceptive pill to a mechanical method is sometimes helpful if symptoms are severe.
• Although there is little evidence to support its use, some women find a soft support sleep bra helpful at night.
• Continue treatment for 6 months before considering second-line treatment.⁶

Second-line management

Consider referring to a specialist for other treatment options if pain is severe or persistent. A diary of pain and symptoms for 2 months may help in assessment.⁶ Further treatment may include:

• Danazol (an anti-gonadotrophin) 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 100 mg from initial starting dose of 300 mg daily, and restricting treatment to 2 weeks preceding menstruation. Non-hormonal contraception is essential as danazol has androgenic effects in the fetus.⁸
• Tamoxifen (an oestrogen-receptor antagonist) is effective and one trial suggested its benefits lasted longer than that of danazol.⁹ 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.¹⁰
• Goserelin injections (a gonadorelin analogue inhibiting gonadotrophin release) 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.^10,11
• Bromocriptine is now rarely used because of frequent and intolerable adverse effects (mainly nausea, dizziness, postural hypotension, constipation). In one large trial, the overall withdrawal rate was 29%.¹²
• Toremifene (a selective oestrogen-receptor modulator).⁶

Non-cyclical breast pain^4,7

• 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.