Breast tenderness/pain
Breast pain (mastalgia) is a very common symptom in women, accounting for up to 70% of breast clinic referrals in the UK.
Most cases are benign and non-cancerous, often related to hormonal fluctuations or benign breast disease.
⚠️ However, persistent, focal, or unexplained pain may rarely signal breast cancer.
🎯 For students: the aim is to take a clear history, identify red flags, and know when to reassure vs when to refer.
📝 Clinical History
- ⏳ Onset & Duration: Acute, chronic, or cyclical (linked to menstrual cycle).
➡️ Rapid onset with fever/swelling → infection.
➡️ Chronic pain → cysts or fibrocystic change.
- 📍 Location & Nature: Localised vs generalised; unilateral vs bilateral.
Pain character: dull, sharp, throbbing, or burning 🔥 (neuropathic features = referred pain).
- 📆 Timing & Pattern:
🌀 Cyclical mastalgia = common, bilateral, premenstrual.
⚠️ Non-cyclical, persistent pain → further evaluation.
- 🔍 Associated Symptoms:
- Breast lump, swelling, redness, warmth 🟥
- Nipple changes: discharge 💧, inversion ↩️, ulceration
- Systemic symptoms: fever 🤒 (infection), weight loss ⚖️ (malignancy)
- 🧬 Risk Factors:
- Family history 👩👩👧 of breast/ovarian cancer (BRCA genes).
- Past breast problems: lumps, cysts, fibroadenomas.
- Hormonal exposure 💊: contraceptives, HRT.
- 💊 Medication History: Some drugs may cause mastalgia - SSRIs, contraceptives, HRT, antihypertensives (methyldopa, spironolactone).
- 🌱 Lifestyle Factors: High caffeine ☕, smoking 🚬, alcohol 🍷, poorly fitting bras, trauma, or strenuous physical activity 🏋️.
👩⚕️ Physical Examination
- 👀 Inspection: Asymmetry, skin dimpling, erythema, peau d’orange 🍊, nipple inversion/discharge.
- ✋ Palpation: Examine all quadrants & axillary tail. Note size 📏, shape 🔺, mobility 🔄, and consistency 🧱 of any masses.
- 🎯 Nipple & Skin Changes: Retraction, eczema (Paget’s disease), ulceration.
- 🧾 Lymph Nodes: Palpate axillary & supraclavicular nodes for enlargement.
🧪 Investigations
- 🩻 Mammography: Women >40 or suspicious mass.
- 🔊 Ultrasound: Best for younger women; distinguishes cystic vs solid.
- 🧲 MRI: If high suspicion or inconclusive findings.
- 🧬 Hormones: Oestrogen/progesterone if imbalance suspected.
- 🧫 FNA / Biopsy: Gold standard for suspicious lumps.
❓ Possible Causes of Breast Pain
- 🌀 Cyclical Mastalgia: Hormonal; bilateral, premenstrual.
- 📍 Non-Cyclical Mastalgia: Localised, persistent → cysts, fibroadenoma, mastitis.
- 👶 Hormonal States: Pregnancy 🤰, contraceptives 💊, HRT.
- 💊 Medication-Related: SSRIs, hormonal therapy.
- 💢 Costochondritis: Chest wall pain mimicking breast pain.
- 🤕 Trauma: Direct injury or strain.
- 🎗️ Breast Cancer: Rarely presents with pain - consider with red flag signs.
🛠️ Management
- ✅ Reassurance: Benign pain is common. Encourage self-exam 🖐️.
- 💊 Symptomatic Relief: Warm compresses, NSAIDs/Paracetamol, supportive bra 👙.
- 🌱 Lifestyle Changes: Reduce caffeine ☕, limit smoking 🚭 & alcohol 🍷.
- ⚖️ Hormonal Therapy Review: Adjust HRT/contraceptives if needed.
- 📋 Referral: Breast clinic if suspicious mass, red flags 🚩, or persistent unexplained pain.
