What is the appropriate work‑up and initial management for breast pain (mastalgia) in women, including history, examination, imaging criteria, and treatment options?

Breast Pain Work-Up

Begin by categorizing the pain as cyclical versus noncyclical and focal versus diffuse, as this determines whether imaging is needed and guides treatment strategy. 1, 2

Initial Clinical Assessment

History - Key Elements to Elicit

• Pain pattern: Relationship to menstrual cycle (cyclical accounts for 70% of cases, noncyclical 25%) 3
• Pain location: Focal (patient can point to one specific area) versus diffuse/bilateral 1, 2
• Duration and severity: Whether pain interferes with daily activities 4, 5
• Associated symptoms: Palpable masses, skin changes (retraction, peau d'orange), nipple discharge, or axillary lymphadenopathy 1, 2
• Medication history: Oral contraceptives, hormone replacement therapy, other medications that may cause mastalgia 3, 4
• Breast size and bra fit: Large breasts with poorly fitting bras can cause noncyclical pain 3, 4
• Smoking history: Heavy smoking associated with duct ectasia and periductal inflammation 3

Physical Examination - Specific Findings to Document

• Palpable masses or asymmetric thickening (even if patient denies feeling a mass) 1
• Skin changes: Erythema, warmth, induration (suggesting mastitis/abscess), retraction, or peau d'orange 1, 2
• Nipple abnormalities: Discharge, retraction, or eczematous changes 1
• Axillary lymphadenopathy 1
• Reproducibility of focal tenderness: Can the patient and physician localize pain to one specific area? 3
• Chest wall tenderness: To identify extramammary causes 4, 5

Imaging Algorithm

For Diffuse/Non-Focal Pain with Normal Examination

No imaging is indicated regardless of age or whether pain is cyclical or noncyclical. 1, 2, 6 Imaging in this setting does not increase cancer detection but leads to additional unnecessary clinical visits and procedures. 3, 2

For Focal, Noncyclical Pain

Age ≥40 years:

• Diagnostic mammography ± digital breast tomosynthesis (DBT) PLUS targeted ultrasound 1, 2
• This combination has a negative predictive value of 97.4-100% 3, 1, 2
• Cancer detection rate at site of focal pain is 2.3%, with overall cancer rate of 4.6% (including incidental findings) 3

Age 30-39 years:

• Diagnostic mammography and ultrasound are equivalent and appropriate alternatives 2, 6

Age <30 years:

• Ultrasound is the primary imaging modality 2
• Mammography is rated "usually not appropriate" (exposes to unnecessary radiation without benefit) 6

Important Imaging Caveats

• 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 2, 6
• Do not aspirate small cysts found incidentally on ultrasound - these are unlikely to be the source of pain and aspiration provides no benefit 2, 6

Management Based on Imaging Results

BI-RADS 1 (Negative)

• Provide reassurance and symptomatic treatment 1, 2
• Return to routine screening schedule 2

BI-RADS 2 (Benign)

• If cyst correlates with painful area, consider drainage; otherwise symptomatic treatment 1, 6

BI-RADS 3 (Probably Benign)

• Short-interval follow-up per standard BI-RADS protocol 3

BI-RADS 4-5 (Suspicious/Highly Suggestive of Malignancy)

• Core needle biopsy required 1, 2, 6

Treatment Approach

First-Line: Reassurance and Conservative Measures

Reassurance alone resolves symptoms in 86% of women with mild pain and 52% with severe pain. 1, 6 Many women do not seek further medical attention after reassurance that pain is not due to cancer. 3

• Well-fitting, supportive bra 1, 4
• Over-the-counter analgesics (NSAIDs, acetaminophen) as needed 1, 4
• Application of ice or heat 1, 6
• Regular physical exercise 1
• Dietary modifications: Decrease dietary fat intake 4, 7
• Discontinue oral contraceptives or hormone replacement therapy if applicable 4, 7

Second-Line: Pharmacologic Treatment (for severe, life-altering pain)

Only 15% of patients require pharmacologic treatment. 8, 7 Using a stepwise approach:

• Evening primrose oil (gammalinolenic acid) as first-line pharmacologic therapy 8, 7
• Danazol or bromocriptine as second-line agents 8, 7
• Tamoxifen, goserelin, or testosterone reserved for severe recurrent or refractory cases, but adverse effects preclude first-line use 8, 7

With this approach, clinically useful improvement can be anticipated in 92% of patients with cyclical mastalgia and 64% with noncyclical mastalgia. 8

Cancer Risk Context

The risk of breast cancer with isolated breast pain is extremely low (0-3%), comparable to asymptomatic women. 3, 1, 2 However, certain cancers can present with pain:

• Advanced cancers deep in large breasts or with chest-wall invasion 3
• Invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia 3
• Interval cancers between mammographies can present with pain 1

Natural History

Cyclical Mastalgia

• 14-20% have spontaneous resolution within 3 months 3
• At least 60% recur within 2 years 3
• About 40% experience resolution at menopause 3
• Women with onset before age 20 usually have prolonged course 3

Noncyclical Mastalgia

• Spontaneous resolution occurs in up to 50% of patients 3
• Tends to be of shorter duration than cyclical mastalgia 3

Common Pitfalls to Avoid

• Do not order routine imaging for diffuse breast pain - this increases healthcare utilization without improving cancer detection 3, 2, 6
• Do not order mammography for women <40 with routine breast pain - unnecessary radiation exposure without benefit 6
• Do not order MRI for breast pain - leads to unnecessary biopsies without improving outcomes 2, 6
• Do not dismiss focal pain without proper evaluation - some cancers can present with pain, particularly noncyclical focal pain 3, 2, 6
• Do not aspirate small incidental cysts - unlikely to be pain source 2, 6
• Consider non-breast causes (musculoskeletal, chest wall conditions) if breast exam and imaging are normal 6