Clinical Overview: Breast Pain (Mastalgia)

Clinical Overview: Breast Pain (Mastalgia)

Breast pain, or mastalgia, is a frequently encountered complaint in clinical practice, affecting women across all age groups.

While it can prompt significant concern, particularly with fears of malignancy, the vast majority of cases are benign and self-limiting.

This article provides an evidence-based overview of the differential diagnosis, evaluation, and management strategies for mastalgia, with an emphasis on distinguishing benign causes from those warrant further investigation.

Breast pain can be classified as cyclical - related to the menstrual cycle or non-cyclical, which occurs independently of hormonal changes. The causes of breast pain vary and can include:

Hormonal fluctuational (especially estrogen and progesterone)

• Pregnancy
• Breastfeeding and conditions like mastitis or abscess
• Fibrocystic breast changes or fibromyalgia
• Injury or trauma to the breast
• Musculoskeletal such as costochondritis or soft tissue injury
• Herpes Zoster
• Referred pain from heart or gastrointestinal condition
• Ill-fitting bras
• Large breast size
• Medications such as hormonal therapy and antidepressants
• Diet such as fat intake, caffeine, iodine deficiency
• Stress
• Smoking
• Breast cancer-rarely 

Cyclical breast pain

This is associated with menstrual cycle with symptoms starting within two weeks and improving at the onset of the menstrual period. Pain feels dull, heavy or aching involving both breasts which may also radiate to the arm or armpit. It's more common than the non-cyclical type. There could be associated premenstrual syndrome

Non-cyclical breast pain

This is not related to menstrual cycle, feels sharp, burning or stabbing in nature. Its commoner in postmenopausal women and can affect one or both breasts.

Additional symptoms to consider

While breast cancer is an uncommon cause of mastalgia, the presence of additional concerning features may warrant further investigation for underlying malignancy or infection. These red flags include:

• Persistent or worsening pain
• Localized swelling
• Redness
• Warmth
• Fever
• Feeling of unwellness
• Breast lump or thickening
• Axillary lump
• Nipples discharge or retraction
• Skin changes
• Weight loss

Treatment 

If there are no concerning symptoms, there are a number of self-care options which include:

• Keeping a symptom diary
• Wearing firm supportive bra during the day and soft bra to sleep at night
• Reducing fatty diet and caffeine
• Smoking cessation
• Warm or cold compressors
• Use of over-the-counter paracetamol and ibuprofen.

If no improvement with the above or there are other symptoms which maybe requiring investigations including scans, biopsy and other treatments such as stronger pain killer, antibiotics, hormonal treatment and surgery.

Recommendation for your patients

Women with personal or family history of cancer are advised to see their GP or healthcare professionals immediately. These group of women should also ensure they attend their surveillance appointment as scheduled.

All women between age of 50-70 years should attend the NHS breast screening services.

It's advisable for premenopausal women with regular cycle to perform breast self-examination at least once monthly usually about a week after the monthly period. For women with irregular period or post-menopausal a specific and consistent day each month for early detection of lump, nipple discharge or abnormal breast change.

Final Thoughts

Mastalgia is a common clinical presentation, and while it often stems from benign and self-limiting causes, a systematic approach to evaluation is essential to rule out more serious underlying conditions.

Differentiating between cyclical and non-cyclical pain, identifying associated red flag symptoms, and considering patient history and risk factors are key steps in guiding appropriate management.

Most cases can be managed conservatively, but clinicians should remain vigilant for signs that warrant imaging or specialist referral. Prompt reassurance, patient education, and evidence-based interventions can significantly reduce anxiety and improve quality of life for those affected.

Author Dr Morenikeji Olaniyi, GP