5 Breast pain

Definition
Mastalgia is any pain felt in the breast. Cyclical mastalgia is pain in the breast which varies in association with the menstrual cycle. Non-cyclical mastalgia is pain in the breast which follows no pattern or is intermittent.
KEY POINTS
• Mastalgia is commonly due to disorders of the breast or nipple tissue
but may also be due to problems in the underlying chest wall or overlying
skin.
• Pain is an uncommon presenting feature of tumours but any
underlying mass should be investigated as for a mass (see Chapter 4).
• Always look for an associated infection in the breast.
• Mammography should be routine in women presenting over the age of
45 years to help exclude occult carcinoma.
Important diagnostic features
Non-breast conditions
• Tietze’s disease (costochondritis): tenderness over medial ends of ribs, not limited to the breast area of the chest wall, relieved by NSAIDs.
• Bomholm’s disease (epidemic pleurodynia): marked pain with no physical signs in the breast, worse with inspiration, no chest disease underlying, relieved with NSAIDs.
• Pleurisy: associated chest thfection, pleural rub, may be bilateral.
• Angina: usually atypical angina, may be hard to diagnose, previous history of associated vascular disease.
Mastalgia due to breast pathology
Mast itis! breast abscess
• During lactation: red, hot, tender lump, systemic upset.
Treatment: aspirate abscess (may need to be repeated), do not stop breast feeding, oral antibiotics.

• Non-lactational abscesses: recurrent, associated with smoking, associated with underlying ductal ectasia.
Treatment: aspirate or incise and drain abscess, give oral antibiotics, stop smoking, prophylactic metronidazole for recurrent sepsis.
Jn,fècted sehaceous cyst
Single lump superficially in the skin of the periareolar region, previous history of painless cystic lump.
Treatment: excise infected cyst.
Fibrocystic disease
Irregular, ill defined, may be associated lumps, tender more than very painful.
Mastalgia without breast pathology
Pain often felt throughout the breast, often worse in the axillary tail, moderately tender to examination.
Treatment for cyclical mastalgia: ‘y linoleic acid (evening primrose oil), danazol, tamoxifen.
Treatment for non-cyclical mastalgia: NSAIDs, ylinoleic acid.

KEY INVESTIGATIONS
Non-breast origin
Chest X-ray, EGG (exercise)
Breast pathology
• ENAC (MC+S): associated palpable lump, ?fibrocystic disease,
?mastitis/abscess.
• Ultrasound (young women/dense breasts) or mammography (older
women/small breasts).
Mastalgia without breast pathology
Mammography in women over 45 years