Painful Breasts

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 so excessive that it begins to interfere with the patient’s lifestyle, for example making it difficult to wear seatbelts or having difficulty with sexual intercourse, it is known 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 40.

It is easiest 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 its cause can be determined.

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

True breast pain can be dived into 4 types:

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, in the same way, the breasts pull on the attachments below. This pain is usually worse at the end of the day and is related to poor fitting bras which will not support the breast adequately from below.

These types of pains, particularly around the nipple and associated with an itchy feeling can be due to duct ectasia. This is a dilatation or 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.

This is known as costochondritis or as Tietze’s syndrome 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.

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 (a stress hormone). 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 like chronic diseases, emotional or mental) which results in transient changes in the prolactin levels. 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 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.

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.

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. This unusual condition can be associated with an underlying Breast Cancer so it is important to ensure appropriate breast investigations before treatment.

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

Breast pain that does not respond to any treatment should never be treated with 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.