From the Guidelines
Breast pain evaluation should begin with a thorough clinical history and physical examination to determine the nature of the pain and guide further management, as imaging beyond usual screening recommendations is not indicated for women with clinically insignificant breast pain. According to the American College of Radiology Appropriateness Criteria 1, the approach to breast pain evaluation depends on the age of the patient and the characteristics of the pain.
Key Considerations
- 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.
- In women less than 30 years of age with clinically significant breast pain (focal and noncyclical), ultrasound (US) is the appropriate imaging modality 1.
- For women between 30 to 39 years of age with clinically significant breast pain, mammography, including digital breast tomosynthesis (DBT), and US are equivalent alternatives 1.
- In women 40 years of age and older with clinically significant breast pain, mammography and DBT are appropriate and complementary to US 1.
Management Approach
- The initial evaluation should focus on determining if the pain is cyclical or non-cyclical, as this distinction guides treatment options.
- For cyclical mastalgia, conservative measures such as wearing a well-fitted supportive bra, reducing caffeine intake, and using NSAIDs like ibuprofen can be beneficial.
- Non-cyclical breast pain requires a thorough investigation for underlying causes, including examination for breast masses, skin changes, or nipple discharge, and may necessitate imaging studies based on age and clinical findings.
- Referral to a breast specialist is warranted for pain that significantly impacts daily life, does not respond to conservative measures, or is accompanied by other concerning symptoms.
From the Research
Breast Pain Evaluation
Breast pain is a common symptom experienced by women, and its evaluation is crucial to determine the underlying cause. The following points highlight the key aspects of breast pain evaluation:
- Breast pain can be classified into cyclic mastalgia, noncyclic mastalgia, and extramammary (nonbreast) pain 2
- Cyclic mastalgia is breast pain that has a clear relationship to the menstrual cycle, while noncyclic mastalgia is not associated with the menstrual cycle and often occurs after menopause 2
- The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low 2, 3
- A comprehensive history and thorough clinical breast exam is essential to evaluation 4
- Imaging studies should be reserved for use in women who fall within usual screening guidelines or when a palpable mass is present 3
Diagnostic Approach
The diagnostic approach to breast pain evaluation involves:
- A detailed clinical history and physical examination 5, 6
- Diagnostic mammography or ultrasonography may be used to evaluate a suspicious mass or focal breast pain 5
- Targeted ultrasonography localized to discrete areas of the breast can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older 5
- A core needle biopsy should be performed with imaging guidance for evaluation of a suspicious mass 5
Treatment Options
Treatment options for breast pain include:
- Reassurance and nonpharmacological measures, which are effective for most patients 2
- Topical nonsteroidal anti-inflammatory drugs, such as diclofenac, as a first-line treatment option 5
- Medications like danazol, tamoxifen, and bromocriptine may be effective for severe, sustained breast pain, but their use is limited due to potentially serious adverse effects 2