Painful Stinging Nipples When Period is Due
This is cyclical mastalgia (breast pain), a benign hormonal condition affecting up to 70% of women with breast pain that requires only reassurance and symptomatic treatment in most cases, as the likelihood of breast cancer is extremely low in the absence of other signs or symptoms. 1
Understanding the Cause
Cyclical breast pain is hormonal in origin, related to increased sensitivity to normal hormone levels rather than abnormal hormone levels themselves. 1 The key features that confirm this diagnosis include:
- Pain that waxes and wanes with the menstrual cycle, most pronounced in the luteal phase (when period is due) 1
- Can be unilateral or bilateral, often diffuse rather than focal 1
- May be accompanied by swelling and tenderness 1
- Typically affects women in their third decade of life 1
The "stinging" quality described is consistent with the pain characteristics of cyclical mastalgia, which can manifest as sharp, burning, or stinging sensations. 1
Initial Management Approach
Reassurance alone resolves symptoms in 86% of mild cases and 52% of severe cases. 2 The most important intervention is explaining that:
- Breast pain alone rarely indicates cancer 2
- The likelihood of malignancy is extremely low without other symptoms 1
- Spontaneous resolution occurs in 14-20% of patients within 3 months 1
First-Line Treatment Options
Start with non-pharmacological measures before considering medication:
- Wear a well-fitted supportive bra, especially during exercise 2
- Apply cold compresses or heating pads for comfort 2
- Regular physical exercise can help alleviate symptoms 2
- Over-the-counter NSAIDs (ibuprofen 400 mg every 4-6 hours) for symptomatic relief 2, 3
Important caveat: Despite widespread belief, there is no convincing scientific evidence that eliminating or reducing caffeine intake significantly affects breast pain. 1, 2
When to Consider Further Evaluation
Imaging is NOT indicated for cyclical breast pain alone when clinical examination is normal. 1 However, consider diagnostic imaging if:
- A focal mass is palpable on examination 1
- Pain becomes noncyclical or focal rather than diffuse 1
- Patient is over 30 years with new focal symptoms 1
Natural History and Prognosis
Understanding the expected course helps with patient counseling:
- Most patients experience decreasing severity of pain over time 1
- At least 60% of cases recur within 2 years 1
- About 40% experience resolution at menopause 1
- Women who start having cyclical pain before age 20 usually have a prolonged course 1
Common Pitfalls to Avoid
Do not dismiss the pain without proper evaluation, as some cancers can present with pain, though this is rare. 2 However, do not order unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal. 2
Do not prescribe antibiotics, as the pain is caused by hormonal mediator release, not infection. 2
Do not repeatedly treat for Candida infection without confirming the diagnosis, as cyclical mastalgia is often mistaken for thrush. 4