Red flag symptoms: Breast pain

Contributed by Dr Kamilla Porter, a salaried GP in Rochford, Essex

Women with lactation mastitis should be treated with antibiotics
Women with lactation mastitis should be treated with antibiotics

Breast pain is a common presentation and anxiety about breast cancer may account for high attendance levels. However, the risk of malignancy is low.

Red flag symptoms
  • Breast lump
  • Nipple eczema or retraction
  • Skin distortion
  • Shortness of breath
  • Pain on exertion
  • Sweating
  • Nausea
  • Persisting, intense unilateral pain

Breast pain may be classified as cyclic mastalgia, non-cyclic mastalgia and extramammary pain. It is helpful to have this classification in mind when taking a history.

Cyclic mastalgia
Breast tenderness and pain are normal premenstrual changes. However, women who suffer severe and prolonged pain related to their cycle are considered to have cyclic mastalgia.

The pain is typically in the outer breast, often bilateral and can radiate to the upper arm and axilla. Physical activity can aggravate the pain.

Non-cyclic mastalgia
Non-cyclic mastalgia refers to pain unrelated to the menstrual cycle. It generally affects older women and the pain tends to be unilateral, localised to within a quadrant of the breast and often described as 'burning'.

Non-cyclic breast pain may result from a variety of conditions but in most cases the cause is unknown. Traditional teaching is to consider malignancy in a woman presenting with persistent non-cyclic pain. However, there is conflicting evidence as to whether there is an increased risk of breast cancer in these women.

Extramammary pain
The causes of breast pain arising from outside the breast are extensive but the most common are costochondritis and other chest wall syndromes. Consider the possibility of angina in older women and pulmonary embolism in patients with risk factors and/or respiratory symptoms.

Always undertake a full breast examination to check for signs of malignancy or infection and to establish whether the pain is localised to the breast or coming from the chest wall.

Signs which are highly suggestive of cancer - such as a discrete lump, ulcers, skin distortion, nipple eczema or retraction - necessitate an urgent referral.

Where examination is normal, reassure the patient that the risk of breast cancer is low. Suggest wearing a correctly fitted bra, a soft sleep bra at night and a sports bra during exercise.

NSAIDs may be of help but antibiotics should only be prescribed when periductal mastitis or lactational infection is diagnosed.

There is no value in recommending evening primrose oil, diuretics, vitamin supplements or changing the contraceptive pill.

It is important not to underestimate the impact of breast pain on a woman's quality of life. For patients with severe, sustained breast pain consider referral to a breast clinic where danazol, tamoxifen or bromocriptine may be prescribed.

Possible causes
  • Cyclic mastalgia
  • Non-cyclic mastalgia
  • Mastitis
  • Breast trauma
  • Thrombophlebitis
  • Cysts and tumours
  • Pregnancy
  • Costochondritis
  • Cervical spondylosis
  • Angina
  • Pericarditis
  • Pulmonary embolism
  • HRT

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