How to manage breast pain?

Management of Breast Pain

For most women with breast pain, reassurance and conservative measures are sufficient, as breast pain is rarely associated with breast cancer. 1, 2

Classification and Initial Assessment

• Determine if the pain is:

  • Cyclical: Related to menstrual cycle, affecting up to 70% of women 3
  • Noncyclical: Not related to menstrual cycle, accounts for about 25% of cases 4
  • Extramammary: Pain originating from chest wall or other sources outside the breast 1

• Evaluate for associated symptoms such as palpable masses, skin changes, or nipple discharge 2

Diagnostic Approach

Imaging Recommendations Based on Pain Characteristics:

• Cyclical or diffuse/nonfocal pain: Imaging is usually not indicated 1

• Focal, noncyclical pain:

  • Women under 30: Ultrasound is the initial recommended imaging study 1
  • Women 30-39: Ultrasound with consideration of unilateral mammography 1
  • Women 40 and older: Diagnostic mammography/digital breast tomosynthesis with complementary ultrasound 2

Management Algorithm

Step 1: Reassurance

• Inform patients that breast pain alone rarely indicates cancer, with reassurance alone resolving symptoms in 86% of women with mild pain 4

Step 2: Conservative Measures

• Well-fitted supportive bra, especially during exercise 2, 4
• Application of ice packs or heating pads for comfort 2
• Over-the-counter pain medications as needed (NSAIDs) 4
• Consider reducing caffeine, chocolate, and high-fat foods (though evidence is limited) 5

Step 3: Pharmacological Options for Severe Pain

For persistent severe pain affecting quality of life, consider:

• First-line: Topical NSAIDs 6
• Second-line: Consider oral medications only for severe, persistent pain:
  • Danazol - effective but has potential serious adverse effects including weight gain, acne, and hirsutism 7
  • Tamoxifen - effective but can cause hot flashes (64% vs 48% with placebo), vaginal discharge (30% vs 15%), and irregular menses (25% vs 19%) 8
  • Bromocriptine - effective but has significant side effects 7

Special Considerations

• Extramammary pain: Consider musculoskeletal causes such as costochondritis, pectoral muscle strains, or nerve entrapment 1

• Focal breast pain with suspicious findings on imaging: Follow appropriate BI-RADS recommendations:

  • BI-RADS 1-2: Provide reassurance and symptomatic management 2
  • BI-RADS 4-5: Perform tissue biopsy 2

Common Pitfalls to Avoid

• Ordering unnecessary imaging for diffuse, non-focal breast pain, which may lead to additional clinical visits without increasing cancer detection 4

• Using medications like danazol, tamoxifen, or bromocriptine as first-line treatments due to their significant side effect profiles 7, 5

• Dismissing breast pain without proper evaluation, as some cancers can present with pain, though this is rare 4

• Failing to consider non-breast causes of pain when breast exam and imaging are normal 4