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.
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:
diffuse, bilateral cyclical mastalgia
diffuse, bilateral non-cyclical mastalgia
unilateral diffuse non-cyclical mastalgia
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 summary of the diagnostic strategy model for mastalgia is presented in TABLE 100.1.
Table 100.1Mastalgia: diagnostic strategy model ||Download (.pdf) Table 100.1 Mastalgia: diagnostic strategy model
Cracked or inflamed nipple
Serious disorders not to be missed
Pitfalls (often missed)
Chest wall pain (e.g. costochondritis)
Pectoralis muscle spasm
Referred pain, esp. thoracic spine
Bornholm disease (epidemic pleurodynia)
mammary duct ectasia
Seven masquerades checklist
Drugs (e.g. OCP, HRT, marijuana)
Is the patient trying to tell me something?
Yes. Fear of malignancy. Consider psychogenic causes.
In the non-pregnant patient, generalised pain, which may be cyclical or non-cyclical, is commonest. Typical patterns are illustrated in FIGURE 100.1.