Evaluation of breast pain
Breast pain (mastalgia) is classified as cyclic, noncyclic, or extramammary based on its relationship to the menstrual cycle. History, clinical breast examination, and age-appropriate mammography or ultrasonography show that fewer than 1% of women with a normal exam and imaging have cancer. First-line treatment is conservative measures and a supportive bra, escalating to danazol, the only FDA-approved agent, for severe refractory cyclic pain.
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What this article covers
- Overview
Definition: Breast pain (mastalgia) is discomfort localized to breast tissue, classified as cyclic, noncyclic, or extramammary by its relation to the menstrual cycle and point of origin.
- Epidemiology
Prevalence: Mastalgia is common across reproductive life and is a frequent reason for an outpatient breast visit.
- Risk factors
Hormonal exposure: Exogenous estrogen, from combined oral contraceptives or menopausal hormone therapy, can precipitate or worsen cyclic-pattern pain.
- Pathophysiology
Cyclic pain: Rising luteal-phase estrogen and progesterone drive ductal epithelial proliferation, stromal edema, and breast vascularity, producing diffuse bilateral tenderness that peaks…
- Clinical features
Cyclic mastalgia: Bilateral, diffuse, dull or heavy aching in the upper outer quadrants, occasionally worse in one breast, beginning about 2 weeks before menses and resolving with menstruation; often…
- Differential diagnosis
Fibrocystic breast change: cyclical bilateral tenderness with nodularity fluctuating with the cycle, but examination reveals discrete, rope-like or cystic nodularity rather than diffuse tenderness alone.
- Diagnosis
The diagnosis is established by history and clinical breast examination (CBE): mastalgia is a clinical diagnosis; a normal CBE with a cycle-consistent history of bilateral pain establishes cyclic…
- Management
First action: educate and reassure that isolated mastalgia with a normal examination is unlikely to represent cancer, and confirm the patient is up to date with age-appropriate screening.
- Complications
Functional impact: chronic mastalgia can impair sleep and activity, and drives anxiety about occult malignancy even when the cause is benign.
- Prognosis
Cyclic pain: resolves spontaneously in most women within months to a few years and often abates at menopause.
- Prevention
Maintain routine screening: continue age- and risk-appropriate mammographic screening regardless of mastalgia; pain alone is not an indication for earlier screening.
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