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Chapter 100: Breast pain (mastalgia)

INTRODUCTION

Many women suffer breast pain so severe that it affects their lifestyles, marriages and sexual relationships, and even prevents them from hugging their children.

DR JOHN DAWSON, 1990

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.

SYMPTOMS

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.

Key facts and checkpoints

  • The typical age span for mastalgia is 30–50 years.

  • The peak incidence is 35–45 years.

  • There are four common clinical presentations:

    1. diffuse, bilateral cyclical mastalgia

    2. diffuse, bilateral non-cyclical mastalgia

    3. unilateral diffuse non-cyclical mastalgia

    4. localised breast pain

  • The specific type of mastalgia should be identified.

  • The commonest type is cyclical mastalgia.

  • Premenstrual mastalgia (part of type 1) is common.

  • An underlying malignancy should be excluded.

  • Less than 10% of breast cancers present with localised pain.

  • Only about 1 in 200 women with mastalgia are found to have breast cancer.

  • The problems, especially types 2 and 3, are difficult to alleviate.

A DIAGNOSTIC APPROACH

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

Table 100.1Mastalgia: diagnostic strategy model
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Table 100.1 Mastalgia: diagnostic strategy model

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

  • pendulous breasts stretching Cooper’s ligaments

  • weight change

  • trauma

Rarities:

  • hyperprolactinaemia

  • nerve entrapment

  • mammary duct ectasia

  • sclerosing adenosis

  • ankylosing spondylitis

Seven 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.

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.

FIGURE 100.1

Pain patterns for ...

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