What causes nipple and areola pain in a 45-year-old?

Nipple and Areola Pain at Age 45

At age 45, nipple and areolar pain is most likely noncyclical mastalgia, which commonly presents in women in their fourth decade of life and is often localized to the subareolar area, requiring diagnostic mammography with ultrasound to exclude underlying benign or malignant breast lesions before initiating symptomatic management. 1

Understanding the Type of Pain

Your age and location of pain are highly characteristic of noncyclical breast pain, which:

• Accounts for approximately 25% of all breast pain cases and is most common in women in their 40s 1
• Typically presents as unilateral, focal pain precisely localizable to the subareolar area or nipple (unlike cyclical pain which is diffuse and bilateral) 1
• Has no relationship to menstrual cycles and may be persistent or worse in cold weather 1
• Is predominantly inflammatory rather than hormonal in nature, meaning it doesn't respond well to hormonal treatments 1
• Spontaneously resolves in up to 50% of patients, though it tends to be shorter in duration than cyclical pain 1

Critical First Step: Rule Out Serious Causes

You need diagnostic mammography with ultrasound because noncyclical pain, even without other symptoms, requires additional evaluation to exclude underlying benign or malignant breast lesions. 1

This is essential because:

• Mammography may reveal duct ectasia or secretory calcifications at the site of pain 1
• While breast cancer rarely presents with pain alone, some cancers (especially invasive lobular carcinoma) can present with pain as the only symptom 1
• The risk of malignancy with isolated breast pain ranges from 0-3%, but proper evaluation is still necessary 2, 3

Important Warning Signs Requiring Immediate Evaluation

Seek urgent evaluation if you develop: 1

• Skin changes: redness, dimpling (peau d'orange), or thickening
• Nipple changes: scaling, eczema, excoriation, bleeding, or ulceration (may indicate Paget's disease)
• A palpable mass or thickening
• Nipple discharge, especially if bloody or unilateral

Specific Causes to Consider at Your Age

Common Benign Causes in the Subareolar Region

• Duct ectasia: Dilated milk ducts that can cause subareolar pain 1
• Periductal mastitis: Inflammation around the ducts, particularly common in smokers, causing burning pain behind the nipple 1, 2
• Mastitis or breast abscess: May present with focal pain before developing redness, warmth, and fever 1
• Mondor disease: Thrombophlebitis of breast veins, which can present initially as breast pain 1

Less Common but Important Causes

• Paget's disease of the breast: Presents with nipple eczema, itching, burning, or pain; requires skin biopsy for diagnosis even if mammography is normal 1, 4
• Trauma-related pain: Accounts for approximately 10% of noncyclical pain cases 1
• Medication-induced pain: Various medications can cause breast pain, though presentations vary 1

Extramammary (Non-Breast) Causes

10-15% of "breast pain" actually originates outside the breast, including: 1

• Costochondritis (Tietze syndrome): Inflammation of chest wall cartilage
• Nerve entrapment: Particularly the lateral cutaneous branch of the third intercostal nerve
• Musculoskeletal conditions: Pectoral muscle strains, fibromyalgia
• Referred pain: From cardiac, esophageal, pulmonary, or even dental sources

Management After Imaging

If Imaging is Normal (BI-RADS 1-3)

Reassurance alone resolves symptoms in 86% of women with mild pain and 52% with severe pain. 2, 3

First-line non-pharmacological measures: 2

• Wear a well-fitted, supportive bra, especially during physical activity
• Apply ice packs or heating pads for comfort
• Regular physical exercise can help alleviate symptoms
• If you smoke, cessation is crucial for periductal inflammation and burning nipple pain 2

Pharmacological options: 2

• Over-the-counter NSAIDs (ibuprofen, naproxen) for symptomatic relief
• Note: Hormonal treatments are generally ineffective for noncyclical pain 1

Important: What NOT to Do

• Don't eliminate caffeine expecting significant improvement - there is no convincing scientific evidence that reducing caffeine affects breast pain 2
• Don't pursue MRI for breast pain evaluation - no evidence supports its use and it leads to unnecessary biopsies without improving cancer detection 2, 3
• Don't assume small cysts found on ultrasound are causing your pain - they're unlikely to be the source and aspiration provides no benefit 3

When to Seek Further Evaluation

Return for reassessment if: 2, 3

• Pain characteristics change (becomes more focal, more severe, or constant)
• New symptoms develop (mass, skin changes, nipple discharge)
• Pain persists despite conservative management after several weeks
• You develop systemic symptoms (fever, malaise) suggesting infection

Critical Pitfall to Avoid

Never dismiss focal nipple/areolar pain without proper imaging evaluation at your age, as some breast cancers can present with pain as the only symptom, and noncyclical pain specifically requires evaluation to exclude underlying pathology. 1, 2