Breast Pain
Breast pain has a variety of innocent causes: The commonest are puberty and pregnancy. It can be a troublesome recurrent problem for women with cyclical mastalgia. Cancer is very likely to be a major concern: this is an uncommon cause and pain is an unfortunately late sign of the disease.
Differential diagnosis
Common Diagnoses
- Pregnancy
- Cyclical Mastalgia
- Cracked or Inflamed Nipple
- Breast Abscess
- Mastitis
Occasional Diagnoses
- Carcinoma
- Onset of Puberty
- Lactation and/or Galactocoele
- Simple Cyst
- Trauma
Rare Diagnoses
- Chondritis of Costal Cartilage
- Angina
- Cervical Spondylosis
- Herpes Zoster
- Mondor’s Disease (Thrombophlebitis of Chest Wall or Breast Veins – Rare)
- Tuberculosis
Ready reckoner
Key distinguishing features of the most common diagnoses
| Pregnancy | Cyclical Mastalgia | Inflamed Nipple | Abscess | Mastitis | |
|---|---|---|---|---|---|
| Bilateral | Yes | Yes | No | No | No |
| Fever | No | No | No | Yes | Yes |
| Discrete Mass | No | No | No | Yes | No |
| Local Erythema | No | No | Yes | Possible | Yes |
| Diffuse Nodularity | Possible | Yes | No | No | No |
Possible investigations
Likely: None
Possible: Pregnancy test, mammography
Small Print: Swab of any nipple discharge, other investigations if non-breast causes suspected.
- Pregnancy test worthwhile in bilateral pain if a period has been missed.
- Mammography may help if pain is accompanied by a mass or ill-defined nodularity but this would normally be performed in secondary care after referral.
- If the aetiology is infective and the nipple is discharging, a swab may help guide treatment.
- Other investigations: If a non-breast cause is suspected, other tests may be required according to the pattern of the symptoms, e.g. cardiac tests (angina) or cervical spine X-ray (cervical spondylosis)
Top Tips
- Offer to examine the breasts even if you are sure from the history that there is no significant pathology – many women fear breast cancer and will find your reassurance hard to accept if they feel they haven’t been taken seriously.
- Don’t reflexly prescribe in cyclical mastalgia; the patient’s agenda is often to exclude serious disease rather than seek drug therapy.
- Remember pregnancy as a cause – the patient will not always volunteer this as a possibility, even if she has just missed a period.
- Unilateral breast pain with no other local signs may be an early symptom of shingles. Check the back in the T4/5 dermatomes for a rash.
Red Flags
- ‘Chest pain’ may be a euphemism used by a (frequently older) woman in denial. Don’t miss advanced tumour through not examining the breasts.
- Cancer rarely presents with breast pain but consider this possibility in a woman complaining of constant ‘pricking’ breast pain.
- A lactating woman with unilateral breast pain and flu-type symptoms is probably developing mastitis – treat early to avoid the development of an abscess.
- If the pain is related to exertion in a late middle-aged or elderly woman, consider angina as a possibility.