Breast Pain: Causes, Diagnosis, Treatment

Breast pain is also known as mastalgia. Mastalgia is classified as cyclical or noncyclic breast pain. Breast pain during menstruation is known as cyclical mastalgia. Noncyclical breast pain is caused by diseases of breast, muscles, rib and sensory nerve. Breast lies over muscle and ribs. Pain caused by muscle and rib diseases underneath the breast is often misdiagnosed as breast pain. The topic covers all disease that causes shooting pain in breast and originates in breast or underneath the breast.

Breast Pain: Causes, Diagnosis, Treatment

Causes of Breast Pain

  1. Cyclical Mastalgia (breast pain)
  2. Non-cyclical Mastalgia (breast pain)
  1. Large Breast
  2. Breast Cyst
  3. Breast Infection
  4. Breast Cancer
  5. Musculoskeletal Causes
    1. Muscle
      1. Pectoral Muscle spasm
      2. Intercostal muscles
    2. Ribs
      1. Costochondritis
      2. Rib contusion
      3. Rib hairline fracture
      4. Rib displace fracture
      5. Sternum
  6. Neuralgic Pain-
    1. Intercostal Neuralgia
    2. Post-herpetic Neuralgia
    3. Radicular Pain

Cyclical Mastalgia As A Cause of Breast Pain

Most cyclic breast pain is observed during menstrual cycle.1 Cyclic breast pain is thus caused by hormonal changes frequently seen during menstruation. Cyclic pain is seen during ovulation and continuous during entire period of menstruation. Cyclical breast pain during menstruation is caused by either hormonal changes or side effects of medication. One of the hormonal changes observed in individual suffering with non-cyclical breast pain during menstrual period is less progesterone than estrogen. The other hormonal causes observed to trigger non-cyclic headache is decrease level of hormone prolactin. Medication that triggers menstrual pain are oral contraceptives, hormone therapy, psychotropic drugs, and some cardiovascular agents.

Symptoms of Cyclical Mastalgia

  1. Pain- Intensity of breast pain is mild to moderate. Wearing tight fitting bra increases pain intensity. Breast pain is mostly bilateral but in few cases pain is unilateral. Pain radiates to side of breast as well as armpit.
  2. Breast Swelling- Breast is big and heavy.

Diagnosis of Cyclical Mastalgia: Cause of Pain in Breast

  1. Mammography- Mammography is an X-Ray examination of breast. During examination, breast is compressed between parallel plate. X-Ray beam is passed from one plate and recorded over the opposite plate. The information collected creates images of the breast. Images shows the normal breast and swollen breast glands.
  2. 3D Mammography- 3D mammography is also known as breast Tomosynthesis. Tomosysnthesis is similar to CT scan. The multi angle images creates 3D images. The study usage minimum X-Ray exposure. Thus radiation dose delivered is lot less than CT scan and avoids radiation exposure. The test prevents false positive finding of mammography. Findings like absence of cyst, abscess, infection and tumor suggests possible cause of pain is cyclical mastalgia.
  3. Ultrasound examination- The ultrasound examination of breast is also known as sonography. Investigational study of breast is safe and painless. Ultrasound examination of breast involves transmission of ultrasound waves through skin in to the breast tissue. The ultrasound is transmitted through a small probe that is placed over the breast. The high frequency sound waves reflect on a transducer that collects information and converts into images. The study does no cause radiation effects. Ultrasound image shows absence of large cystic swelling, abscess and solid tumor.

Treatment of Cyclical Mastalgia: Cause of Breast Pain

a. Diet-
  • Low fat diet
  • Avoid caffeine
  • Consume food that contains Vitamin E (Nuts, sunflower seeds, spinach and broccoli)
b. Topical
  • Local Anesthetics- Local anesthetic lidocaine is mixed in ointment and used for topical application. Ointment causes numbness of the skin and subcutaneous tissue. The effects help to relieve pain in skin, subcutaneous tissue and breast.
  • NSAIDs- The research data suggests ointment most effective to relive pain contains anti-inflammatory medications diclofenac.2
c. Pain Medications
  • Non-steroidal anti-inflammatory drugs (NSAIDs)- NSAIDs are prescribed for pain and inflammation. Most frequent anti-inflammatory medications prescribed are motrin, naproxen and tylenol.
  • Tylenol- Tylenol helps to relieve mild to moderate pain.
d. Medications-
  • Birth Control Pills- Birth control pill adjusts the hormonal imbalance between estrogen and progesterone.
  • Danazol2– Danazol is a male hormone prescribed for breast pain and endometriosis. Danazol has antigonadotropic and anti-estrogenic activities. Danazol balances the hormonal changes and prevents breast shooting pain.
  • Bromocriptine3– Bromocriptine blocks prolactin in the hypothalamus and decreases secretion of milk. The bromocriptine treatment decreases breast blood supply that results in less pain.
  • Tamoxifen4– Tamoxifen is an estrogen blocker and prescribed if cyclical mastalgia is caused by increased blood estrogen concentration.

Non-cyclical Mastalgia: Cause of Breast Pain

Noncyclic breast pain is the breast pain observed during menstrual and non-menstrual period.5 The non-cyclic breast pain is less common than cyclic breast pain. Noncyclic breast pain may or may not be restricted only to breast. Non-cyclic breast pain is caused by diseases of breast and tissue that surrounds the breast.1 The diseases of skin, muscles, rib and nerves that lies close to breast causes pain around or within breast tissue.

  1. Large breast
  2. Breast Cyst
  3. Breast Infection
  4. Breast Cancer
    1. Large Breast-

      Large breast causes breast pain as the breast drags the muscles and subcutaneous tissue while standing and sitting. Breast Pain is caused by pull and stretch of ligaments as well as tissue underneath the skin.

      Symptoms of Large Breast Causing Breast Pain
      1. Pain- Mild to moderate breast pain is felt mostly in upper 1/3rd of breast that is in most cases pulled down while standing and sitting. Examination also indicates pain located behind the breast over ribs and pectoralis major muscle.
      2. Enlarged Breast- Most large sized breast is diagnosed during examination. The entire breast is enlarged. The physician performs the examination to rule out cyst and cancer swelling. Cyst is a soft fluctuating swelling and cancer tissue is felt hard during examination.
      Diagnoses of Large Breast Causing Breast Pain-

      Mammography- Mammography study is performed to rule out breast cyst, abscess and cancer.

      Treatment of Large Breast –
      1. Pain Medication- Mild to moderate breast pain is treated with non-steroidal anti-inflammatory medication and tylenol.
      2. Surgery- Breast reduction surgery is performed to reduce the size of the pain. The pain intensity reduces because of reduction in breast volume as well as weight.
    2. Breast Cyst Causing Breast Pain

      Breast glands are tiny sacs known as alveoli that produces milk. Bundle of several breast alveoli form a lobule. Lobules are connected to duct. Duct opens into nipples and carry milk produced by alveoli to nipple. Several lobules and fatty subcutaneous tissue form a breast. Hormonal changes stimulate the alveoli to secrete milk. Hormonal imbalance causes swelling or cyst within alveoli. Cyst is formed by increasing and enlarging the size of the alveolar sac. Cyst is solitary (single) or multiple and size of cyst varies from 1 mm to 30 mm (3 cm). Large sized breast cyst is filled with fluid. Breast cyst is not cancerous. Breast cyst is classified as micro cyst and macrocyst.6 Microcyst is 1 mm to 2 mm in size and macrocyst is larger than 2 mm in size and grows up to 20 to 30 mm (2 to 3 cm) in size. Microcyst is difficult to feel during examination, but seen in mammography studies. Macrocyst is a large cyst and forms an oval swelling within breast tissue. Breast cyst swelling is felt by individual as well as physician during breast examination. Cyst feels soft and tender. Most cysts appear between age 35 and 50 years before menopause.

      Diagnosis of Breast Cyst Causing Breast Pain
      1. Mammography- Mammography is an X-Ray examination of breast. During examination, breast is compressed between parallel plate. X-Ray beam is passed from one plate and recorded over the opposite plate. The information collected creates images of the breast. Images shows the cystic swelling as well as solid tumor.
      2. 3 D Mammography- 3 D mammography is also known as breast Tomosynthesis. Tomosysnthesis is similar to CT scan created 3 D images, but uses less X-Ray exposure. Thus radiation dose delivered is lot less than CT scan and avoids radiation exposure. The test prevents false positive finding of mammography.
      3. Ultrasound Examination- The ultrasound examination of breast is also known as sonography. Investigational study of breast is safe and painless. Ultrasound examination of breast involves transmission of ultrasound waves through skin in to the breast tissue. The ultrasound is transmitted through a small probe that is placed over the breast. The high frequency sound waves reflect on a transducer that collects information and converts into images. The study does no cause radiation effects. Ultrasound image shows the cystic swelling, abscess and solid tumor.
      4. Needle Biopsy- Needle biopsy procedure is performed in procedure room under aseptic surrounding. The needle placement in cyst is performed while using ultrasound. The fluid inside the cyst is collected and examined under microscope.
      Treatment of Breast Cyst Causing Breast Pain
      1. Preventive-
        • No smoking- Smoking causes breast engorgement that frequently results in cystic glands.
        • Diet- Low fat diet is recommended to prevent breast enlargement and cyst formation.
      2. Topical Ointment
        • NSAIDs- Ointment containing diclofenac helps to relieve inflammation and pain associated with enlarged breast cyst.
      3. Analgesics (Pain Medications)
        • Non-steroidal anti-inflammatory drugs (NSAIDs)- Mild to moderate pain as well as inflammation is treated with non-steroidal anti-inflammatory medications. The NSAIDs most frequently used are motrin, naproxen and celebrex.
        • Tylenol- Tylenol is prescribed for moderate to severe pain.
      4. Antibiotics- Cystic swelling if ignored occasionally gets infected. Infection is treated with antibiotics.
      5. Hormonal Treatment- Hormonal treatment like birth control pill helps to prevent hormonal fluctuation and imbalance. Birth control pills regulate menstruation and prevents cyst formation.
      6. Needle Aspiration- The fluid within the breast cyst is aspirated that helps to reduce swelling and pressure over breast tissue. Needle is placed within cyst under guidance of ultrasound. The fluid is aspirated by gentle negative pressure.
      7. Surgery- Painful large breast cyst is surgically removed. Surgery is performed in outpatient surgery.
    3. Breast Infection As A Cause Of Breast Pain

      Breast infection or inflammation is also known as mastitis. Breast infection is common among breast feeding female. Breast infection is also observed following breast injury.
      Types of Breast Infection- Breast infection is classified as follows-

      1. Central or Sub-Areolar Breast Infection- Most often observed in female who are chronic smoker. The first sign of infection is pain, retracted nipple and foul smelling discharged from breast.
      2. Granulomatous Lobular Mastitis- The infected firm mass is often mistaken for cancer. The mass is formed when lobular mastitis is inadequately treated with antibiotics.
      3. Peripheral Non-Lactating Mastitis- The infection is localized in surrounding adipose tissue that does not contain any milk producing gland. The infection often follows breast trauma and more common in patient suffering with diabetes and rheumatoid arthritis.
      Symptoms of Breast Infection Causing Breast Pain
      1. Pain- Breast Pain intensity is mild during initial phase and become severe when abscess is formed. Breast become tender during examination.
      2. Fever- Breast infection causes fever. Temperature is fluctuating between 980 F and 1020 F.
      3. Nausea- Pain and fever is associated with nausea.
      4. Cracked Nipples- Infection spreads into alveoli and pus discharges through the milk duct into nipple. The pus spread over nipple causes crackling of nipple epithelial tissue.
      5. Red Streaks On Breast- The inflammation increases diameter of blood arteries and veins since blood flow is increased to inflammatory tissue. The inflamed blood vessels look like ref streaks on breast skin.
      6. Purulent Discharge- Purulent secretion of pus discharged is observed coming out of nipples.
      Diagnosis (Investigation) of Breast Infection-
      1. Blood Examination- White blood cell count is increased.
      2. Mammography- The inflamed tissue and abscess is observed over mammography.
      3. 3 D Mammography (Tomosynthesis)- 3 D mammography shows inflamed tissue and abscess in 3 D images. The 3 D images helps to locate the exact depth of abscess and inflammatory tissue.
      4. Ultrasound- Ultrasound helps to confirmed the diagnosis.
      5. Needle biopsy- Needle biopsy helps to examine inflammatory breast tissue and also aspirated abscess under microscope. The bacterial colonies from bacterial culture are examined to find out causative bacteria. Cultural colonies are treated with several antibiotics to find out most effective antibiotics to treat the infection. Most breast infection is caused by staphylococcus aureus. The other bacteria that also causes breast infection are streptococcus and E. Coli.
      Treatment of Breast Infection Causing Breast Pain-
      1. Preventive-
        • No smoking
        • Diet- Less fatty food and no alcohol.
        • Warm moist compression
      2. Topical
        • NSAIDs- diclofenac ointment
      3. Antibiotic- Erythromycin, Keflex and dicloxacillin
      4. Pain Medication for Breast Pain Caused Due to Breast Infection
        • NSAIDs- Motrin, Naproxen and Celebrex
        • Tylenol
      5. Hormonal Treatment
        • Birth control pills
      6. Needle Aspiration- Large abscess is drained through large diameter needle. Procedure is performed in surgical center under sedation or local anesthetics.
      7. Surgery- Open surgical procedure is performed in surgical center. Procedure is performed under sedation and local anesthesia. Surgery involves skin incision over the most tender area. The abscess area is marked after seeing 3 D and ultrasound images. The abscess area is explored and abscess as well as wall covering abscess is removed.
    4. Breast Cancer: Cause of Breast Pain

      Breast cancer is more common in middle age and elderly female, than young female individuals. Breast cancer is considered as familiar disease since breast cancer is found frequently among close relatives. The chances of developing breast cancer are higher if cancer is observed in siblings and mother. Breast cancer is known to be genetic disease and mutated cancer gene is found to cause the cancer. Breast cancer is triggered by exposure to radiation and disease is frequently seen in females who had radiation treatment.

      Types of Breast Cancer-
      1. Angiosarcoma- Cancer growth originates in blood vessels.
      2. Ductal Carcinoma In Situ (DCIS)- The cancer develops in epithelial cells of mild duct. Cancer does not spread outside duct.
      3. Invasive Lobular Carcinoma- Cancer growth begins in milk gland. The cancer of epithelial cells of milk gland spreads to distant organs through blood and lymph. The cancer is known as invasive cancer since cancer cells rapidly spreads to distant organs through lymph and blood vessels.
      4. Inflammatory Breast Cancer- Cancer growth begins in breast gland and spread into lymphatic vessels. In few cases lymphatic spread is restricted since lymphatic vessels are blocked by breast gland cancer cells. The lymphatic channels and skin overlying lymph vessels gets inflamed. Entire breast become red and inflamed. The disease is thus known as inflammatory breast cancer.
      5. Paget’s Disease Of Breast- Paget’s disease is rare type of carcinoma. The cancer begins in nipple and spreads over circular dark alveolar tissue.
      Symptoms and Sign Of Breast Cancer
      1. Pain- Breast Pain intensity is mild to moderate during initial phase. Pain intensity increases in advanced sage of cancer. Inflammatory breast cancer is very painful. Most breast cancer are tender and breast pain increases following examination.
      2. Fever- Fever is observed in individual suffering with inflammatory breast cancer. Temperature varies between 990 F and 1010 F.
      3. Breast Lump- In most cases breast examination indicates small to medium sized breast. The breast lump of cancer is felt firm to hard. The margins of tumor look irregular and painful.
      4. Inverted Nipple- Nipples looks inverted in individual suffering with ductal carcinoma in situ and Paget’s disease of breast.
      5. Skin- Skin shows dimple in individual suffering with ductal carcinoma and invasive lobular carcinoma. Inflammatory changes of skin are observed in individual suffering with inflammatory breast carcinoma.
      6. Areolar Tissue- Areolar tissue shows peeling, scaling and crusting in patient suffering with ductal carcinoma and Paget’s disease of breast.
      7. Enlarged Lymph Node- Axillary and sternal lymph node are enlarged.
      8. Purulent Discharge- Purulent discharged is observed coming out of nipple in patient suffering with ductal carcinoma and Paget’s disease.
      Diagnosis of Breast Cancer
      1. Blood Examination- White blood cell count is increased in patient suffering with inflammatory breast carcinoma.
      2. Mammography- Prophylactic and diagnostic mammography. Most female age over 30 are recommended to get elective breast mammography yearly or every two years. Early detection and removal of breast cancer cures cancer disease. Mammography helps to diagnosed breast cancer in patient suffering with breast pain.
      3. 3 D Mammography (Tomosynthesis)-Tomosynthesis helps to diagnose ductal carcinoma as well as invasive lobular carcinoma 3 D images helps to targets the cancer growth.
      4. Ultrasound- Ultrasound helps to find solid and fluctuating soft mass in breast. Ultrasound is not used as an investigation to screen breast cancer.
      5. Needle Biopsy- Needle biopsy is performed once cancer growth is felt during palpation and confirmed by mammogram. Procedure is performed in surgical center or doctor’s office. The needle is placed within tumor mass under 3 D mammogram or ultrasound guidance. The tumor tissue is aspirated in syringe and sent to lab for further study to diagnosed cancer.
      Treatment of Breast Pain Caused Due to Breast Cancer
      1. Surgery-
        • Excision of tumor mass is also known as lumpectomy.
        • Excision of breast is also known as mastectomy
        • Removal of breast and lymph node- This procedure involves mastectomy and removal of lymph node that may be involved in breast cancer.
      2. Radiation Therapy- Treatment involves targeting cancer tissue by high energy rays so as to kill most cancer cells. Radiation therapy may follow surgery. In few cases patients are given chemotherapy after radiation treatment.
      3. Chemotherapy- Chemotherapy treatment is preferred after surgery and radiation treatment just to make sure any left breast cancer cells are killed. Chemotherapy most often preferred to treat breast cancer are Adriamycin, Taxol, Taxotere, Cyclophosphamide and Paraplatin.
      4. Hormonal Therapy- Hormonal therapy like chemotherapy is used after surgery to prevent growth of breast cancer from residual cancer cells. The hormones are taken for 5 years if not more. Breast cancer cells has a receptor for estrogen and estrogen stimulates rapid growth and multiplication of cancer cells. The hormones prescribed to prevent breast cancer growth are classified into following groups-
        • Anti-estrogen receptor-Drugs like tamoxifen or toremifene blocks the estrogen receptors and prevents growth as well as multiplication of cancer cells. Similarly, faslodex destroys the estrogen receptor and prevents any estrogen effects on cancer cells.
        • Prevent estrogen synthesis-
          • Aromatase inhibitors- These drugs inhibit secretion of estrogen.
          • Luteinizing hormone-releasing hormone (LHRH)- inhibits ovaries to secrete estrogen and ovarian suppression.
          • Oophorectomy- Removal ovary prevents secretion of estrogen.

References

  1. A Systematic Review of Current Understanding and Management of Mastalgia Kamal KatariaAnita DharAnurag SrivastavaSandeep Kumar, and Amit Goyal, Indian J Surg. 2014 Jun; 76(3): 217–222., Published online 2013 Feb 5. 
  2. Cyclic and non-cyclic breast-pain: A systematic review on pain reduction, side effects, and quality of life for various treatments. Groen JW1Grosfeld S2Bramer WM3Ernst MF2Mullender MM4., Eur J Obstet Gynecol Reprod Biol. 2017 Dec;219:74-93.
  3. Treatment of Cyclical Breast Pain with Bromocriptine R. E. ManselP. E. Preece*, L. E. Hughes, First Published October 1, 1980 Research Article
  4. Breast pain Amit Goyal, Consultant Oncoplastic Breast Surgeon and Honorary Associate Professor, BMJ Clin Evid. 2014; 2014: 0812. 
  5. New Breast Pain Chart for Objective Record of Mastalgia. Gautam S1Srivastava A1Kataria K1Dhar A1Ranjan P1Kumar J1., Indian J Surg. 2016 Jun;78(3):245-8.
  6. Cystic Breast Masses and the ACRIN 6666 Experience Wendie A. Berg, MD, PhD,a,b,* Alan G. Sechtin, MD,b Helga Marques, MS,c and Zheng Zhang, PhDc, Radiol Clin North Am. Author manuscript; available in PMC 2011 Sep 1.
  7. Common Breast Problems. Salzman B1Collins E1Hersh L1., Am Fam Physician. 2019 Apr 15;99(8):505-514.
     
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