Dr Toni Hazell uses case studies to explore three possible causes of breast pain (mastalgia) and how each condition should be managed in primary care

Dr Toni Hazell

Dr Toni Hazell

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Read this article to learn more about:

  • some causes of breast pain you might encounter in general practice
  • how to manage certain kinds of breast pain
  • whether a referral for potential breast cancer might be needed.

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Breast pain is common—around two-thirds of women will experience cyclical breast pain at some point in their lives and 10% of women will have pain that they describe as moderate or severe.1 Breast pain can be a normal physiological event (e.g. before a period or during early pregnancy) or it can represent pathology such as a mastitis. This article will use case studies to illustrate different causes of breast pain and the guidelines that can be used to inform management decisions.

Case 1

A 24-year-old woman comes to see you about her breast pain. It has been an issue for at least a year and is worse just before her period, improving once her period starts. She says that the pain is like a dull ache, usually in both breasts and that her breasts feel heavier than usual. She has come to see you 1 week before her period, so that you can see her when she is in pain, but there is nothing to find on examination—both breasts appear normal, albeit slightly tender to touch. There is no focal area of pain and there are no lumps.

Diagnosis

From the information given, the diagnosis is likely to be cyclical breast pain, defined by NICE as pain ‘related to the menstrual cycle, with symptoms usually starting within 2 weeks of, and improving at the onset of, the menstrual period’. Cyclical breast pain is a clinical diagnosis and no specific imaging is needed. Factors to consider when making the diagnosis are listed in Box 1.

Box 1: Factors to consider when diagnosing cyclical breast pain

  • Is the patient pregnant or breastfeeding?
  • Could this be infection? Look for a hot, red, tender area of the breast and systemic signs of infection such as fever
  • Are there other symptoms that may make a diagnosis of PMS appropriate? Look for a combination of physical symptoms (e.g. breast pain) with psychological symptoms such as depression and anxiety. The RCOG recommends that PMS only be diagnosed based on a prospective symptom diary kept over at least two cycles2
  • Is there a lump or any skin or nipple changes that might raise suspicion of malignancy?
  • Is the diagnosis obvious based on the patient’s description of symptoms? If not, consider asking the patient to keep a prospective symptom diary over two cycles.1

PMS=pre-menstrual syndrome; RCOG=Royal College of Obstetricians and Gynaecologists

Management

The cause of cyclical breast pain is not fully understood, but the patient can be reassured that it is not related to breast cancer or any other known pathology of the breast.1 Explain to the patient that there is no indication for any tests, and outline the possible treatments. Management is largely supportive—she should ensure that she wears a well-fitting bra and consider wearing a soft bra at night. She can use over-the-counter oral analgesia or non-steroidal anti-inflammatory drugs (NSAIDs)—there is also evidence that topical NSAID preparations can be effective for breast pain.1 If the patient has pre-menstrual syndrome (PMS) then it may be appropriate to treat this with the combined contraceptive pill (if not contraindicated). The Royal College of Obstetricians and Gynaecologists (RCOG) recommends that cognitive behavioural therapy should be considered routinely as a treatment option for PMS.2

NICE recommends that the following treatments should not be recommended routinely for the treatment of cyclical breast pain:1

  • stopping or changing other medication that the person already takes
  • progestogen-only contraceptives
  • vitamin E
  • evening primrose oil
  • dietary changes (such as reducing fat or caffeine)
  • other prescribed medicines such as antibiotics, diuretics, pyridoxine and tibolone.

If supportive measures do not help and the patient is having significant pain then it may be worth referring them to secondary care—treatments such as danazol and tamoxifen are sometimes used, but should not be started in primary care.1

The patient can be reassured that cyclical breast pain will resolve spontaneously in around 20–30% of women within 3 months of onset (though in some it may recur at a later date)3 and that it is not a risk factor for the future development of breast cancer.1

Clinical outcome

You don’t see this patient again for another 6 months, when she comes in to see you with an upper respiratory tract infection. You ask her about the pain and she tells you that she did keep a diary for a while, but the pain resolved spontaneously after about 6 weeks so she didn’t bother to come back and see you again.

Case 2

A 35-year-old woman, who had her first baby 4 weeks ago, comes to see you almost in tears because she has so much pain in her left breast. She is exclusively breastfeeding, and very keen to continue, but the pain is so bad that she has considered changing to formula milk. On examination, she has a temperature of 38.2°C and there is a wedge-shaped area on her left breast that is red, warm, and tender to touch.

Diagnosis

The likely diagnosis in this case is mastitis, a common condition that occurs in up to one-third of lactating women. It usually occurs in the first 6 weeks after delivery and can also occur when the baby is being weaned. Symptoms of mastitis include breast pain, a red, swollen, wedge-shaped area on the breast that may feel hot and painful to touch, and general fever and malaise. There may be a nipple fissure. Not all mastitis is infectious and it can be difficult to reliably differentiate between infectious and non-infectious mastitis—consider a diagnosis of infectious mastitis if there are systemic features (such as fever and malaise) that last longer than 24 hours, or if the pain is severe. There are several conditions that can be mistaken for mastitis; some important possibilities to consider are listed in Box 2.

Box 2: Other considerations when mastitis is suspected4

  • Don’t miss a breast abscess—these should be suspected in women with a recent history of mastitis. There is likely to be a discrete lump which is painful, with hot red skin overlying it. The lump may feel fluctuant. Women with a breast abscess should be referred urgently for a surgical review
  • Mastitis is much less common in non-lactating women—consider causes such as eczema, candida, and breast cancer (in the presence of a lump). All women with suspected mastitis whose symptoms fail to settle after 48 hours of first-line antibiotic treatment, and in whom an alternative diagnosis is unlikely, should be treated with second-line antibiotics (co-amoxiclav or a macrolide plus metronidazole), for 10–14 days. Recurrent mastitis in a non-lactating woman should prompt referral to a breast clinic as it may be a presentation of ductal carcinoma in situ or other ductal pathology.
  • Consider admission for a woman who is systemically septic or immunocompromised (regardless of whether or not she is lactating).
  • Consider sending breast milk for culture in lactating women with recurrent mastitis, severe burning pain, or where there is a risk of a hospital-acquired infection. The culture can then guide the choice of future antibiotics. Give the woman advice from the NICE CKS on Mastitis and breast abscess about how to collect a clean sample (cks.nice.org.uk/mastitis-and-breast-abscess#!diagnosissub:2).4

Management

Initial treatment involves simple analgesia and ensuring that milk removal is effective, which can be supported by a breastfeeding counsellor to check the latch and improve the infant’s attachment to the breast. If this does not help within 12–24 hours or there is an obviously infected nipple fissure, then flucloxacillin should be given (or a macrolide for women who are allergic to penicillin). The woman should be encouraged to continue to feed from the affected breast—if it is too painful to do so then she should express milk, either by hand or using a pump.4

Clinical outcome

You decide to treat this patient with antibiotics as she has severe pain and a temperature and you encourage her to continue feeding. Her symptoms resolve with no further treatment and she is able to continue breastfeeding.

Case 3

A 54-year-old woman presents to primary care having noticed some pain in her right breast from time to time. She is concerned because her mother had breast cancer. On direct questioning, she has noticed some discharge from the nipple. You examine her and can see that the right nipple looks slightly retracted, but you can’t feel a discrete lump.

Diagnosis

In this case, the patient’s clinical symptoms and family history are cause for suspicion of breast cancer. It has often been given as perceived wisdom that breast changes that are painful are less likely to be cancerous; however, this is not supported by NICE guidance on suspected cancer,5 which states that people should be referred under the 2-week wait if they are aged 30 years and over and have an unexplained breast lump with or without pain. Pain on its own is not a specific referral criterion, although it could be argued that new-onset, severe unilateral pain is a concerning change and would therefore merit referral in a woman aged over 50 years. The NICE referral criteria for suspected breast cancer can be found in Box 3.

Box 3: NICE Referral criteria for suspected breast cancer5

Refer under the 2-week wait system people who are:

  • aged 30 years or over with an unexplained breast lump with or without pain
  • aged 50 years or over with discharge, retraction, or other changes of concern in one nipple only [‘other changes of concern’ is not defined]

Consider referral under the 2-week wait system for people:

  • with skin changes that suggest breast cancer or
  • aged 30 years or over with an unexplained lump in the axilla

Consider non-urgent referral for people:

  • aged under 30 years with an unexplained breast lump with or without pain

© NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015 (updated 2017). Available at: nice.org.uk/ng12 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Management

The patient needs to be referred to the local breast clinic under the 2-week wait referral system; she should be offered an appointment at a one-stop clinic where she will see a consultant and have appropriate imaging.

Clinical outcome

This patient is seen promptly in the breast clinic and has appropriate imaging which finds an early breast cancer—she is treated surgically and makes a good recovery from her surgery, remaining under the care of oncology for appropriate follow up.

Conclusion

Breast pain is a common symptom and many patients who present with it may be concerned about cancer. Breast pain alone, however, is not usually associated with breast disease and can often be managed in general practice in the first instance, using the principles discussed in this article and the related guidelines. The presence of other associated symptoms or examination findings may however mean that secondary care referral is indicated.

Dr Toni Hazell

Part-time GP, Greater London

References

  1. NICE. Cyclical breast pain. Clinical Knowledge Summary. NICE, 2016. Available at: cks.nice.org.uk/breast-pain-cyclical
  2. Green L, O’Brien P, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. BJOG 2017; 124: e73–e105.
  3. Goyal A. Breast pain. BMJ Clin Evid 2011: 1: 812
  4. NICE. Mastitis and breast abscess. Clinical Knowledge Summary. NICE, 2015. Available at: cks.nice.org.uk/mastitis-and-breast-abscess
  5. NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015 (updated 2017). Available at: www.nice.org.uk/ng12