What should be done for an adult female with breast pain or a lump?

Evaluation and Management of Breast Pain and Breast Lumps in Adult Women

Immediate Triage: Distinguish Between Pain and Palpable Mass

If a palpable mass is present, imaging is mandatory regardless of pain—proceed directly to diagnostic workup for the mass. 1

For Palpable Breast Masses:

• Women ≥40 years: Obtain diagnostic mammography (with or without digital breast tomosynthesis) plus targeted ultrasound 1, 2

  • Mammography sensitivity for palpable masses is 86-91%, but negative imaging never overrules a clinically suspicious mass 1
  • The negative predictive value of combined mammography and ultrasound ranges from 97.4-100% 1

• Women 30-39 years: Diagnostic mammography and ultrasound are equivalent, appropriate alternatives 1, 3

• Women <30 years: Ultrasound is the primary imaging modality 1, 3

• Any highly suspicious mass on imaging (BI-RADS 4-5) or physical examination requires core needle biopsy with imaging guidance 1, 2, 3

  • Even clearly benign imaging correlates (oil cyst, hamartoma, degenerating fibroadenoma, lipoma, benign lymph node) may allow clinical follow-up alone 1

For Isolated Breast Pain Without Palpable Mass:

Step 1: Characterize the Pain Pattern

Determine if pain is cyclical versus noncyclical, and focal versus diffuse—this dictates the entire management pathway. 1, 2

• Cyclical pain: Bilateral or unilateral pain that waxes and wanes with menstrual cycle, most pronounced in luteal phase, accounts for 70% of breast pain cases 1

  • Typically affects women in their third decade 1
  • 14-20% resolve spontaneously within 3 months, but 60% recur within 2 years 1

• Noncyclical pain: Unilateral, focal, precisely localizable, no chronological pattern, accounts for 25% of cases 1, 4

  • More common in women in their fourth decade 1
  • Spontaneous resolution occurs in up to 50% 1
  • May indicate underlying breast lesion requiring evaluation 1

Step 2: Age-Stratified Imaging Algorithm for Focal, Noncyclical Pain

For diffuse or cyclical breast pain at any age: No imaging is indicated—provide reassurance and symptomatic management only. 2, 4, 3

Focal, Noncyclical Pain:

• Women ≥40 years: Diagnostic mammography (with or without DBT) plus ultrasound 2, 3

  • Both modalities are complementary and appropriate (ACR rating 7-9/9) 2

• Women 30-39 years: Mammography or ultrasound are equivalent alternatives 3

  • Either modality is appropriate (ACR rating 5/9) 3

• Women <30 years: Ultrasound may be appropriate 4, 3

  • Use is discretionary to provide reassurance and exclude treatable causes like cysts (ACR rating 5/9) 4, 3
  • Mammography is rated "usually not appropriate" (rating 1/9) due to unnecessary radiation exposure 4, 3

Step 3: Management Based on Imaging Results

• BI-RADS 1 (negative): Reassure patient and provide symptomatic management 2, 4

  • Return to routine screening schedule 4
  • Instruct patient to return if pain characteristics change or new symptoms develop 4

• BI-RADS 2 (benign): Consider cyst drainage only if cyst correlates with pain location 4

  • Do not aspirate small incidental cysts—they are unlikely to cause pain and aspiration provides no benefit 4, 3

• BI-RADS 3 (probably benign): Short-interval follow-up imaging 3

• BI-RADS 4-5 (suspicious/malignant): Immediate core needle biopsy 2, 4, 3

Step 4: Symptomatic Management

Reassurance alone resolves symptoms in 86% of women with mild pain and 52% with severe pain. 4

• Over-the-counter NSAIDs (topical diclofenac is first-line) 2, 5
• Supportive bra 2, 4
• Ice packs or heating pads 2, 4

Medication Review:

• Evaluate for causative medications: hormone replacement therapy, oral contraceptives, infertility treatments, SSRIs, certain cardiovascular agents 1, 5
• Consider smoking cessation counseling—heavy smoking is associated with duct ectasia causing exquisite burning pain behind the nipple 1

Critical Pitfalls to Avoid

• Never order MRI for breast pain evaluation—no evidence supports its use, and it leads to unnecessary biopsies of benign findings without improving cancer detection 4, 3

• Never dismiss focal pain based solely on negative imaging—clinical correlation is essential, and highly suspicious findings on examination warrant biopsy regardless of imaging 1, 3

• Never order mammography for women <40 years with diffuse breast pain—this exposes patients to unnecessary radiation without benefit (ACR rating 1/9) 4, 3

• Never pursue additional imaging after normal mammography and ultrasound for isolated pain—the negative predictive value approaches 100%, and further workup does not improve cancer detection 4

Important Context

• Breast pain affects 70-80% of women during their lifetime 2, 4
• The risk of breast cancer in women with isolated breast pain is extremely low (0-3%), comparable to asymptomatic women 4, 3, 5
• Breast pain alone is rarely a presenting symptom of cancer 1, 6
• If breast examination and imaging are completely negative, consider non-breast causes such as musculoskeletal or chest wall conditions 4, 3