Breast Pain Flashcards
Can breast pain be an indication of breast cancer?
- Pain is one of the most common breast symptoms experienced by women.
- Most women worry about breast cancer but 3% of women presenting with breast pain are diagnosed with breast cancer.
Can men have breast pain?
Yes.
Breast pain is uncommon in men.
Pain and tenderness may occur in men who develop gynaecomastia secondary to medication, hormonal factors, cirrhosis and other conditions.
What are the classification of breast pain?
o Cyclical breast pain - breast pain that has a clear relationship to the menstrual cycle, and the most common type of breast pain.
o Non-cyclical breast pain - may be constant or intermittent but is not associated with the menstrual cycle.
o Extramammary (non-breast) pain - is interpreted as having a cause within the breast but arises from elsewhere (the chest wall or other sources).
How do you take a history of breast pain?
• SOCRATES
• Any relationship to activity.
• Presence of other breast symptoms (lumps, discharge).
• Relationship to menstrual cycle and periodicity. Establish whether the pain is cyclical, or whether it has no relationship to menstrual cycle.
• If there is recent or current breast-feeding.
• Medication history, particularly hormonal medication.
• Reproductive, medical and family history.
• Ask about any associated problems. Such problems are common and disruptive. Likely findings include:
o Sleep problems.
o Symptoms affecting sex life.
o Work, school and social disruption.
o Quality of life adversely affected.
What are the features that suggest cyclical breast pain?
o Severity of pain is variable in different menstrual cycles.
o Pain is usually present in the same part of each menstrual cycle (most commonly starting 1-3 days before menses start).
o Pain has usually settled by the time menstruation ends.
o Pain tends to be in the upper outer quadrant(s) and may extend to the axillae.
o Pain is usually diffuse and bilateral (may be more severe in one breast).
o There may be generalised swelling and lumpiness, but no specific lump found.
What are the features of non-cyclical breast pain?
• Pain is not related to the menstrual cycle and is more likely to be unilateral or focal.
• Medication history is particularly important in this type of breast pain; establish whether the person has been on medication which may cause mastalgia - for example:
o Hormonal medication, especially hormone replacement therapy (HRT). Also oral contraceptive pills.
o Antidepressants (including sertraline, venlafaxine and mirtazapine).
o Antipsychotics (including haloperidol).
o Cardiovascular drugs (including digoxin and spironolactone).
o Antibiotics (including metronidazole) and antifungals (including ketoconazole).
What are the features of extramammary pain?
- Extramammary pain due to various conditions may present as breast pain.
- There are many such conditions but most common are costochondritis and other chest wall syndromes.
- Features such as location and radiation of pain, history of recent trauma or aggravating activities may lead the clinician to suspect the cause of the pain to be extramammary.
What are you looking for in an examination of a patient presenting with breast pain?
- This should include all four quadrants of each breast from the under surface of each breast right up to the upper end of the breast tail, the nipple and areola, together with examination of the regional lymph nodes.
- Palpation may demonstrate an abnormality. Commonly it reveals coarse nodular areas resembling bundles of string in the breast but check carefully for any discrete lump.
- Look for skin changes and nipple distortion or discharge.
- Look for signs of infection (localised redness, swelling, warmth and tenderness).
- If there is tenderness on examination, establish whether this is within the breast or in the underlying chest wall.
- Try lifting the breast with one hand while palpating the chest wall underneath or ask the woman to lie on each side in turn, allowing the breast to fall away from the chest wall. It may be very reassuring for the woman if this demonstrates the area of tenderness is not within the breast tissue.
- Large pendulous breasts may be a clue that the pain is musculoskeletal in nature, especially if a well-fitting, supportive bra is not worn.
- It may be appropriate to examine other potential causes of the pain.
What are the investigations for breast pain?
- Exclude pregnancy where indicated. Refer urgently if there is a discrete lump, any sinister feature, or a past history of breast cancer.
- Breast pain alone with no associated findings is not an indication for imaging.
- Consider referral, however, if there are risk factors or if pain is persistent, atypical or unexplained.
Breast related differentials for breast pain
Cyclical breast pain Mastitis Breast trauma. Thrombophlebitis/Mondor's syndrome. Breast cysts. Benign breast tumours. Breast cancer Lactation-associated - may have an infectious aetiology. Postoperative breast pain.
Musculoskeletal causes of breast pain?
Costochondritis Tietze’s syndrome Bornholm disease Chest wall trauma and/or rib fracture Fibromyalgia Cervical and thoracic spondylosis/ radiculopathy Shoulder pain Thoracic outlet syndrome
Other differentials of breast pain
Pregnancy Herpes zoster CAD/angina Pericarditis PE Pleurisy GORD Peptic ulcer disease Cholecystitis Sickle cell anaemia Psychological
Medications such as HRT, antidepressants, antipsychotics, cardiovascular causes such as digoxin and spinolactrone and antibiotics such as metronidazole.
What are the measures of managing breast pain no longer recommended?
o Diets low in fat and high in carbohydrate, or low in caffeine. o Stopping or changing other medication, including combined oral contraceptives. o Evening primrose oil. o Progestogen-only contraceptives. o Antibiotics. o Diuretics. o Pyridoxine. o Tibolone. o Vitamin E
What is the first line management for cyclical breast pain?
Reassurance that the pain is not due to breast cancer and an explanation as to its hormonal nature may be all the management that some women require.
A better-fitting bra and simple analgesia is the first line of treatment. Simple non-opioid analgesia can be helpful for mild discomfort.
What is the second line management for cyclical breast pain?
Consider referring to a specialist for other treatment options if pain is severe or persistent.
A diary of pain and symptoms for two months may help in assessment.
Further treatment may include:
• Danazol(an anti-gonadotrophin) is licensed for severe pain and tenderness in benign fibrocystic breast disease which has not responded to other treatment. Adverse effects (commonly nausea, dizziness, rash, backache, weight gain, menorrhagia) may be minimised by reducing the dose of danazol to 100 mg from the initial starting dose of 300 mg daily, and restricting treatment to two weeks preceding menstruation. Non-hormonal contraception is essential, as danazol has androgenic effects in the fetus.
• Goserelin injections (a gonadorelin analogue which inhibits gonadotrophin release) are occasionally used for severe refractory mastalgia.
