Breast pain (mastalgia)

Probability diagnosis

Pregnancy

Cracked or inflamed nipple

Cyclical mastalgia:

• benign mammary dysplasia

Serious disorders not to be missed

Vascular:

• acute coronary insufficiency

• thrombophlebitis (Mondor disease)

Infection:

• mastitis

• breast abscess

Cancer:

• breast (uncommon presentation)

• mastitis carcinomatosa

Pitfalls (often missed)

Pregnancy

Chest wall pain (e.g. costochondritis)

Pectoralis muscle spasm

Referred pain, esp. thoracic spine

Bornholm disease (epidemic pleurodynia)

Herpes zoster

Mechanical:

• bra problems

• weight change

• trauma

Rarities:

• hyperprolactinaemia

• nerve entrapment

• mammary duct ectasia

• sclerosing adenosis

• ankylosing spondylitis

Masquerades checklist

Depression

Drugs (e.g. OCP, HRT, marijuana)

Spinal dysfunction

Is the patient trying to tell me something?

Yes. Fear of malignancy. Consider psychogenic causes.

Key history

Relate the pain to the menstrual cycle and determine whether the patient is pregnant or not.

Key questions:

• Could you be pregnant?

• Is your period on time or overdue?

• Is the pain in both breasts or only one?

• Do you have pain before your periods (cyclical mastalgia) or all the time during your cycle (non-cyclical mastalgia)?

• Do you have pain in your back or where your ribs join your chest bone?

Key examination

• Systematic breast palpation to check for soreness or lumps including regional lymph nodes

• Underlying chest wall and thoracic spine (T3–T6)

Key investigations

• Pregnancy test

• Mammography (>40 years) and ultrasound

• FNA/excision biopsy for lump with localised pain

• Consider CXR and ECG

Diagnostic tips

• Consider cancer or candida if constant (prickling) breast pain.

• Consider a rare florid form of breast cancer, ‘mastitis carcinomatosa’, if red, hot area.

• Watch for abscess if a lactating woman has unilateral breast pain and ‘flu’ symptoms.