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Breast pain

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

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

in the absence of an abnormal examination. The odds ratio of cancer for mastalgia was 1. is it bilateral. (See "Physical examination" below and see "Evaluation" below). axillae. . and increased to 3. In an observational study in a large integrated health plan.32 for severe pain. such as a mass. Perineural invasion or mass effect compression of sensory nerves are uncommon findings in the pathologic evaluation of specimens from resected breast cancer. the adjusted relative risk for breast cancer in premenopausal patients with cyclical mastalgia was 2. when both imaging studies and breast examination are normal. and how severe is it? Is it phasic. PHYSICAL EXAMINATION — The key point in examining a woman with breast pain is to look for additional signs suggestive of breast malignancy. 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. and see "Primary care evaluation of breast lumps" and see "Nipple discharge"). 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. On the other hand. (See "Initial approach to the woman with breast complaints". In the second study. but not for patients with breast pain alone. what does it feel like. these findings suggest that women who present with mastalgia can be reasonably reassured that their risk of breast cancer is low. Risk assessment for breast cancer can be done. subareolar areas.000 patients having screening mammograms [9] . The prevalence of breast cancer was the same in symptomatic and asymptomatic women. breast symptoms were reported for 32 percent of 13. 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. recall of breast pain might be significantly increased in a retrospective survey of women with breast cancer.12 [8] .control subjects [7] . Questions the patient should be asked about her pain include: Where in the breast does the pain occur. Another observational study included two year follow-up for breast imaging in 987 women with breast pain and 987 asymptomatic women [10] . The odds of having breast cancer were increased only for patients with complaints of breast lump. it is unusual to detect an underlying occult breast cancer in women presenting with breast pain. malignancy was only diagnosed in women who had suspicious radiology [10] . However. Taken together.000 patients undergoing diagnostic mammograms and 5 percent of 110. a complete medical and surgical history and systematic review of systems should be obtained. 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. skin changes. (See "Screening for breast cancer").35. 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. The four breast quadrants. or bloody nipple discharge.

the nipple and areolar skin often undergo local inflammation and swelling until the nipple is conditioned to frequent suckling. vascular pattern. skin retraction. Mastitis — Mastitis or breast abscess is most common in lactating women in the first month after giving birth.13] . it begins during the late luteal phase and dissipates with onset of menses. scars. and school activity in 8 percent [12. section on Mastitis). and most severe in the upper outer quadrants the week prior to onset of menses. and changes in skin color ETIOLOGY — Breast pain may be cyclical (two-thirds) or noncyclical (one-third) [11] . swollen. social activity in 12 percent. The breast becomes diffusely painful. Estrogen stimulation of ductal elements. When initiating lactation. Fibrocystic changes/disease — Breast pain is caused by associated stromal edema. progesterone stimulation of the stroma. . ulceration or crusting of the nipple. It is also more diffuse than normal cyclic breast pain. or infraclavicular lymph nodes Detect skin changes noting the symmetry and contour of the breasts. physical activity in 37 percent. 11 percent had moderate to severe cyclic breast pain. position of the nipples. In a study of 1171 healthy premenopausal women. and red. It is usually caused by an obstructive lactopathy. Cyclical — Pain arising from cyclic hormonal effects on the breast is associated with ovulation or from pharmacologic agents (eg. Minor cyclic breast discomfort is normal. Staphylococcus aureus or Streptococcal species) leading to bacterial mastitis. and/or prolactin stimulation of ductal secretion contribute to cyclic pain during the menstrual cycle. Cyclical pain is usually associated with hormonal changes of the menstrual cycle. This swelling results in relative obstruction to milk flow that can then be seeded by skin bacteria (eg.supraclavicular. ductal dilatation. Non-cyclical breast-related — Multiple etiologies can cause non-cyclical breast pain. as detailed below. 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. oral contraceptive pills). it is frequently bilateral. 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] . dimpling. which interfered with sexual activity in 48 percent. Noncyclical pain is more likely to be related to a breast or chest wall lesion and may be constant or intermittent. (See "Common problems of breastfeeding in the postpartum period". edema or erythema. with an area of fluctuance and eventually pointing if an abscess develops. Physical examination revealing focal tenderness suggests a cyst or rupture through the wall of an ectatic duct.

although this effect may also be related to a placebo effect [19-21] . Hormone replacement therapy — Up to one-third of menopausal women receiving hormone replacement therapy (HRT) experience some degree of noncyclic breast pain. Diet. In one study. Neck and shoulder pain and headache may be present. though patients report pain relief with caffeine avoidance. as well as a rash under the pendulous breast. although some women have reported benefit from modifying aspects of their usual diet. which may resolve to leave a subareolar nodule. macrocysts. Thus. (See "Clinical features and management of locally advanced and inflammatory breast cancer". the site and degree of duct dilatation correlated with the intensity of noncyclical breast pain [22] . cardiovascular agents. and a variety of medications (hormones as well as some antidepressants. which may spontaneously resolve over time [14-16] . possibly through a placebo effect. Other — Other etiologies of breast pain include pregnancy. prior breast surgery. thrombophlebitis. Hidradenitis suppurativa — Hidradenitis suppurativa can involve the breast and present as breast nodules and pain. enlarged breast. and diagnosis of hidradenitis suppurativa"). lifestyle — The role of diet and lifestyle in causing breast pain is uncertain. . firm. (See "Pathogenesis. Controlled studies have not demonstrated an effect of caffeine on fibrocystic breast disease [17. with a "peau d'orange" (orange skin) appearance.Inflammatory breast cancer — Women with de novo inflammatory breast cancer (primary disease) may present with pain and a rapidly progressing tender. but there is no fever or leukocytosis. and antibiotics) [5] . Ductal ectasia — Duct ectasia is characterized by distention of subareolar ducts due to inflammation unrelated to infection. clinical features. Nicotine may increase breast pain by increasing epinephrine levels and through epinephrine's stimulatory effect on cyclic AMP. The skin over the breast is warm and thickened. Large pendulous breasts — Large pendulous breasts may cause pain due to stretching of Cooper's ligaments. Extramammary — Many patients who present with self-diagnosed breast pain actually have referred pain from sources outside of the breast.18] . cessation of smoking may be associated with a reduction of mastalgia. Duct ectasia may be associated with fever and acute local pain and tenderness caused by penetration of the duct wall by lipid material. section on Biology and histology of inflammatory breast cancer).

Chest wall pain is frequently due to the pectoralis major muscle. related to activities such as water-skiing. gallbladder disease or ischemic heart disease may present as intermittent chest pain attributed to the breast. Imaging studies of the neck may reveal the etiology of the pain. In severe cases. and paraspinal problems in the neck and upper thorax accumulate with age. breast pain. A similar effect can be seen with other forms of chest wall irritation. but most women don't require therapy beyond reassurance that the source of pain is muscle strain or articular. (See "Epidemiology and risk factors for breast cancer"). 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. Spinal and paraspinal disorders — This is pain that typically occurs in older women in whom vertebral. spinal. 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). is a common feature. Burning pain. raking. shoveling. which is typical of nerve root pressure. parasternal discomfort. and milk production. or other actions that strain or use the pectoral muscle repetitively. injection of the affected area with an anesthetic and corticosteroid can be diagnostic and therapeutic. and underlying pleuritic lesions can mimic benign breast disease. including burns and chafing from clothing overlying the nipple [23] . Postthoracotomy syndrome — Postthoracotomy syndrome is an unusual disorder in which a healing chest wound simulates the effect of a suckling infant. Similarly. 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. which usually cause bilateral. . Other — Chest wall pain induced by trauma or trauma-induced fat necrosis. EVALUATION — In general. Radicular chest wall pain may be due to cervical arthritis. Other etiologies include slipping and clicking ribs and arthritis. It can be associated with an elevated prolactin concentration. intercostal neuralgia often due to a respiratory infection.Chest wall pain — Chest wall pain is often lateral and may be burning or knife-like. (See "Major causes of musculoskeletal chest pain"). Local heat and analgesics may be prescribed to relieve pain. The pain can be reproduced by asking the woman to place her hand flat on the iliac wing and push inward. 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. rowing. localized or diffuse.

27] . although ultrasonography may be considered as an adjunct examination in women with focal breast pain. Topical NSAIDs may also be useful [24] . Women with vertebral. TREATMENT — After obtaining normal findings on clinical and imaging studies. except in the evaluation of galactorrhea. or paraspinal problems in the neck and upper thorax may benefit from stretching and yoga-like shoulder and neck rotation exercises. However. Decompressive surgery for the nerve roots in the neck may be considered when there is significant cervical radiculopathy. 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. The treatment of cyclic breast pain is discussed separately. (See "Treatment of neck pain"). Some women obtain relief from application of warm compresses or ice packs or gentle massage. the incidence of breast cancer was similar in the painful breast (0. section on Mastitis). use of a "sports bra" during exercise has been shown to reduce pain related to breast movement [26. Those with negative findings can be treated supportively. (See "Common problems of breastfeeding in the postpartum period". spinal. and in women without breast pain undergoing routine screening (0. as described below. most recommendations for treatment of mastalgia are based upon data from observational or case-controlled studies. In addition. One casecontrol study showed that in women referred for mammography. Analgesics — Symptomatic relief may be achieved in some women with acetaminophen or a nonsteroidal antiinflammatory drug (NSAID).5 percent). if indicated.7 percent) [10] . the nonpainful breast (0. but is rarely indicated for isolated breast pain.5 percent). 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. simple reassurance that she does not have breast cancer provides adequate relief for most women [5] . with minimal or no data from randomized controlled trials. Positive imaging studies require appropriate follow-up. several therapies have been shown to relieve breast pain. Nonpharmacologic therapies — A well-fitting brassiere to better support the breast is widely advocated [25] .Women over age 35 are evaluated with mammography. (See "Clinical manifestations and diagnosis of hyperprolactinemia"). The use of support bra with steel underwiring tends to reduce mastalgia in women with pendulous breasts. For those who seek treatment. (See "Overview of benign breast disease"). or both [5] . . Blood tests are not useful. However.

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