Breast Pain Evaluation and Management

Introduction to Breast Pain

The American College of Radiology suggests that breast swelling and pain most commonly result from benign hormonal causes, infection, or musculoskeletal chest wall conditions, but require clinical evaluation to exclude less common malignancies, particularly if pain is focal, unilateral, and persistent 1, 2

Cyclical mastalgia accounts for approximately 70% of breast pain cases and is related to hormonal fluctuations during the menstrual cycle 3
The American College of Radiology recommends that this pain is typically bilateral or diffusely unilateral, waxes and wanes with the menstrual cycle, and is most common in women in their fourth decade of life 1, 3
Pregnancy and breastfeeding commonly cause noncyclic breast pain and tenderness that usually resolves spontaneously 2, 4

Mastitis or breast abscess can cause focal pain with swelling, often preceding induration, redness, warmth, and fever 1, 2
Mondor disease (thrombophlebitis of the thoracoepigastric vein) may present initially as breast pain and swelling 2, 5

Noncyclical breast pain is usually unilateral, more focal, often located in the subareolar area or lower inner breast, and is predominantly inflammatory rather than hormonal 3
The American College of Radiology states that noncyclical mastalgia is more common in women in their fourth decade, though 10-15% present after age 50 1

Extramammary causes account for 10-15% of "breast pain" cases, as the breast's nerve supply from intercostal nerves T3-T5 means irritation anywhere along their course can cause perceived breast pain 2, 4, 5
Tietze syndrome (costochondritis) is a common chest wall condition mimicking breast pain 2, 4, 5

Advanced cancers may present with breast pain as the only symptom, especially if deep in a large breast or with chest-wall invasion 1, 2, 4
Invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia compared to other cancer types 2, 4, 5

Focal, unilateral breast pain without additional signs of breast disease may need evaluation to exclude underlying lesions 1, 2
Diagnostic mammography is the imaging study of choice for women ≥30 years; ultrasound alone for women <30 years 3
Ultrasound is first-line imaging if a mass is palpable or infection is suspected, avoiding radiation exposure 6

Never dismiss breast pain without proper evaluation, as some cancers can present with pain alone 3
Always rule out extramammary causes (costochondritis, cervical radiculopathy, cardiac issues) when breast exam and imaging are normal 3, 7