Chapter 100: Breast pain (mastalgia)

Breast pain, or mastalgia, is a common problem, accounting for at least 50% of breast problems presenting in general practice and 14% of referrals to an Australian breast clinic.¹ It can vary from localised breast pain due to an infection or a breast cyst to diffuse bilateral pain. If no obvious physical cause is found, the problem is all too often dismissed, without appropriate empathy and reassurance, as a normal physiological effect. However, its aetiology is not clear.

A careful, sympathetic clinical approach, however, followed by reassurance after examination, will be sufficient treatment for most patients.

Mastalgia usually presents as a heaviness or discomfort in the breast or as a pricking or stabbing sensation. The pain may radiate down the inner arm when the patient is carrying heavy objects or when the arm is in constant use, as in scrubbing floors.

A summary of the diagnostic strategy model for mastalgia is presented in TABLE 100.1.

Probability diagnosis

In the non-pregnant patient, generalised pain, which may be cyclical or non-cyclical, is commonest. Typical patterns are illustrated in FIGURE 100.1.

Cyclical mastalgia is the commonest diffuse breast pain. It occurs in the latter half of the menstrual cycle, especially in the premenstrual days, and subsides with the onset of menstruation. It obviously has a hormonal basis, which may be an abnormality in prolactin secretion. The main underlying disorder is benign mammary dysplasia, also referred to as fibroadenosis, chronic mastitis, cystic hyperplasia or fibrocystic breast disease.

Non-cyclical mastalgia, which is pain that does not vary within the menstrual cycle, is also quite common and the cause is poorly understood. It may be associated with mammary duct ectasia (see CHAPTER 101).

Serious disorders not to be missed

The three important serious disorders not to be missed with any painful chest condition—neoplasia, infection and myocardial ischaemia—are applicable for breast pain.

Neoplasia

We must avoid the trap of considering that breast pain is not compatible with malignancy. Mastalgia can be a presenting symptom (although uncommon) of breast cancer. ‘Mastitis carcinomatosa’, which is a rare florid form of breast cancer found in young women, often during lactation, is red and hot but not invariably painful or tender.² Pain may also be a symptom in juvenile fibroadenoma, a soft rapidly growing tumour in adolescents, and in the fibroadenoma of adult women.

Infection

Mastitis is common among nursing mothers. It should be regarded as a serious and urgent problem because a breast abscess can develop quickly. Apart from bacterial infection, infection with Candida albicans may occur following the use of antibiotics. Candida infection usually causes severe breast or nipple pain, producing a feeling like ‘hot cords’, especially during and after feeding.

Myocardial ischaemia

A constricting pain under the left breast should be regarded as myocardial ischaemia until proved otherwise.

Pitfalls

These include various causes of apparent mastalgia, such as several musculoskeletal chest wall conditions and referred pain from organs such as the heart, oesophagus, lungs and gall bladder and, in particular, from the upper thoracic spine.

Musculoskeletal conditions include costochondritis, pectoralis muscle strains or spasm, and entrapment of the lateral cutaneous branch of the third intercostal nerve. Ankylosing spondylitis can affect the chest wall under the breasts. Mastalgia may be the first symptom of pregnancy. Pregnancy should be excluded before commencing drug treatment.

Seven masquerades checklist

Of these, depression, drugs and spinal dysfunction are probable causes. Drugs that can cause breast discomfort include oral contraceptives, HRT and methylxanthine derivatives such as theophylline. Drugs that cause tender gynaecomastia (more applicable to men) include digoxin, cimetidine, spironolactone and marijuana.

Dysfunction of the upper thoracic spine and even the lower cervical spine can refer pain under a breast. If suspected, these areas of the spine should be examined.

Psychogenic considerations

The symptoms may be exaggerated as a result of an underlying psychogenic disorder, but with a symptom such as breast pain most women fear malignancy and need reassurance.

History

It is important to 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 menstrual cycle?

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

Examination

The breasts should be systematically palpated to check for soreness or lumps. The underlying chest wall and thoracic spine should also be examined.

Investigations

The following specialised tests could be considered.

Mammography should be considered in older women. It is unreliable in young women. With few exceptions it should not be used under 40 years.

Ultrasound can be complementary to mammography as it is useful to assess a localised mass or tender area. It is inappropriate to evaluate a diffuse area. It is not so useful for the postmenopausal breast, which is fatty and looks similar to cancer on ultrasound.

FNA excision biopsy can be useful for an area of localised pain, especially in the presence of a possible mass.

Consider a chest X-ray and ECG.

Breast pain is uncommon in children, including puberty, but it may be a presenting problem in the late teens. Pubertal boys may complain of breast lumps under the nipple (adolescent gynaecomastia) but these are rarely tender and do not require specific treatment.

Breast pain is rare after the menopause but can be associated with HRT use, where it tends to present as the diffuse bilateral type. If the problem is related to the introduction of HRT, the oestrogen dose should be reduced or an alternative preparation used.

Cyclical mastalgia

The features of cyclical mastalgia are:

• the typical age is 30–40 years (mean 35)

• discomfort and sometimes pain are present

• usually bilateral but one breast can dominate (usually upper outer quadrant)

• related to the menstrual cycle, mainly premenstrual

• usually resolves on commencement of menstruation

• breasts may be diffusely nodular or lumpy

• variable relationship to the pill

Cyclical mastalgia is rare after the menopause.

Non-cyclical mastalgia

The features of non-cyclical mastalgia are:

• the typical age is the early 40s (median age 41 years)

• bilateral and diffuse

• continuous or intermittent

• pain present throughout the cycle

• no obvious physical or pathological basis

Management for mastalgia (both types)

After excluding a diagnosis of cancer and aspirating palpable cysts, various treatments are possible and can be given according to severity.³

Acknowledge the condition and its discomfort.

• Reassurance—explain high remission rate

• Regular review and breast self-examination

• Proper brassiere support—expert fitting

• Cease smoking (if applicable)

• Aim at ideal weight

• Adjust oral contraception or HRT (if applicable)

• Analgesia (e.g. paracetamol 0.5–1 g (o) 4–6 hourly prn)

Many products have been promoted and tried but there is no convincing evidence to support the use of vitamins B1, B6, B12 and E, diuretics, NSAIDs, narcotics, caffeine reduction and even evening primrose oil, which is a favoured product and has been helpful for many women.^5,6,7

Evening primrose oil contains an essential fatty acid claimed to be lacking in the diet, and replacement allows for the production of prostaglandin E, which counters the effect of oestrogen and prolactin on the breast. However, according to the multi-centred European RCT, it is no more effective than placebo,¹ but the placebo effect in these trials was strong.^6,7

A dose of 1000 mg three times daily for 3–4 months is recommended if a trial of treatment is planned.⁶ There is some evidence to support the use of a topical NSAID medication (e.g. diclofenac gel).⁵

Recent systemic reviews from RTCs assessed the effectiveness of danazol,⁸ bromocriptine and tamoxifen and showed that all provided significant relief, but that all have the potential for severe adverse effects.

For very severe mastalgia it is recommended to refer to a breast specialist to consider prescribing tamoxifen or danazol.⁶

Non-cyclical mastalgia is very difficult to treat, being more refractory than cyclical mastalgia.

Surgical excision may be required for local lesions. If there is no discrete lesion but a tender trigger point (including costochondritis), the injection of local anaesthetic and corticosteroid may relieve the problem.

Costochondritis (Tietze syndrome)

This is a common cause of referral to a breast pain clinic. The cause is often obscure, but the costochondral junction may become strained in patients with a persistent cough. The pain can appear to be in the breast with intermittent radiation round the chest wall and is initiated or aggravated by deep breathing and coughing.

Features:

• the pain is acute, intermittent or chronic

• the breast is normal to palpation

• palpable swelling about 4 cm from sternal edge due to enlargement of costochondral cartilage

• X-rays are normal

• it is self-limiting, but may take several months to subside

Treatment. Infiltration with local anaesthetic and corticosteroid with care. Otherwise use NSAIDs or paracetamol.

Mastitis

Mastitis is basically cellulitis of the interlobular connective tissue of the breast. Mostly restricted to lactating women, it is associated with a cracked nipple or poor milk drainage, including poor infant positioning. The infecting organism is usually Staphylococcus aureus. Mastitis is a serious problem and requires early treatment. Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply.

Clinical features

• A lump and then soreness (at first)

• A red tender area

  Possibly

• Fever, tiredness, muscle aches and pains

Note: Candida infection usually causes severe breast or nipple pain—a feeling like a hot knife or hot shooting pains, especially during and after feeding. It may occur after a course of antibiotics.

Prevention (in lactation)

• Maintain free breast drainage—keep feeding

• Encourage milk expression from the infected breast manually or by breast pump

• Attend to breast engorgement and cracked nipples

Treatment

If systemic symptoms develop:

• antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics⁷ di/(flu)cloxacillin 500 mg (o) 6 hourly for at least 5, and up to 10, days

  or (if hypersensitive to penicillin),^9,10 cephalexin 500 mg (o) 6 hourly for at least 5 days

  If severe cellulitis, di/(flu)cloxacillin 2 g (IV) 6 hourly, then switch to oral therapy when symptoms are resolving

• therapeutic ultrasound (2 W/cm² for 6 minutes) daily for 2–3 days

• ibuprofen or paracetamol for pain

• for Candida albicans infection of the breast: fluconazole 150 mg (o) every second day for 1–2 weeks followed by a course of nystatin 1 000 000 U (o) tds¹¹

Breast abscess

If tenderness and redness persist beyond 48 hours and an area of tense induration develops, then a breast abscess has formed (see FIG. 100.2).

The preferred treatment is serial aspiration drainage with a large bore needle under ultrasound guidance. Often 3 or 4 aspirations are required. Adjunct treatment is antibiotics, rest and complete emptying of the breast. Breastfeeding can continue, with provision of lactation support. Surgical drainage may be required but should be avoided if possible because fistula formation is common.

Inflammatory breast cancer

Also referred to as ‘mastitis carcinomatosa’, this rare condition develops quickly with florid redness, swelling, dimpling and heaviness of the breast. It is not as painful as it appears and can be confused with mastitis but does not respond to antibiotics.

Refer immediately.

• Undiagnosed localised breast pain or lump

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Painful breasts