Evaluation and Management of Breast Tenderness in a 47-Year-Old Woman
For a 47-year-old woman with breast tenderness, perform a focused clinical assessment to determine if the pain is focal or diffuse, then proceed with diagnostic mammography and ultrasound only if the pain is focal and unilateral—otherwise, provide reassurance and symptomatic management without imaging. 1, 2
Initial Clinical Assessment
Determine the specific characteristics of the breast pain through targeted questioning:
- Pain pattern: Is it cyclical (related to menstrual cycle) or non-cyclical? 1, 3
- Location: Is it focal (localized to one specific area) or diffuse (spread throughout the breast)? 2
- Laterality: Is it unilateral or bilateral? 1
- Associated symptoms: Check for skin changes (erythema, edema, peau d'orange), palpable masses, nipple discharge, or nipple retraction 1, 2
- Duration: Acute (1-2 weeks) versus chronic symptoms 2
Perform a clinical breast examination specifically looking for palpable masses, skin changes, or lymphadenopathy. 2
Imaging Decision Algorithm
For Diffuse or Bilateral Breast Tenderness (Most Likely Scenario)
No imaging is indicated regardless of age. 1, 2 The American College of Radiology assigns a rating of 1-2 out of 9 ("usually not appropriate") to all imaging modalities for diffuse bilateral breast pain, as the risk of underlying malignancy is extremely low (0-3%) and imaging rarely changes management. 1, 2, 4
For Focal, Unilateral Breast Pain
At age 47, perform diagnostic mammography with ultrasound if the clinical examination reveals focal tenderness. 1, 2 Both modalities are complementary and appropriate (ACR rating 4-5/9) for women 40 years and older with focal pain. 1
Critical pitfall to avoid: Do not order MRI for breast pain evaluation—there is no evidence supporting its use, and it leads to unnecessary biopsies of benign findings without improving cancer detection. 1, 2, 4
Management Based on Clinical Findings
If Clinical Exam is Normal (Most Common)
Provide reassurance as primary therapy—this alone resolves symptoms in 86% of women with mild pain and 52% with severe pain. 2, 4, 5 Explain that breast pain as the only symptom carries an extremely low cancer risk (0-3%). 1, 5, 6
First-Line Symptomatic Management
Recommend the following non-pharmacological measures:
- Well-fitted supportive bra, especially during exercise 2, 4, 5
- Over-the-counter NSAIDs (ibuprofen) as needed 2, 4, 5
- Ice packs or heating pads for comfort 2, 4
- Regular physical exercise 4
Important caveat: Despite widespread belief, there is no convincing scientific evidence that eliminating caffeine affects breast pain. 4
If Imaging is Performed and Shows Benign Findings
- BI-RADS 1 (negative): Return to routine screening schedule, provide symptomatic management 2
- BI-RADS 2 (benign cyst): Consider drainage only if the cyst correlates precisely with the focal pain location 2
- BI-RADS 4-5: Perform core needle biopsy 2
Natural History and Follow-Up
Counsel the patient that:
- Approximately 14-20% of cyclical mastalgia cases resolve spontaneously within 3 months 5
- Most women experience decreasing severity over time, with about 40% experiencing resolution at menopause 5
- However, 60% may have symptom recurrence within 2 years 5
Instruct the patient to return if pain characteristics change or new symptoms develop (palpable mass, skin changes, nipple discharge). 2
When to Consider Specialist Referral
Refer to a breast care specialist only if pain is severe, persistent, and unresponsive to first-line conservative measures after an adequate trial period. 7, 8 At that point, second-line topical NSAIDs or third-line hormonal therapies (danazol, tamoxifen) may be considered, though these carry significant adverse effects. 6, 8