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Mastalgia (Breast Pain)

by Mary Ann Kosir, MD

Mastalgia (breast pain) is common and can be localized or diffuse and unilateral or bilateral.

Etiology

Localized breast pain is usually caused by a focal disorder that causes a mass (see Breast Masses (Breast Lumps)), such as a breast cyst, or an infection (eg, mastitis, abscess). Most breast cancers do not cause pain.

Diffuse bilateral pain may be caused by fibrocystic changes or, uncommonly, diffuse bilateral mastitis. However, diffuse bilateral pain is very common in women without breast abnormalities. The most common causes are

  • Hormonal changes that cause breast tissue proliferation (eg, during the luteal phase or early pregnancy, in women taking estrogens or progestins)

  • Large, pendulous breasts that stretch Cooper ligaments

Evaluation

History

History of present illness should address the temporal pattern of pain and its nature (focal or diffuse, unilateral or bilateral). The relation between chronic or recurrent pain and menstrual cycle phase should be ascertained.

Review of systems should seek other symptoms suggesting pregnancy (eg, abdominal enlargement, amenorrhea, morning nausea) or fibrocystic changes (eg, presence of many masses).

Past medical history should cover disorders that could cause diffuse pain (eg, fibrocystic changes) and use of estrogens and progestins.

Physical examination

Examination focuses on the breast and adjacent tissue, looking for abnormalities such as skin changes including erythema, rash, exaggeration of normal skin markings, and trace edema sometimes termed peau d’orange (orange peel), and signs of infection, such as redness, warmth, and tenderness.

Red flags

The following are of particular concern:

  • Signs of infection

Interpretation of findings

Absence of abnormal findings suggests that pain is due to hormonal changes or large, pendulous breasts. Abnormal findings may suggest other specific problems.

Testing

Pregnancy testing should be done if pain is unexplained and has lasted less than several months, particularly if other symptoms or signs are consistent with pregnancy.

Other testing is indicated infrequently--only if physical findings suggest another problem that requires testing.

Treatment

For menstrual-related mastalgia, acetaminophen or an NSAID is usually effective. If pain is severe, a brief course of danazol or tamoxifen may be given. These drugs inhibit estrogen and progesterone. If estrogen or a progestin is being taken, stopping may be necessary.

For pregnancy-related breast pain, wearing a firm, supportive brassiere, taking acetaminophen, or both, can help.

Recent evidence suggests that evening primrose oil, vitamin E, or both used together may reduce the severity of mastalgia.

Key Points

  • Diffuse, bilateral breast pain is usually caused by hormonal changes or large, pendulous breasts and causes no abnormal physical findings.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • NOLVADEX
  • CRINONE
  • No US brand name
  • TYLENOL

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