Pain in the breast is a frequent complaint. All women will experience breast pain at some stage in their lives but some women are unfortunate enough to suffer from constant or repeated episodes of breast pain. When breast pain becomes excessive, it begins to interfere with the patient’s lifestyle such as being unable to wear seatbelts or having difficulty with sexual intercourse. These women have what is referred to as mastalgia.

For most women breast pain is something that is experienced just prior to the menstrual period, or otherwise may be felt as an occasional twinge, but it does not feature heavily in our lives. Importantly, Breast Cancer only presents with pain in less than 10% of cases and will be a constant pain usually associated with a lump. Even if there is no mass but a constant localised pain a mammogram or sonar should be obtained. Only 2% of these cases will be due to cancer.

Trying to treat or cope with breast pain is often very frustrating. Most textbooks describe breast pain as cyclic or non-cyclic depending if it is related to the menstrual cycle. Two thirds of breast pain is cyclical and caused by the changes in hormones in our breasts. The rest is non-cyclical, of which one half is related to the bones and joints beneath the breast. Unfortunately it is difficult for women to differentiate these symptoms. All patients presenting with breast pain should have a thorough history and clinical examination with an ultrasound, and a mammogram if over forty.

But it is possible to approach pain according to the symptoms and type of pain. Sometimes women may have more than one type of pain. Sometimes it is only by treating the pain that it can be determined what the cause is.

When is a breast pain not a breast pain?...

… when it doesn’t come from the breast.

Nearly one fifth of all “breast pains” are actually due to non-breast causes such as:

  • cardiac problems (heart related), especially with left sided pressing breast pain
    respiratory problems (lung problems such as pneumonia or pleurisy), often breast pain that is worse on breathing
  • gastro-intestinal problems (reflux heartburn), which might cause pain that wakes you at night or when you are lying flat
  • rib inflammation (costochondritis), which feels like pinpoint pain on either side of the breast
  • Shingles (Herpes Zoster infection), causing an incredibly painful rash from the back to the front.

What is breast pain then?

True breast pain can be dived into 4 types:

Lateral pulling pain

This is a pain that extends from the armpit down towards the nipples along the sides of the breasts. It is normally more common in big-breasted women.

The breasts hang on the pectoral muscle in a fine fibrous coating. Imagine the muscle as a coat hanger and the breast as a heavy jacket hanging on the coat hanger. The coat will drag on the hanger and just like that the breasts pull on the attachments below. This pain is usually worse at the end of the day and is related to breast poor fitting bras which will not support the breast adequately from below.

Burning, shooting pains

These types of pains, particularly around the nipple and associated with an itchy feeling can be due to duct ectasia. This is a dilatation on widening of the small milk ducts. These breast ducts are lined by fine hairs and inflammation in the ducts is similar to asthma or emphysema in the lungs. It causes debris to fill up inside and can increase the risk of infections.

The causes of duct ectasia are smoking and pollution. Patients can experience burning discomfort in the breast and occasional shooting pains. Some complain of hot poking pains in the breast.

Topical antibiotics dabbed on the nipples may help for this type of pain.

Full, heavy uncomfortable breasts (feels like one needs to feed a baby)

This type of breast pain is hormonal and is most commonly caused by a change in the female hormone levels in the breast. It can be cyclical and related to the menstrual cycle, or non-cyclical and may be related to a hormone called prolactin. Most commonly the change in the breast tissue around the time of your period increases the amount of blood in your breast and the amount of water retained by the breast. This can make the breasts feel heavy and full, causing pain down the side of the breast, and throughout.

When the pain is not related to the menstrual cycle, it may be caused by stress (either physical (even chronic diseases), emotional or mental) which results in transient changes in the prolactin levels (a stress hormone). Women who are patients in Intensive Care Units also have raised prolactin levels. Prolactin is a fascinating hormone which is difficult to switch off once activated. Transient increases in prolactin may not reflected in blood levels tested but result in a full heavy discomfort in the breast. Women who have breastfed say the pain is similar to the discomfort experienced when the breast is full of milk. It is important to check thyroid function as an underactive thyroid causes similar breast discomfort, and consider any medication (such as some anti-depressants) which can affect prolactin levels as well.

No conventional pain medication works very well for this type of breast pain. Successful management of this breast pain is by understanding the cause, and trying evening primrose oils and Vitamin B6 combinations as the first line of treatment.

Fibroadenosis is not breast pain it is a lumpiness seen in the breast confirmed on a needle biopsy. However, a large number of women with lumpy breasts do have frequent breast pain.

Isolated medial and lateral pain on pressure (Chest Wall Pain)

This is known as costochondritis or as Tietze’s disease and accounts for 10% of breast pain. Men and women both suffer from this complaint but because the breasts are above these joints, most women perceive the pain as breast pain. The pain is localised to the breast and feels like particular tenderness over the costochondral junction (the ribs under the inner part of the breasts). The actual cause is often not known but may be due to a viral infection or may be related to or exacerbated by excessive muscle strain (sport). Treatment is to abstain from doing the implicated sport for a few weeks and take NSAIDS (non-steroidal anti-inflammatory drugs).

Mondor’s disease is a rare and unusual cause of breast pain associated with a cord like structure running over the breast. It is the pain in the lower or lateral aspect of the breast from a thrombophlebitis (inflammation of a vein) crossing within the breast tissue. Anti-inflammatory drugs (NSAIDS) and aspirin may give relief. This unusual condition can be associated with an underlying Breast Cancer so it is important to ensure appropriate breast investigations before treatment.

How can I treat this pain?

First determine what kind of pain it is. Treatments for most breast pains entail the following principles:

  • If your breast pain does not settle, please see a general practitioner or specialist with an interest in breast health.
  • Ensure that you have been for age appropriate investigations such as an ultrasound and/or mammogram and any blood tests.
  • If your breast pain is affecting your day to day life try recording your breast pain on a pain chart for four months. You can notice its variations over the menstrual cycles and it may help your treating doctor identify the cause.
  • Poorly fitting bras or old bras, combined with large breasts, result in pain under breasts and down the side of the breast, particularly as the day progresses and gravity takes its toll on the breast ligaments.
  • Medications that can be tried at home include Vitamin B6 (pyridoxine) and gamma linolenic acid (GLA, Evening Primrose Oil) should be tried first. GLA in particular tends to stabilize breast epithelial activity via hormonal metabolism. The dose of evening primrose oil is 2-6 capsules daily and B6 and evening primrose oil should be taken in combination. Treatment is continued for a minimum of 3 months. In some studies over 70% of patients had a good response.
  • If you are on the contraceptive pill or suitable for it, your doctor may suggest an alternative contraceptive pill after checking the relevant tests.

Previously breast pain was treated with strong hormonal manipulative medication such as Danazol or Bromocriptine. Often, however, the side effects of these drugs (weight gain, growing facial hair) often outweigh the benefit.

Breast pain that does not respond to supplements may be treated with low dose anti-oestrogen medicines such as Tamoxifen or Fareston (although these do not have FDA approval in the USA for this use). Tamoxifen taken orally at very low doses is incredibly useful in premenopausal women. Alternatively some studies suggest crushing these SERMS and mixing them in KY jelly and applying them topically to the breast tissue. In post-menopausal women, a related drug called raloxifene (Evista) works in a similar way and may help decrease breast pain. This medication may have the added benefit of decreasing risk of Breast Cancer as will Tamoxifen.

Would surgery help?

Breast pain that does not respond to any treatment should never be treated with surgery. A doctor does not treat a headache by chopping off the patients head and even after surgery 50% of women who have breast surgery for breast pain have continuous pain post-surgery. The only type of breast pain that is improved by surgery may be lateral pulling pain in large breasted women where a breast reduction is helpful.

Remember that breast pain with an associated normal mammogram is almost never a Breast Cancer.