Mastalgia (breast pain) is common and can be localized or diffuse and unilateral or bilateral.
Etiology of Mastalgia
Localized breast pain is usually caused by a focal disorder that causes a mass, such as a breast cyst, or an infection (eg, mastitis, abscess). Most breast cancers do not cause pain.
Diffuse bilateral pain may be caused by fibrocystic changes or, uncommonly, diffuse bilateral mastitis. However, diffuse bilateral pain is very common in women without breast abnormalities. The most common causes in these women are
Hormonal changes that cause breast tissue proliferation (eg, during the luteal phase or early pregnancy, in women taking estrogens or progestins)
Large, pendulous breasts that stretch Cooper ligaments
Some studies have found that a high-fat diet and caffeine intake are associated with mastalgia, but it is uncertain whether reducing these dietary factors decreases symptoms (1).
Etiology reference
1. Goyal A: Breast pain. BMJ Clin Evid 2011:0812, 2011. Published 2011 Jan 17.
Evaluation of Mastalgia
History
History of present illness should address the temporal pattern of pain and its nature (focal or diffuse, unilateral or bilateral). The relation between chronic or recurrent pain and menstrual cycle phase should be ascertained.
Review of systems should seek other symptoms suggesting pregnancy (eg, abdominal enlargement, amenorrhea, morning nausea) or fibrocystic changes (eg, presence of many masses).
Past medical history should cover disorders that could cause diffuse pain (eg, fibrocystic changes) and use of estrogens and progestins.
Physical examination
Examination focuses on the breast, looking for abnormalities such as mass, nipple inversion or discharge, skin changes including erythema, rash, eczematous appearance, edema, or dimpling (sometimes termed peau d’orange [orange peel]), and signs of infection, such as redness, warmth, and tenderness.
Red flags
The following is of particular concern:
Signs of infection
Mass, nipple inversion, or skin changes
Interpretation of findings
Absence of abnormal findings suggests that pain is due to hormonal changes or large, pendulous breasts.
Testing
Pregnancy testing should be done if pain is unexplained and has lasted less than several months, particularly if other symptoms or signs are consistent with pregnancy.
Other testing is indicated infrequently—only if breast examination detects abnormal findings.
Treatment of Mastalgia
estrogen and progesterone. If estrogen or a progestin is being taken, stopping may be necessary.
Evening primrose oil may reduce the severity of mastalgia.
Key Points
Diffuse, bilateral breast pain is usually caused by hormonal changes or large, pendulous breasts.
