CHAPTER 6 Breast pain

Nearly 70% of women experience breast pain (clinically known as mastalgia) during their lives; it is the most common breast-related complaint among women. Although a common problem in menstruating women, breast pain is less common in postmenopausal women. The pain can be mildly annoying or severe, and it can be periodic or nearly constant. Breast pain can occur in one or both breasts or in the underarm (axilla) region of the body.

Because of awareness about breast cancer, many women worry that breast pain indicates malignancy. The cause of breast pain is not known. Its relationship to the menstrual cycle and its occurrence in premenopausal women suggest a hormonal etiology. Breast pain is rarely associated with breast cancer and is usually related to fibrocystic changes in premenopausal women.

Breast pain associated with gynecomastia is seen in some young males. An abnormal ratio of estrogen to androgen causes the breast tissue to grow and become tender. It is also seen with Klinefelter syndrome, a sex chromosomal disorder (XXY) that occurs in males.

Diagnostic reasoning: focused history

Could age help explain the cause?

Key question

How old are you?

Breast tissue changes with age. Women under the age of 25 years have more stromal and lobular breast characteristics, and fibroadenomas are more frequently seen in this kind of tissue. Women ages 25 to 40 years are more likely to have cyclic mastalgia and nodularity. After age 40, women’s breasts begin to involute and they are more likely to have cysts and duct ectasia. Women over the age of 50 years have an increased risk of breast cancer.

In adolescent males, an abnormal ratio of estrogen to androgens can occur, causing breast tissue to grow and become tender.

Is this cyclic or noncyclic mastalgia?

Key questions

Are you still menstruating?

What is the relationship of the pain to your menstrual cycle?

What is the pattern and severity of the pain?

Pre- or postmenopausal

Cyclic mastalgia occurs premenopausally and is associated with the menstrual cycle. Postmenopausal pain is not cyclic.

Relationship to menstrual cycle/severity

Cyclic mastalgia occurs in relation to the menstrual cycle. Typically it is most severe before the menses and goes away spontaneously with or after the menses. Premenstrual water retention in the breasts has also been proposed as a cause of breast pain.

What other characteristics of the pain will help me with a diagnosis?

Key questions

Can you describe the pain?

Is the pain in one breast or both?

Where in the breast(s) is it?

Does the pain radiate?

Pain description

Cyclic mastalgia is usually described as a heaviness most likely caused by hormonal changes that affect the breast tissue, resulting in edema and increased nodularity. Noncyclic mastalgia is described as sharp and burning.

Location and radiation

Cyclic mastalgia is usually bilateral and poorly localized. Women often describe it as radiating to the axillae and arms. Noncyclic mastalgia is often unilateral and well localized.

Is the pain associated with a lump or discharge?

Key questions

Have you felt a lump?

Do you have a history of cystic breast changes or lumpy breasts?

Do the lumps come and go or change with your periods?

Have you ever had a mammogram or ultrasound? Why was it done? What were the results?

Have you ever had a lump drained or biopsied? What was the diagnosis?

Do you have any nipple discharge?

Lumps

Noncyclic mastalgia is occasionally secondary to the presence of a fibroadenoma or cyst. Cysts that increase in size and tenderness as the menstrual cycle approaches can contribute to breast pain. Cyclic cysts of the breast are less common after menopause and necessitate diagnostic investigation. A postmenopausal woman with unilateral breast pain has a greater risk of a diagnosis of breast cancer.

Previous mammograms or biopsies

History or documentation of cyclic changes in lumps or the presence of cystic or glandular breast tissue on a mammogram or ultrasound supports a clinical diagnosis of benign disease.

What else could be causing the pain?

Key questions

When was your last period?

Have you missed any periods?

Could you be pregnant?

Is your breast hot or red?

Does the pain get worse with deep inspiration?

What medications are you taking?

Have you had any trauma to your chest?

Have you had chicken pox?

Missed periods/pregnancy

Pregnancy is the most common cause of breast tenderness.

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