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Breast pain

Authors
Mehra Golshan, MD
Dirk Iglehart, MD Section Editor
Anees B Chagpar, MD, MSc, MPH Deputy Editor
Susan E Pories, MD, FACS

Last literature review version 17.1: January 2009 | This topic last updated: December 7,
2007 (More)

INTRODUCTION Breast pain is common in women, and occasionally occurs in men.


Evaluation of breast pain is important, to determine whether the pain is due to normal
physiological changes related to hormonal fluctuation or to a pathological process, such as
breast cancer. Breast pain is usually mild, although approximately 11 percent of affected
women will describe their pain as moderate to severe [1] .
This topic will discuss the etiology, evaluation and treatment of breast pain in women.
Evaluation of breast lumps is discussed separately. (See "Primary care evaluation of breast
lumps").

INCIDENCE The incidence of breast pain depends upon the population studied and
definition used. A survey of working women found that 45 percent had mild and 21 percent
had severe breast pain, although most had not reported their symptoms to a clinician [2] .
In a large cohort of women 40 to 69 years of age enrolled in a health maintenance
organization, breast pain was the most common breast related symptom prompting
evaluation and accounted for almost one-half of breast related office visits [3] . By
comparison, a series of 10,000 consecutive surgical consultations for new female patients
(mean age 46 years) referred for breast evaluation reported only 5 percent had a chief
complaint of breast pain [4] .

RISK FOR BREAST CANCER The frequency of breast cancer reported for women
presenting with breast pain ranges from 1.2 to 6.7 percent [5] . Conversely, 15 percent of
women with newly diagnosed breast cancer had localized breast pain as the presenting
symptom in one study [6] and breast pain was the only presenting symptom in 8 percent of
symptomatic cancers in another study [3] .
While both breast pain and breast cancer may occur in the same patient, data conflict on
whether the presence of breast pain increases a patient's risk for breast cancer: Two older
case control studies found an increased risk of breast cancer for women with mastalgia. In
one study, 192 women with premenopausal node-negative cancer were matched with

control subjects [7] . The odds ratio of cancer for mastalgia was 1.35, and increased to 3.32
for severe pain. In the second study, the adjusted relative risk for breast cancer in
premenopausal patients with cyclical mastalgia was 2.12 [8] . However, recall of breast
pain might be significantly increased in a retrospective survey of women with breast cancer.
On the other hand, when both imaging studies and breast examination are normal, it is
unusual to detect an underlying occult breast cancer in women presenting with breast pain.
In an observational study in a large integrated health plan, breast symptoms were reported
for 32 percent of 13,000 patients undergoing diagnostic mammograms and 5 percent of
110,000 patients having screening mammograms [9] . The odds of having breast cancer
were increased only for patients with complaints of breast lump, but not for patients with
breast pain alone, Another observational study included two year follow-up for breast
imaging in 987 women with breast pain and 987 asymptomatic women [10] . The
prevalence of breast cancer was the same in symptomatic and asymptomatic women;
malignancy was only diagnosed in women who had suspicious radiology [10] . Perineural
invasion or mass effect compression of sensory nerves are uncommon findings in the
pathologic evaluation of specimens from resected breast cancer,
Taken together, these findings suggest that women who present with mastalgia can be
reasonably reassured that their risk of breast cancer is low, in the absence of an abnormal
examination. (See "Physical examination" below and see "Evaluation" below).

HISTORY It may be helpful to ask women with cyclic pain to record the occurrence and
severity of breast pain in a diary and note potential aggravating and ameliorating factors.
Questions the patient should be asked about her pain include: Where in the breast does
the pain occur, is it bilateral, what does it feel like, and how severe is it? Is it phasic, with
peaks at midcycle and premenstrually? Is it associated with use of oral contraceptive pills
or hormone replacement therapy? Did it begin after a recent birth or pregnancy loss or
termination? Is it related to vigorous or repetitive use of the pectoral muscle group? Is there
concurrent neck problem? Are there systemic or other local symptoms, such as fever or
erythema? Is there a history of recent trauma to the chest? Does the pain affect her ability
to perform daily activities?
In addition, a complete medical and surgical history and systematic review of systems
should be obtained. Risk assessment for breast cancer can be done. (See "Screening for
breast cancer").

PHYSICAL EXAMINATION The key point in examining a woman with breast pain is to
look for additional signs suggestive of breast malignancy, such as a mass, skin changes, or
bloody nipple discharge. (See "Initial approach to the woman with breast complaints", and
see "Primary care evaluation of breast lumps" and see "Nipple discharge").
The four breast quadrants, subareolar areas, axillae, supraclavicular and infraclavicular
areas should be systematically examined with the woman both lying and sitting with her
hands on her hips and then above her head.
The specific goals of the examination are to: Delineate and document breast masses Elicit
discharge from a nipple Identify localized areas of tenderness and relate them to areas of
pain noted by the woman and to other physical findings Detect enlarged axillary,

supraclavicular, or infraclavicular lymph nodes Detect skin changes noting the symmetry
and contour of the breasts, position of the nipples, scars, vascular pattern, skin retraction,
dimpling, edema or erythema, ulceration or crusting of the nipple, and changes in skin color

ETIOLOGY Breast pain may be cyclical (two-thirds) or noncyclical (one-third) [11] .


Cyclical pain is usually associated with hormonal changes of the menstrual cycle; it is
frequently bilateral, and most severe in the upper outer quadrants the week prior to onset of
menses. Noncyclical pain is more likely to be related to a breast or chest wall lesion and
may be constant or intermittent.

Cyclical Pain arising from cyclic hormonal effects on the breast is associated with
ovulation or from pharmacologic agents (eg, oral contraceptive pills). Estrogen stimulation
of ductal elements, progesterone stimulation of the stroma, and/or prolactin stimulation of
ductal secretion contribute to cyclic pain during the menstrual cycle. Minor cyclic breast
discomfort is normal; it begins during the late luteal phase and dissipates with onset of
menses.
Cyclic mastalgia is often defined as pain severity greater than four out of ten on a visual
analog scale and pain lasting at least seven days per month [12] . It is also more diffuse
than normal cyclic breast pain. In a study of 1171 healthy premenopausal women, 11
percent had moderate to severe cyclic breast pain, which interfered with sexual activity in
48 percent, physical activity in 37 percent, social activity in 12 percent, and school activity
in 8 percent [12,13] .

Fibrocystic changes/disease Breast pain is caused by associated stromal edema,


ductal dilatation, and inflammation. Pain associated with fibrocystic change can be present
throughout the cycle but is typically most intense the week prior to and the week of the
menstrual cycle.

Non-cyclical breast-related Multiple etiologies can cause non-cyclical breast pain, as


detailed below. Physical examination revealing focal tenderness suggests a cyst or rupture
through the wall of an ectatic duct.

Mastitis Mastitis or breast abscess is most common in lactating women in the first
month after giving birth. It is usually caused by an obstructive lactopathy. When initiating
lactation, the nipple and areolar skin often undergo local inflammation and swelling until the
nipple is conditioned to frequent suckling. This swelling results in relative obstruction to milk
flow that can then be seeded by skin bacteria (eg, Staphylococcus aureus or Streptococcal
species) leading to bacterial mastitis. The breast becomes diffusely painful, swollen, and
red; with an area of fluctuance and eventually pointing if an abscess develops. (See
"Common problems of breastfeeding in the postpartum period", section on Mastitis).

Inflammatory breast cancer Women with de novo inflammatory breast cancer (primary
disease) may present with pain and a rapidly progressing tender, firm, enlarged breast. The
skin over the breast is warm and thickened, with a "peau d'orange" (orange skin)
appearance, but there is no fever or leukocytosis. (See "Clinical features and management
of locally advanced and inflammatory breast cancer", section on Biology and histology of
inflammatory breast cancer).

Hormone replacement therapy Up to one-third of menopausal women receiving


hormone replacement therapy (HRT) experience some degree of noncyclic breast pain,
which may spontaneously resolve over time [14-16] .

Diet, lifestyle The role of diet and lifestyle in causing breast pain is uncertain, although
some women have reported benefit from modifying aspects of their usual diet. Controlled
studies have not demonstrated an effect of caffeine on fibrocystic breast disease [17,18] ,
though patients report pain relief with caffeine avoidance, possibly through a placebo effect.
Nicotine may increase breast pain by increasing epinephrine levels and through
epinephrine's stimulatory effect on cyclic AMP. Thus, cessation of smoking may be
associated with a reduction of mastalgia, although this effect may also be related to a
placebo effect [19-21] .

Large pendulous breasts Large pendulous breasts may cause pain due to stretching
of Cooper's ligaments. Neck and shoulder pain and headache may be present, as well as a
rash under the pendulous breast.

Ductal ectasia Duct ectasia is characterized by distention of subareolar ducts due to


inflammation unrelated to infection. Duct ectasia may be associated with fever and acute
local pain and tenderness caused by penetration of the duct wall by lipid material, which
may resolve to leave a subareolar nodule. In one study, the site and degree of duct
dilatation correlated with the intensity of noncyclical breast pain [22] .

Hidradenitis suppurativa Hidradenitis suppurativa can involve the breast and present
as breast nodules and pain. (See "Pathogenesis, clinical features, and diagnosis of
hidradenitis suppurativa").

Other Other etiologies of breast pain include pregnancy, thrombophlebitis, macrocysts,


prior breast surgery, and a variety of medications (hormones as well as some
antidepressants, cardiovascular agents, and antibiotics) [5] .

Extramammary Many patients who present with self-diagnosed breast pain actually
have referred pain from sources outside of the breast.

Chest wall pain Chest wall pain is often lateral and may be burning or knife-like,
localized or diffuse. (See "Major causes of musculoskeletal chest pain").
Chest wall pain is frequently due to the pectoralis major muscle, related to activities such
as water-skiing, raking, rowing, shoveling, or other actions that strain or use the pectoral
muscle repetitively. The pain can be reproduced by asking the woman to place her hand
flat on the iliac wing and push inward.
Chest wall pain can also arise from costochondritis (typically the second through fifth
costochondral junctions) or Tietze's syndrome (typically second and third costochondral
junctions), which usually cause bilateral, parasternal discomfort.
Other etiologies include slipping and clicking ribs and arthritis. Radicular chest wall pain
may be due to cervical arthritis.
Local heat and analgesics may be prescribed to relieve pain, but most women don't require
therapy beyond reassurance that the source of pain is muscle strain or articular. In severe
cases, injection of the affected area with an anesthetic and corticosteroid can be diagnostic
and therapeutic.

Spinal and paraspinal disorders This is pain that typically occurs in older women in
whom vertebral, spinal, and paraspinal problems in the neck and upper thorax accumulate
with age. Paraspinal muscle spasm and other impingements on the free course of the
sensory nerves from the neck and upper thorax can cause a radiculopathy leading to pain
or hyperesthesia. Burning pain, which is typical of nerve root pressure, is a common
feature. Imaging studies of the neck may reveal the etiology of the pain.

Postthoracotomy syndrome Postthoracotomy syndrome is an unusual disorder in


which a healing chest wound simulates the effect of a suckling infant. It can be associated
with an elevated prolactin concentration, breast pain, and milk production. A similar effect
can be seen with other forms of chest wall irritation, including burns and chafing from
clothing overlying the nipple [23] .

Other Chest wall pain induced by trauma or trauma-induced fat necrosis, intercostal
neuralgia often due to a respiratory infection, and underlying pleuritic lesions can mimic
benign breast disease. Similarly, gallbladder disease or ischemic heart disease may
present as intermittent chest pain attributed to the breast.

EVALUATION In general, women under age 35 with mastalgia and no breast mass or
nipple discharge do not require diagnostic studies and may be treated as described below.
Ultrasonography should be considered if the breast pain is focal and mammography should
be considered in women at high risk of breast cancer because of family history or clinical
findings. (See "Epidemiology and risk factors for breast cancer").

Women over age 35 are evaluated with mammography, although ultrasonography may be
considered as an adjunct examination in women with focal breast pain. Those with negative
findings can be treated supportively, as described below. Positive imaging studies require
appropriate follow-up.
However, the value of both mammography and ultrasound for evaluation of breast pain
have not been proven and the yield is low if physical examination is normal. One casecontrol study showed that in women referred for mammography, the incidence of breast
cancer was similar in the painful breast (0.5 percent), the nonpainful breast (0.5 percent),
and in women without breast pain undergoing routine screening (0.7 percent) [10] .
Blood tests are not useful, except in the evaluation of galactorrhea. (See "Clinical
manifestations and diagnosis of hyperprolactinemia").

TREATMENT After obtaining normal findings on clinical and imaging studies, if


indicated, simple reassurance that she does not have breast cancer provides adequate
relief for most women [5] . For those who seek treatment, several therapies have been
shown to relieve breast pain. However, most recommendations for treatment of mastalgia
are based upon data from observational or case-controlled studies, with minimal or no data
from randomized controlled trials. The treatment of cyclic breast pain is discussed
separately. (See "Overview of benign breast disease").

Analgesics Symptomatic relief may be achieved in some women with acetaminophen


or a nonsteroidal antiinflammatory drug (NSAID), or both [5] . Topical NSAIDs may also be
useful [24] .

Nonpharmacologic therapies A well-fitting brassiere to better support the breast is


widely advocated [25] . The use of support bra with steel underwiring tends to reduce
mastalgia in women with pendulous breasts. In addition, use of a "sports bra" during
exercise has been shown to reduce pain related to breast movement [26,27] .
Some women obtain relief from application of warm compresses or ice packs or gentle
massage.
Women with vertebral, spinal, or paraspinal problems in the neck and upper thorax may
benefit from stretching and yoga-like shoulder and neck rotation exercises. (See
"Treatment of neck pain"). Decompressive surgery for the nerve roots in the neck may be
considered when there is significant cervical radiculopathy, but is rarely indicated for
isolated breast pain.
Ice packs are recommended during the obstructive (prebacterial) phase of puerperal
mastitis to decrease milk production regionally and thereby relieve ductal intraluminal
pressure and subsequent pain. (See "Common problems of breastfeeding in the
postpartum period", section on Mastitis).

Other therapies Cyclical breast pain can be treated, if bothersome, with a variety of
hormonal and nonhormonal interventions. Women with severe non-cyclical breast pain may
experience temporary or permanent relief with injection of the affected area with an
anesthetic and corticosteroid.

PROGNOSIS The prognosis is variable and influenced by the age of onset of pain and
whether pain is cyclic or noncyclic [28] . In one series, cyclical breast pain spontaneously
resolved within three months of onset in 20 to 30 percent of women, but transient relapses
were common [29] . In another series, noncyclical breast pain spontaneously resolved in 50
percent of patients [30] . Relief may be spontaneous or related to a hormonally mediated
event, such as pregnancy or menopause [28] .

SUMMARY AND RECOMMENDATIONS Breast pain is common, affecting as many as 65


percent of women, though many do not report their symptoms to their clinician. Elements
from the history can help distinguish pain that is cyclical (often related to fibrocystic
changes), non-cyclical but breast related, or extramammary (see "Etiology" above). The
frequency of breast cancer in women presenting with breast pain ranges for 1.2 to 6.7
percent (see "Risk for breast cancer" above). We suggest ultrasonography to evaluate
women under age 35 if the breast pain is focal. Mammography should be considered for
women under age 35 if they are at high risk of breast cancer because of family history (see
"Evaluation" above). We recommend mammography for women over age 35.
Ultrasonography should be done as an adjunct examination if the breast pain is focal (see
"Evaluation" above). Treatment with analgesics, and a supportive brassiere, can be helpful
for many women with mastalgia (see "Treatment" above).

Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES


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