What could be causing a pulsating sensation under my right breast?

Pulsating Sensation Under Right Breast

A pulsating sensation under the right breast is most likely benign and related to musculoskeletal chest wall conditions, normal vascular pulsations, or noncyclical breast pain, but requires clinical evaluation to exclude less common serious causes, particularly if accompanied by other symptoms. 1

Most Common Benign Causes

Musculoskeletal/Chest Wall Origins:

• Costochondritis (Tietze syndrome) is one of the most common causes of localized sensations perceived as breast-related, as the breast's nerve supply from intercostal nerves T3-T5 means irritation anywhere along their course can cause perceived breast symptoms. 2, 1
• Pectoral muscle strains or spasms can create pulsating sensations that are often precisely localizable and reproducible. 2
• These extramammary causes account for 10-15% of all "breast pain" presentations. 2, 1

Vascular Causes:

• Normal awareness of intercostal artery pulsations or internal mammary artery pulsations can be perceived as pulsating sensations, particularly in thin individuals or when lying in certain positions. [@General Medicine Knowledge@]
• Mondor disease (thrombophlebitis of the thoracoepigastric vein) may initially present with unusual sensations including pulsating feelings, though typically progresses to visible cord-like structures. 2, 1

Noncyclical Breast-Related Causes

Primary Breast Tissue:

• Noncyclical mastalgia is usually unilateral, more focal, often located in the subareolar area or lower inner breast, and could manifest as various sensations including pulsating feelings. 1
• This type is more common in women in their fourth decade, though 10-15% present after age 50. 1
• Spontaneous resolution occurs in up to 50% of patients with noncyclical mastalgia. 2

Serious Causes to Exclude

Cardiac Considerations:

• Coronary ischemia can refer pain or unusual sensations to the breast area and must be considered, especially with risk factors for cardiac disease. 2
• Any associated chest pressure, shortness of breath, or radiation to the arm warrants immediate cardiac evaluation. [@General Medicine Knowledge@]

Pulmonary Causes:

• Pleurisy or pulmonary embolus can present with chest wall sensations that may be perceived as breast-related. 2

Malignancy:

• Advanced cancers, particularly those deep in large breasts or with chest-wall invasion, can present with unusual sensations as the only symptom. 1
• Invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with atypical breast symptoms compared to other cancer types. 1

Clinical Evaluation Algorithm

History to Obtain:

• Relationship to menstrual cycle (cyclical vs. noncyclical pattern). 2
• Precise location and whether reproducible with palpation. 2
• Associated symptoms: fever, redness, warmth (suggesting infection), chest pain, shortness of breath (cardiac/pulmonary), or visible changes. 2, 1
• Recent trauma, surgery, or exercise patterns. 2
• Medications (oral contraceptives, hormone therapy, psychotropic drugs, cardiovascular agents). 3
• Cardiac risk factors and family history of breast cancer. [@General Medicine Knowledge@]

Physical Examination:

• Palpate for reproducibility of sensation with chest wall pressure (suggests musculoskeletal origin). 2
• Examine for visible cord-like structures (Mondor disease), masses, skin changes, or warmth. 2, 1
• Assess for costochondral junction tenderness. 2, 1

Imaging Recommendations:

• If focal and unilateral without additional signs, diagnostic mammography is the imaging study of choice for women ≥30 years; ultrasound alone for women <30 years. 1
• Ultrasound is first-line if a mass is palpable or infection is suspected. 1
• If clinical breast examination is normal and sensation is diffuse/non-focal, reassurance and symptomatic management without imaging is appropriate. 4

Management Approach

Conservative Management:

• Reassurance that isolated pulsating sensations without other concerning features rarely indicate serious pathology resolves symptoms in 86% of women with mild symptoms and 52% with severe symptoms. 4
• Over-the-counter NSAIDs for symptomatic relief if discomfort is present. 4, 3
• Supportive bras and avoidance of aggravating activities. 4

When to Escalate:

• Persistent focal, unilateral sensations require imaging to exclude underlying lesions. 1
• Any associated cardiac symptoms require immediate evaluation. [@General Medicine Knowledge@]
• Development of mass, skin changes, or systemic symptoms necessitates prompt workup. 1

Critical Pitfalls to Avoid

• Never dismiss unusual breast sensations without proper evaluation, as some cancers can present with atypical symptoms as the only manifestation. 1, 4
• Always rule out cardiac and pulmonary causes when breast examination and imaging are normal, as these can be life-threatening. 2
• Avoid unnecessary imaging for diffuse, non-focal sensations in patients with normal examination, as this leads to additional visits without increasing cancer detection. 4
• Consider extramammary causes systematically, as they account for 10-15% of perceived breast symptoms and are often the actual source. 2, 1