Is Fibroglandular Tissue in the Breast Painful?
Fibroglandular tissue itself is not inherently painful, but women with dense breasts (increased fibroglandular tissue) are more likely to experience cyclical mastalgia, particularly premenopausal women with severe pain of long duration during their menstrual cycles. 1
Understanding the Relationship Between Dense Tissue and Pain
Premenopausal women with severe cyclical breast pain commonly have very dense breasts mammographically, suggesting a correlation between increased fibroglandular tissue and hormonal sensitivity rather than the tissue itself being painful. 1
The fibroglandular tissue represents the glandular and stromal components of the breast, which respond to hormonal fluctuations—this hormonal responsiveness, not the tissue density per se, causes the pain. 2
Dense breast tissue is defined as heterogeneously or extremely dense breasts based on the proportion of fibroglandular tissue compared with fat, affecting approximately half of women undergoing screening mammography. 1
Types of Breast Pain in Women with Dense Tissue
Cyclical Mastalgia (Most Common)
Cyclical mastalgia accounts for approximately 70% of breast pain cases and is related to hormonal fluctuations during the menstrual cycle, typically bilateral or diffusely unilateral, waxing and waning with the cycle. 3
This pain is most common in women in their fourth decade of life and represents increased tissue sensitivity to estrogen rather than pain from the dense tissue itself. 1, 3
Noncyclical Pain Considerations
Noncyclical breast pain is usually unilateral, more focal, often located in the subareolar area or lower inner breast, and may require additional evaluation to exclude underlying benign or malignant breast lesions even in dense tissue. 1, 3
Focal, unilateral breast pain without additional signs of breast disease may need evaluation to exclude underlying lesions, as advanced cancers may present with breast pain as the only symptom, especially if deep in a large breast. 3
Clinical Pitfalls to Avoid
Never dismiss breast pain in women with dense breasts without proper evaluation, as invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia compared to other cancer types. 3
The density itself does not cause pain but can mask underlying pathology on mammography, making clinical correlation essential—mammography sensitivity is decreased in women with dense tissue. 1
Always rule out extramammary causes (costochondritis, cervical radiculopathy, cardiac issues) when breast exam and imaging are normal, as these account for 10-15% of "breast pain" cases. 1, 3
Imaging Approach for Dense Breasts with Pain
Diagnostic mammography is the imaging study of choice for women ≥30 years; ultrasound alone for women <30 years when evaluating breast pain in the context of dense tissue. 3
Ultrasound is first-line imaging if a mass is palpable or infection is suspected, avoiding radiation exposure while providing tissue characterization. 3