Breast Pain
Stefani E. Yudasz
Definition
A.Benign breast disorders such as mastalgia, mastodynia, and fibrocystic breast changes are characterized by lumps or pain. The lumps may be physiologic nodularity, a ropy thickening, or distended fluid-filled cysts that are mobile. The pain may be cyclic or noncyclic, and it may be unilateral or bilateral.
Incidence
A.This is a very common problem. Fifty percent or more of menstruating women experience breast pain. Two-thirds of breast pain is cyclic and occurs in women in their 30s; one-third is noncyclic and may occur in women at any age, but it tends to occur in women closer to menopause.
Pathogenesis
A.Dysplastic, benign histologic changes occur in the breast, such as hyperplasia of the breast epithelium, adenosis, microcysts and macrocysts, duct ectasia, and apocrine metaplasia.
Predisposing Factors
A.Menstruation.
B.Ingesting substances containing methylxanthines (coffee, tea, chocolate, and cola drinks). Methylxanthines have been noted to contribute to breast pain by clinical observation only.
Common Complaints
A.My breasts are painful, particularly just before my period.
B.I have lumps in my breasts, and they hurt.
Other Signs and Symptoms
A.Tender breasts with palpation.
B.Ropelike masses, usually bilateral, with mobile, wellcircumscribed masses that are cystic or rubbery.
Subjective Data
A.Elicit history of pain:
1.Note onset, duration, quality, location, and relation to menstrual cycle.
2.Ask: Is pain constant or intermittent? Sharp or dull? Focal or diffuse?
B.What has the patient tried to alleviate the pain? Note what has worked, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and what has been unsuccessful.
C.Note the patient’s family history of breast pain, lumps, fibrocystic breasts, or cancer.
D.Has there been trauma, such as being hit or having a rough sexual experience?
E.Do her breasts hurt during or after aerobic or nonaerobic exercise, such as running, aerobics, soccer, weightlifting, or basketball?
F.Does she wear a good, supportive, properly fitted bra for daily use and for physical activity?
G.Has she had any prior breast surgeries or biopsy?
H.Note medication history such as oral contraceptives, hormone therapy (HT), or phenytoin.
Physical Examination
A.Inspect: Examine the breasts, and note masses; dimples; changes in the skin; changes in the way the nipples are pointed while the patient is in the sitting position with arms in neutral position in lap, above the head, or pressing in on hips.
B.Palpate: Palpate the breasts; look for hard, fixed, or cystic masses in the breast, under the nipple, in the tail of the breast, and in the axilla. Use a standardized breast examination technique:
1.Assess the nipple for discharge.
2.Measure masses identified and use a clock face to describe their location.
3.Document the masses in the patient’s record, describing characteristics such as shape, size, mobility, and associated tenderness.
Diagnostic Tests
A.Mammogram: Gold standard for screening; however, may be difficult to interpret in women younger than 35 years.
B.Ultrasonography to differentiate cystic from solid masses.
C.MRI useful for detecting tissues with increased blood flow but limited by high sensitivity and low specificity for breast cancer, leading to higher rates of false positive results.
D.Fine-needle aspiration and core-needle biopsy.
E.Excisional biopsy for solid lumps.
F.Pregnancy test.
Differential Diagnoses
A.Fibrocystic breast changes with mastalgia.
B.Benign breast masses: fibroadenoma, benign phyllodes tumors, and duct ectasia.
C.Nipple discharge: duct ectasia, prolactin-secreting pituitary tumors.
D.Extramammary pain: costal chondritis, chest wall muscle pain, neuralgia, herpes zoster infection, and fibromyalgia.
E.Heart: angina pectoris.
F.Gastrointestinal (GI): gastroesophageal reflux disease.
G.Psychologic: anxiety and depression.
Plan
A.General interventions: Once malignancy is excluded, reassurance is an effective intervention in the majority of women with breast pain and normal findings. Use the term fibrocystic changes rather than fibrocystic disease to stress the functional nature of the problem. Stress that the pain is real but not a disease state.
B. 
See Section III: Patient Teaching Guide Fibrocystic Breast Changes and Breast Pain
:
1.Teach the patient breast self-awareness. Encourage monthly breast self-exam. Continue clinical breast exams annually.
2.Lumpiness
that varies with the menstrual cycle is not abnormal. Breasts may normally be of different sizes. It is a change that is significant.
3.Evaluate medications as a potential cause/aggravator of pain. Consider changing dose or discontinuing HT for women on HT with mastalgia, and continuous hormonal contraceptive use (skipping the placebo week) in women currently using hormonal methods.
4.Symptomatic measures to relieve discomfort:
a.Good supporting bra, properly fitted. Adolescents whose breasts are maturing and perimenopausal women whose bodies are changing are two groups who often wear improperly fitted bras.
b.Local heat or ice application (whichever works best).
C.Diet: Elimination of methylxanthines is a good idea, but the relationship of methylxanthines to breast pain is unproven in research studies. Sodium intake restriction has also been advocated but has not been supported by research. Decreased caffeine use is commonly recommended; however, it has not been associated with a decrease in breast pain or tenderness.
D.Pharmaceutical therapy:
1.Oral contraceptive pills: Low-dose estrogen (20 mcg) pills are recommended.
2.Topical NSAID gel can be used for local mastalgia. Oral NSAIDs and acetaminophen can be used for diffuse mastalgia.
3.Anti-estrogen treatment:
a.Danazol (Danocrine) 200 mg daily for 6 months. Note: Doses below 400 mg daily may not inhibit ovulation. The patient must use a barrier contraceptive or Intrauterine device (IUD) contraceptive measure. Although the side effect profile is significant, longterm symptomatic relief and histologic changes may be achieved.
b.Tamoxifen citrate 10 or 20 mg per day for 3 to 6 months for severe cyclic breast pain. Side
effect profile is significant. However, 10 mg/d of tamoxifen is equally effective as 20 mg/d with potential for less toxicity.
c.Bromocriptine 2.5 mg orally twice daily may improve cyclic mastalgia. Side effects include nausea and dizziness and may limit compliance.
4.Vitamins:
a.Vitamin E: There is insufficient evidence to support usefulness of vitamin E in treating mastalgia.
b.Research has demonstrated mixed results on the benefits of vitamin B6 and vitamin A.
5.Herbs:
a.Flaxseed 25 mg/d may show benefit in the treatment of cyclic mastalgia.
b.Iodine 1.5 to 6 mg/d may improve pain in cyclic mastalgia.
c.Evening primrose oil (EPO): There is insufficient evidence to recommend EPO for the treatment of mastalgia, with most recent studies demonstrating that it does not appear to improve cyclic mastalgia pain.
Follow-Up
A.Women with fibrocystic changes need to be seen after 1 to 2 months of pharmacologic therapy to assess for complications and efficacy.
B.If a mass or abnormality is identified, published guidelines for diagnostic workup of breast masses should be followed to determine follow-up.
Consultation/Referral
A.Consult or refer the patient to a physician when breast masses are identified.
B.Consult with a physician and refer the patient to a surgeon if findings include a suspicious mammographic study, an abnormal needle biopsy, or a solid mass per ultrasonogram.
Individual Considerations
A.Pregnancy: Consider blocked duct or mastitis.
B.Adults: Mammography is the gold standard screening tool for breast cancer screening. There are various governing bodies with guidelines and recommendations for screening mammography. One source is the American Cancer Society, which recommends for women at average risk: Annual screening for women ages 45 to 54. Women age 40 to 45 should be given the option to begin annual screening. Age 55 and older have the option of biennial screening or continuation of annual screening. Women should continue mammography screening as long as they remain in good health and their life expectancy is estimated at 10 years or more. The important thing of mammography screening is understanding that it is an individualized assessment and discussion with the patient to review the potential risks, benefits, and limitations of screening. Women with risk factors putting them at high risk for breast cancer may benefit from additional screening modalities, including ultrasound and MRI. When clinical breast examination, mammography, and needle aspiration biopsy are used, breast cancer detection rates are 93% to 100%.
C.Geriatric: Breast pain should be worked up as possible cancer.
D.Partners: Pain may inhibit sexual activity involving the breast.