Breast pain (mastalgia) - Clinical Symptoms

Breast pain (mastalgia)

Mastalgia is any pain felt in the breast. A thorough history of the pain (documenting the site, onset and relationship to the menstrual cycle) should be taken. Mastalgia may occur premenstrually (cyclical mastalgia) or may be unrelated to the menstrual cycle. The history should also include any previous or family history of breast disease including carcinoma. A thorough breast examination including examination of the regional lymph nodes may reveal a cyst, an abscess or localised inflammation secondary to mastitis. In non-cyclical mastalgia the chest wall should also be palpated.

·        Cyclical mastalgia: Most premenopausal women get some breast discomfort premenstrually. Symptoms including heaviness, tenderness and increased nodularity of the breast tend to gradually increase during the premenstrual period. The symptoms tend to subside as menstruation starts and generally resolve within a few days. If no other abnormalities are detected imaging is not normally required for cyclical mastalgia.

·        Non-cyclical mastalgia may arise from the breast or from non-mammary causes. True breast pain may be caused by acute mastitis, a breast abscess, fat necrosis or benign breast disorders. Focal mastalgia may rarely be a presentation of breast cancer therefore mammography must be considered for women over the age of 35 years with noncyclical focal mastalgia.

·        Non-mammary causes include Tietze’s disease (chostochondritis) in which patients present with a sharp pain exacerbated by movement and reproduced by pressure on the costochondral junctions. It usually resolves with rest and nonsteroidal anti-inflammatory drugs. Pain arising from the chest wall may require infiltration of local anaesthetic agents and steroids in severe cases. Breast pain may also be referred pain from conditions such as angina, pleural inflammation, pneumonia and oesophageal inflammation.

Once underlying pathology has been excluded the majority of patients can be effectively managed with reassurance. Lifestyle changes have been suggested including the use of a well-fitting sports bra, reduction of stress, relaxation therapy and dietary manipulation. Various drug therapies have been shown to be effective including danazol (a synthetic testosterone), tamoxifen and bromocriptine although all have significant side effects limiting their clinical use. Recent advances include lisuride (a dopamine agonist with fewer side effects than bromocriptine) for cyclical mastalgia and the use of topical nonsteroidal anti-inflammatory preparations for all types of mastalgia.