Breast pain

Published on 10/03/2015 by admin

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Chapter 7 BREAST PAIN

Breast pain, or mastalgia, is a very common complaint in women and represents the most common symptom in women seeking breast evaluation. Breast pain can be divided into three general categories: cyclic breast pain, noncyclic breast pain, and extramammary pain.

In young women, breast pain is usually cyclic, occurring most often a few days before menses and resolving after menses. Minor breast discomfort and swelling within the few days before the onset of menses is considered a normal physiologic occurrence. More severe and prolonged pain is considered cyclic mastalgia. Cyclic breast pain is usually bilateral and diffuse.

Noncyclic breast pain, in contrast, involves constant or intermittent pain that is not associated with the menstrual cycle. Noncyclic mastalgia is less common than cyclic mastalgia, is often unilateral, and often occurs postmenopausally. Noncyclic mastalgia often is described as “burning,” “achy,” or “sore.”

Extramammary pain caused by various conditions may manifest as breast pain, although costochondritis represents the most common cause of extramammary pain. It is usually easy to distinguish between pain localized to the breast or chest wall and that radiating from elsewhere.

Many women who seek treatment for breast pain are concerned about breast cancer, although in the presence of normal examination findings and normal mammograms, the risk of breast cancer is very low. If the pain is mild, an appropriate evaluation is usually sufficient. However, in more severe cases, the mastalgia may interfere with usual daily activities, and treatment may be necessary to help alleviate the symptoms.

Key Historical Features

✓ Location, quality, timing (cyclic vs. noncyclic), relationship to exercise, and severity of the pain

✓ Associated symptoms such as redness, swelling, lump, or nipple discharge (can help focus the examination)

✓ Weight loss

✓ Medications

✓ Medical history

• A personal history of breast cancer, which increases a patient’s risk for recurrent disease

• Cardiac risk factors such as hypertension, hyperlipidemia, diabetes, and tobacco use

✓ Gynecologic and reproductive history

• Early age at menarche, nulliparity, and pregnancy after age 30, which are associated with increased risk of breast cancer

• Breastfeeding or recent childbirth, which increase risk for mastitis

• Pregnancy, which may lead to breast pain

✓ Family history, especially of breast cancer and coronary artery disease

• Chest pain caused by cardiac ischemia is often precipitated by exertion and relieved by rest. Patients often describe the pain as squeezing, tightening pressure. Patients may also experience dyspnea.

• Aortic dissection can cause a painful ripping sensation that radiates to the back and abdomen.

• Shortness of breath can indicate coronary artery disease, pneumonia, or pulmonary embolism.

• Cough, either productive or nonproductive, may indicate pneumonia. A chronic cough can be associated with gastroesophageal reflux disease.

Gastrointestinal

• Chest pain caused by gastroesophageal reflux disease is often associated with meals and worsened with lying flat.

• Patients with biliary colic often complain of epigastric or right upper quadrant pain that radiates to the right shoulder. Patients may also experience chest pain. The pain often starts after a fatty meal, increases over an hour, and then lessens. The pain can be associated with vomiting.

Key Physical Findings

The physical examination should be guided by the history and may include the following evaluations:

✓ Assessment of vital signs

✓ General evaluation of health status

✓ Breast examination

• Both breasts should be visually inspected, with the patient upright and lying down. The physician should inspect for asymmetry, dimpling, retraction, or erythema of the skin and changes to the nipples.

• Both breasts should be palpated for masses, and both the axilla should be palpated for lymphadenopathy.

✓ Cardiopulmonary examination

• A thorough examination of the lungs and heart can help determine the cause of chest or breast pain.

• In order to perform an adequate examination of the chest wall, the patient should roll to the side so that the breast tissue moves out of the way.

✓ Abdominal examination for tenderness, distension, guarding, mass, organomegaly, or rebound

✓ Pelvic examination to evaluate for an ovarian tumor

Initial Work-Up

Mammography	If the pain is localized to the breast and if the patient is aged 30 years or older
Breast ultrasonography	Useful for evaluating for a mass at any age in patients with localized breast pain
Fine-needle aspiration or biopsy	Should be performed if a mass is palpated
Pregnancy test	If the patient is of childbearing age

Additional Work-Up

Radiography	If the pain is not localized to the breasts, chest radiography should be considered to evaluate the bony structures of the chest as well as the lungs and heart
	If the patient has had trauma and the pain is localized to other structures, obtain the appropriate x-ray, such as clavicle, rib, or shoulder
Electrocardiography	If the patient’s pain is typical for cardiac pain or the patient has risk factors for coronary artery disease
Cardiac stress test	If the patient has typical chest pain or risk for cardiac disease; options include treadmill stress test, stress echocardiography, or cardiac nuclear perfusion scan
Abdominal ultrasonography	If the examination findings are suspect for cholecystitis

FURTHER READING

Millet AV, Dirbas FM. Clinical management of breast pain: a review. Obstet Gynecol Survey. 2002;579:451-461.

Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000;61:2371-2378. 2385

Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clin Proc. 2004;79:353-372.

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