What is the next best step for a 30-year-old patient with cyclic mastalgia (breast tenderness) and a firm breast swelling that persists after menstruation, given a normal breasting examination (NBE)?

From the Guidelines

For a 30-year-old patient with breast tenderness before periods, firm breast swelling, and pain that continues after periods, the correct next best step (NBS) is B. Ultrasound. Ultrasound is the preferred initial imaging modality for young women (under 40) with breast symptoms because it provides good visualization of breast tissue without radiation exposure, as recommended by the American College of Radiology (ACR) appropriateness criteria for breast pain 1 and palpable breast masses 2. In this case, the clinical presentation suggests fibrocystic changes or possibly a fibroadenoma, which are common benign breast conditions. Mammography is less sensitive in younger women with dense breast tissue and unnecessarily exposes them to radiation. MRI would be excessive as a first-line investigation and is typically reserved for high-risk screening or problem-solving after initial imaging. Reassurance alone without imaging would be inappropriate given the persistent pain after menses and the presence of a firm swelling, which requires evaluation to rule out other pathologies. Some key points to consider are:

• The ACR recommends ultrasound for women less than 30 years of age with clinically significant breast pain (focal and noncyclical) 1.
• For women 30 to 39 years of age with clinically significant breast pain (focal and noncyclical), mammography, including DBT, and US are appropriate and are equivalent alternatives 1.
• Ultrasound has higher sensitivity for women younger than age 40 years compared to mammography, with similar specificity 2. Ultrasound can effectively characterize the lesion and guide further management decisions.

From the Research

Diagnostic Approach for Breast Pain

The patient presents with breast tenderness before periods and a firm swelling in the breast, with pain continuing after periods. Given the patient's age (30 years) and symptoms, the following diagnostic approaches are considered:

• For women under 40 years old, ultrasound is the recommended initial imaging modality for focal, non-cyclical breast pain 3.
• The American College of Radiology (ACR) recommends ultrasound as the first-line imaging modality for women under 40 years old with breast symptoms, including pain 4.
• Mammography is not typically recommended for women under 40 years old, unless there are specific risk factors or suspicious findings on clinical examination 5, 3.
• MRI may be considered in certain cases, such as when there is a high risk of breast cancer or when ultrasound and mammography are inconclusive 5.

Imaging Recommendations

Based on the patient's symptoms and age, the most appropriate imaging modality would be:

• Ultrasound, as it is the recommended initial imaging modality for women under 40 years old with focal, non-cyclical breast pain 3, 4.
• The other options, such as mammography and MRI, may not be necessary at this stage, unless there are specific risk factors or suspicious findings on clinical examination 5, 3.

Best Course of Action

The best course of action for this patient would be:

• Ultrasound, as it is a non-invasive and effective imaging modality for evaluating breast symptoms in women under 40 years old 3, 4.
• This approach is supported by the studies, which recommend ultrasound as the first-line imaging modality for women under 40 years old with breast symptoms, including pain 5, 3, 4.