From the Guidelines
Breast pain in a young female with a normal mammogram should be managed with reassurance and symptomatic treatment, as the risk of cancer is low, ranging from 1.2% to 6.7%. The evaluation of persistent and severe breast pain includes a comprehensive history, type of pain, relationship to menses, duration, location, impact on activities of daily living, factors that aggravate/alleviate pain, any other medical problems and comorbidities, and a thorough clinical breast exam (CBE) 1.
Key Considerations
- If the CBE fails to identify any physical abnormality and the pain is cyclic or diffuse and nonfocal, the NCCN Panel recommends providing reassurance to the patient and treating the pain with symptomatic management, such as over-the-counter pain medications, use of a good support bra, ice packs or heating pads 1.
- For cyclical breast pain related to hormonal fluctuations, lifestyle modifications such as reducing caffeine and salt intake, especially before menstruation, can be beneficial.
- If pain persists despite these measures, hormonal treatments like oral contraceptives may be considered to stabilize hormonal fluctuations.
Diagnostic Imaging
- The American College of Radiology (ACR) Appropriateness Criteria recommend that for women with clinically insignificant breast pain (nonfocal, diffuse, or cyclical) without other suspicious clinical findings, no imaging beyond usual screening recommendations is indicated 1.
- For women less than 30 years of age with clinically significant breast pain (focal and noncyclical), ultrasound (US) is appropriate 1.
- The use of digital breast tomosynthesis (DBT) and US can be useful in the diagnostic setting, improving lesion characterization and revealing the true nature of potential false-positive findings 1.
Treatment
- First-line treatment includes wearing a well-fitted supportive bra, particularly during exercise, and taking over-the-counter NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (220-440mg twice daily) during painful episodes.
- Topical NSAIDs can also provide relief with fewer systemic side effects.
- For severe, persistent pain unresponsive to conservative measures, prescription medications such as danazol or tamoxifen might be considered, but these have significant side effects and are rarely needed.
Follow-up
- Patients should be advised to return for evaluation if they develop new lumps, skin changes, nipple discharge, or if the pain pattern significantly changes, as these could indicate the need for further investigation.
From the Research
Breast Pain in Young Females
Breast pain, also known as mastalgia, is a common symptom experienced by most women at some point in their lifetime 2, 3. It can be categorized into three main groups: cyclic, noncyclic, and extramammary mastalgia.
Causes of Mastalgia
The causes of mastalgia can be physiologic or pathologic. Physiologic causes include hormonal fluctuations, diet, medications, stress, and an ill-fitting bra 2, 4. Pathologic causes are rare and can include breast cancer, infections, and musculoskeletal abnormalities 3, 5.
Management of Mastalgia
The management of mastalgia depends on the underlying cause. A good history, examination, and targeted imaging can help to delineate the cause of mastalgia and guide treatment options 2, 3. Some key points to consider in the management of mastalgia include:
- Reassurance and support are often sufficient for women with mild breast pain 4, 5
- Dietary changes, such as reducing caffeine intake, and wearing a well-fitted sports bra can be helpful 4, 5
- Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to relieve pain 2, 3
- Hormonal medications, such as tamoxifen and danazol, can be used in severe cases, but have a higher side-effect profile 4, 5
- Topical NSAIDs and lisuride maleate are newer treatments that have shown promise in relieving breast pain 4, 5
Imaging Recommendations
Imaging recommendations for mastalgia depend on the suspected etiology and the age of the patient. For women under 40 years old, ultrasound is the preferred imaging modality, while for women over 40 years old, mammography and ultrasound are recommended 3, 6. Focal breast pain should be evaluated with diagnostic imaging, and targeted ultrasonography can be used alone to evaluate focal breast pain in women under 30 years old 6.
Treatment Options
Treatment options for mastalgia include: