What does breast pain mean?

What Does Breast Pain Mean?

Breast pain is most commonly benign—arising from hormonal fluctuations (cyclical mastalgia), inflammatory conditions, or chest wall sources—but requires clinical evaluation to exclude the small risk of malignancy, particularly when pain is focal, unilateral, and persistent. 1

Classification of Breast Pain

Breast pain falls into three distinct categories that guide both evaluation and management:

Cyclical Mastalgia (70% of cases)

• This is the most common type, directly related to menstrual cycle hormonal fluctuations 1
• Typically bilateral or diffusely unilateral, waxing and waning with the menstrual cycle 1
• Most common in women in their fourth decade of life 1
• Does not require imaging workup 2

Noncyclical Mastalgia

• Usually unilateral and more focal, often located in the subareolar area or lower inner breast 1
• Predominantly inflammatory rather than hormonal in nature 3, 1
• More common in women in their fourth decade, though 10-15% present after age 50 1
• Requires imaging evaluation to exclude underlying pathology 1

Extramammary (Non-Breast) Pain (10-15% of cases)

• Originates from chest wall structures but perceived as breast pain due to shared nerve supply from intercostal nerves T3-T5 1
• Common causes include Tietze syndrome (costochondritis) and cervical radiculopathy 1
• Always consider when breast examination and imaging are normal 1

Specific Causes to Consider

Infectious/Inflammatory Conditions

• Mastitis or breast abscess: Focal pain with swelling, often preceding induration, redness, warmth, and fever 1
• Risk factors include poor infant latch and improper lactation technique in breastfeeding women 3
• Periductal mastitis and duct ectasia are common benign causes of non-lactational mastitis, particularly in women in their fourth decade 3
• Mondor disease: Thrombophlebitis of the thoracoepigastric vein presenting as sudden pain along a palpable cord-like structure 4, 1

Pre-Eruptive Herpes Zoster (Critical Diagnosis Not to Miss)

• Severe pain preceding visible skin changes is the hallmark, intense enough to prompt evaluation before any rash develops 4
• Pain typically described as burning, stabbing, or electric-shock-like, following a dermatomal pattern around the breast (commonly T4-T6 dermatomes) 4
• Perform detailed skin examination for subtle early signs: faint erythema, slight edema, or grouped vesicles just beginning to form 4
• If suspected, start antivirals immediately 4

Malignancy Considerations

• The risk of cancer in women presenting with breast pain as the only symptom is extremely low (1.2-6.7%) 4, 5
• However, advanced cancers may present with pain as the only symptom, especially if deep in a large breast or with chest-wall invasion 1
• Invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia compared to other cancer types 1
• Never dismiss focal, unilateral, persistent breast pain without proper evaluation 1

Imaging Algorithm

The American College of Radiology provides clear imaging recommendations based on age and clinical presentation:

When Imaging Is NOT Needed

• Cyclical mastalgia with normal breast examination 2
• Diffuse bilateral pain clearly related to menstrual cycle 1

When Imaging IS Needed

• For focal, noncyclical breast pain in women ≥30 years: Diagnostic mammography with ultrasound 4, 1
• For focal, noncyclical breast pain in women <30 years: Ultrasound alone 4, 1
• If mass is palpable or infection is suspected: Ultrasound is first-line to avoid radiation exposure 1, 6

If Herpes Zoster Suspected

• Perform detailed skin examination first 4
• If skin remains completely normal after 48-72 hours and pain persists, then perform breast imaging (mammography ± ultrasound) 4

Management Approach

Initial Step for All Patients

• After appropriate clinical evaluation, most patients respond favorably to reassurance and nonpharmacological measures 5
• Reassurance alone resolves pain in the majority of cases 7

Conservative Measures (First-Line)

• Well-fitting supportive bra 4
• Ice packs or heating pads 4
• NSAIDs (ibuprofen or naproxen) for immediate pain relief 4

Pharmacologic Therapy (For Severe, Persistent Pain)

• Only consider for severe symptoms impacting quality of life after conservative measures fail 8
• Topical NSAIDs as second-line therapy 2
• Danazol, tamoxifen, and bromocriptine are effective but have potentially serious adverse effects, limiting use to selected patients with severe, sustained breast pain 5

Critical Pitfalls to Avoid

• Never dismiss breast pain without proper evaluation, as some cancers can present with pain alone 1
• Always rule out extramammary causes (costochondritis, cervical radiculopathy, cardiac issues) when breast exam and imaging are normal 1
• Do not order inappropriate imaging for cyclical mastalgia, as this is associated with significant utilization of healthcare resources 2
• Consider pre-eruptive herpes zoster when severe pain is described as burning/electric and follows a dermatomal pattern, even with unremarkable skin 4