General Breast Pain
Cyclic vs non-cyclic
In general there are two types of breast pain (mastalgia): cyclic and non-cyclic pain. Cyclic pain is much more common, and as the name suggests the pain fluctuates with the menstrual cycle. The exact cause of cyclic pain is not well understood, but it appears that the fluctuations of estrogen and progesterone and prolactin might be responsible for this type of breast pain.
Cyclic pain typically begins at ovulation and escalates until the onset of the period, and the pain tends to subside following the menstruation. Both breasts are involved, but many will report asymmetrical pain, pain only in one breast, or more severe pain in one than the other. Women suffering from breast pain report greatest pain in the upper, outer portion of the breast, adjacent to the armpit. The pain is often referred to as dull and the breasts feel sore, and in some cases pain may radiate to the armpit and then to the entire arm. The sufferers of cyclic pain often report reduction if not elimination of breast pain at menopause if they are not under hormone replacement therapy.
Unlike cyclic pain, non-cyclic pain is unrelated to the hormonal fluctuation of menstrual cycle. Typically, there is a defined area of tenderness or a focal tenderness, which can help with the diagnosis and treatment of the pain. Unlike cyclic breast pain, non-cyclic breast pain is often felt only in one breast. The causes of non-cyclic pain can vary, but the following are the most common causes:
- Periductal mastitis/duct ectasis
- Pregnancy and breast feeding (Puerperal mastitis)
- Sclerosing adenosis
Pain due to fat necrosis (fatty breast tissue that has died and formed cysts), calcification as a result of surgery or other types of trauma can be experienced many years following the initial trauma. Pain associated with trauma to the breasts is described as sore, bruised, or stabbing pain.
One of the common causes of non-cyclic focal breast pain. The presence of cysts can be confirmed by ultrasound and can be treated by aspiration. If blood is drawn or the cysts recur, then further study such as biopsy is warranted.
Periductal mastitis can cause severe breast pain in a significant number of women. The periductal inflammation occurs in non-lactating women when the milk ducts near the nipple become inflamed thus causing extreme breast pain. Other symptoms of this condition are a mass near the nipple, retraction of the nipple, or discharge. Treatment includes antibiotics or, in severe cases, surgery. The pain is described as throbbing and often accompanied by redness and warmth of tissues.
This condition is characterized by the presence of a small mass, 2cm or less, that is firm but poorly defined. The mass if often attached to surrounding breast tissue. Typically the mass is accompanied by breast pain.
Pregnancy and breast feeding (puerperal mastitis)
Many women report discomfort in their breasts during pregnancy and while breast feeding. The breast pain associated with breast feeding is termed puperpeal mastitis. However, neither case requires any medical intervention unless actual infections arise.
Only a small percentage of women (7–10%) suffering from breast cancer report breast pain as the sole symptom. However, any new onset of non-cyclic pain should be carefully examined and should undergo rigorous differential diagnosis.
In some cases women experience breast pain, but the pain does not originate in the breasts. Non-breast pain can be categorized into chest-wall pain and non-chest-wall pain.
- Tietze’s syndrome (costochondritis)
- Cervical radiculopathy
Non-chest wall pain:
- Gallbladder disease
- Ischemic heart disease
Tietze’s syndrome (Costochondritis)
This condition produces significant chest pain due to inflammation of the bones and cartilage in the chest wall. The pain can be exacerbated by deep breathing, coughing, or other activities involving the chest wall. Costochondritis has no known cause (idiopathic). The condition can subside on its own eventually, but in severe cases injection of anesthetic and/or steroid offers a positive clinical result.
Chronic, recurring breast pain accompanied by pain in the shoulder, arm, and hand on the same side can be caused by cervical radiculopathy where nerve roots (C6-C7) are compressed. The compression of the pectoralis muscle, not the breast parenchyma (breast tissue) causes the apparent breast pain. In addition, pain can be accompanied by weaknesses in other muscles such as tripceps and biceps which is indicative of root compressions.
Other non-chest-wall pain that can be incorrectly attributed to breast pain are diseases related to gallbladder and/or heart. Gallbladder infections or cardiovascular abnormalities can exhibit chest pain that can feel as if it is coming from the breasts in women.
Changes in breast tissue known as fibrocystic breast condition or disease can also cause breast pain, which is either cyclical or non-cyclical. For more information on this condition click here.