Breast pain

Mastalgia or Mastodynia

Introduction

Breast pain, or mastalgia, affects up to 70% of women at some point in life. It can be:

• Cyclical: Related to the menstrual cycle (hormonal, premenstrual).

• Non-cyclical: Constant or intermittent, unrelated to cycle (trauma, infection, cysts, medications).

• Extramammary (referred): Pain felt in breast area but originating from chest wall, muscles, heart, or lungs.

While mastalgia is a frequent concern, breast cancer rarely presents with pain alone (less than 5% of cases).

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Pathophysiology

• Cyclical mastalgia: Estrogen and progesterone fluctuations → water retention, ductal and stromal changes → breast swelling and tenderness.

• Non-cyclical mastalgia: Localized pathology (cysts, infection, trauma) or systemic (medications, costochondritis).

• Referred pain: From chest wall (musculoskeletal), cervical spine, cardiac or pulmonary disease.

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Causes of Breast Pain

1. Cyclical Mastalgia (Hormonal)

• Premenstrual breast tenderness.

• Hormonal contraceptives (oral contraceptive pills).

• Hormone replacement therapy (HRT).

• Puberty, pregnancy, perimenopause.

2. Non-Cyclical Breast Pain

• Fibrocystic breast changes.

• Breast cysts.

• Fibroadenomas.

• Mastitis / breast abscess: Common in lactating women.

• Post-surgical pain (scar, nerve injury).

• Trauma.

3. Medications

• Antidepressants (SSRIs: Fluoxetine, Sertraline).

• Spironolactone.

• Digitalis (Digoxin).

• Methyldopa.

4. Extramammary Causes (Referred Pain)

• Musculoskeletal: Costochondritis, muscle strain.

• Cardiac: Angina, myocardial infarction (especially in women, may present atypically).

• Pulmonary: Pleurisy, pulmonary embolism.

• Gastrointestinal: GERD, gallbladder disease.

5. Rare Causes

• Male breast pain (gynecomastia, steroid use).

• Breast cancer (rarely presents with isolated pain, but must be excluded).

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Clinical Features

• Cyclical mastalgia:

  • Bilateral, diffuse, worse in upper outer quadrants.

  • Associated with menstrual cycle, improves after menstruation.

• Non-cyclical mastalgia:

  • Unilateral, localized, sharp or burning.

  • May be associated with lump, infection, trauma.

• Extramammary pain:

  • Often reproducible with chest wall palpation or movement.

  • Not related to breast tissue itself.

Associated features:

• Nipple discharge.

• Breast lump or skin changes (dimpling, redness, ulceration).

• Systemic symptoms: fever (infection), weight loss (cancer).

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Diagnostic Approach

1. History

• Pain pattern: cyclical vs non-cyclical.

• Duration, severity, location.

• Relation to menstrual cycle, pregnancy, lactation.

• Medications, caffeine, smoking, alcohol use.

• Family history of breast cancer.

2. Examination

• Inspect: symmetry, skin changes, nipple retraction/discharge.

• Palpate: tenderness, lumps, nodularity.

• Axillary lymph nodes.

• Chest wall, musculoskeletal exam.

3. Investigations

• Mammography: Women >40, suspicious findings.

• Breast ultrasound: Younger women (<35), cyst vs solid lesion.

• MRI breast: Complex or indeterminate cases.

• Biopsy (FNAC/core): If suspicious lump or abnormal imaging.

• Blood tests: Hormones, prolactin if endocrine disorder suspected.

• ECG, chest X-ray, endoscopy: If extramammary pain suspected.

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Management and Treatment

Treatment depends on whether pain is cyclical, non-cyclical, or extramammary.

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A. General Measures

• Reassurance (breast cancer is rare cause of pain).

• Supportive bra (reduces pain).

• Warm compresses, gentle massage.

• Reduce caffeine and high-fat diet.

• Smoking cessation.

• Regular exercise, stress management.

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B. Pharmacological Treatment

1. Simple Analgesics

• Paracetamol 500–1000 mg orally every 6–8 h (max 4 g/day).

• NSAIDs:

  • Ibuprofen 400 mg orally every 8 h.

  • Diclofenac gel 1% applied topically 3–4 times/day.

2. Hormonal Therapy (for severe refractory cyclical mastalgia)

• Tamoxifen (selective estrogen receptor modulator):

  • 10 mg orally once daily × 3–6 months.

  • Effective in reducing pain but carries risks (thromboembolism, endometrial hyperplasia).

• Danazol (androgen derivative):

  • 200–400 mg orally daily in divided doses.

  • Effective but side effects (weight gain, acne, voice change).

• Bromocriptine (dopamine agonist, reduces prolactin):

  • 2.5 mg orally twice daily.

3. Antibiotics (if infection / mastitis)

• Flucloxacillin 500 mg orally every 6 h for 7–10 days.

• Clindamycin 300 mg orally every 6 h (if penicillin allergy).

4. Hormone-Related Pain

• Consider adjusting oral contraceptives or HRT dose.

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C. Interventional / Surgical Treatment

• Aspiration of breast cysts if symptomatic.

• Drainage of abscess if mastitis not resolving.

• Excision of fibroadenoma / suspicious lump.

• Surgery for refractory mastalgia is rarely indicated.

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Complications

• Anxiety, depression, reduced quality of life.

• Sleep disturbance.

• Misdiagnosis and missed underlying serious pathology (e.g., breast cancer).

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Prognosis

• Cyclical mastalgia: Usually improves after menopause or with lifestyle/hormonal therapy.

• Non-cyclical mastalgia: Depends on underlying cause (infection, cysts, musculoskeletal).

• Extramammary pain: Resolves with treatment of primary disease.

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Patient Education

• Most breast pain is benign and treatable.

• Keep a pain diary (relation to cycle, triggers, severity).

• Wear supportive bra.

• Reduce caffeine and alcohol.

• Complete prescribed antibiotics if infection.

• Always seek medical advice if pain is persistent, associated with lump, nipple changes, discharge, or systemic symptoms.