What is the likely cause of a patient's breast tenderness, given a recent bilateral diagnostic mammogram (DX mammo) with ultrasound (u/s) of the left breast showing a nearly isoechoic lesion, and her reported consumption of coffee and chocolate?

From the Guidelines

The patient should consider reducing her intake of coffee and chocolate to see if symptoms improve, as caffeine can affect blood vessels and hormone levels in some individuals, potentially contributing to breast discomfort. The recent ultrasound revealed a 2.8 x 1.4 x 3.5 cm heterogeneous lesion in the left breast that has benign features (BI-RADS category 3), which requires follow-up ultrasound in 6 months 1. This lesion was not detected on mammography. To address the breast tenderness, the patient should track her symptoms while gradually reducing caffeine consumption over 2-4 weeks to minimize withdrawal symptoms like headaches. Additionally, wearing a supportive bra, applying warm or cold compresses, and taking over-the-counter pain relievers like ibuprofen (400mg every 6-8 hours with food) or acetaminophen (650mg every 6 hours) may help manage discomfort.

Some key points to consider in managing breast tenderness include:

• The etiology of breast pain is multifactorial, and hormonal medications, psychological factors, and other medications may be contributing factors 1
• There is no convincing scientific evidence that eliminating or reducing caffeine intake has any significant effect on breast pain, despite widespread belief to the contrary 1
• Breast pain can be associated with diffuse palpable nodularity, but there is no relationship between the extent of nodularity and the severity of pain 1
• Women with large breasts often have noncyclical pain simply related to the size of their breasts, which may also be associated with neck, shoulder, and back pain 1

It's essential to keep the 6-month follow-up appointment for the left breast ultrasound to monitor the benign-appearing lesion, as recommended. If breast tenderness worsens, changes in pattern, or if new symptoms develop, the patient should contact her healthcare provider promptly. The American College of Radiology Appropriateness Criteria suggest that imaging evaluation is usually not indicated if the pain is cyclic or nonfocal, but for focal, noncyclic pain, imaging may be appropriate, mainly for reassurance and to identify treatable causes 1.

From the Research

Breast Tenderness and Caffeine Consumption

• The patient reports breast tenderness and has a recent mammogram, with a nearly isoechoic lesion involving the left breast that is heterogeneous and has benign features 2, 3.
• Some women find that reducing caffeine consumption may help reduce cyclical breast tenderness, although scientific evidence for this approach is limited 4.
• Caffeine can affect blood vessels and hormone levels in some individuals, potentially contributing to breast discomfort 4.

Imaging Recommendations for Breast Pain

• Ultrasound is the first line investigation for breast pain, before mammography, MRI or biopsy, which may be indicated for suspicious abnormalities 2, 3.
• The patient's ultrasound results show a heterogeneous nearly isoechoic lesion with the subcutaneous tissues measuring 2.8 x 1.4 x 3.5 cm, with no increased color flow associated with it 2, 3.
• The patient has been recommended to have a follow-up left breast ultrasound in 6 months, with a BI-RADS category 3 2, 3.

Caffeine Restriction as Initial Treatment for Breast Pain

• A study found that caffeine restriction is an effective means of management of breast pain associated with fibrocystic disease, with 61% of patients reporting a decrease or absence of breast pain after reducing caffeine intake 4.
• Another study compared the efficacy of a nonnarcotic approach (acetaminophen and ibuprofen) to a combination of acetaminophen, codeine, and caffeine (Tylenol 3) after outpatient breast surgery, and found that the nonnarcotic approach provided at least equivalent analgesia with a more tolerable adverse effect profile 5.

Patient's Caffeine Consumption

• The patient reports drinking coffee and eating chocolate, both of which contain caffeine 6, 4.
• Reducing caffeine consumption may help alleviate the patient's breast tenderness, although more research is needed to fully understand the relationship between caffeine and breast pain 6, 4.