Approach to breast pain (mastalgia): Clinical sciences

Breast pain, also called mastalgia or mastodynia, is a feeling of soreness, heaviness, or tenderness in one or both breasts. The causes of breast pain range widely, so the breast exam will help you narrow down your potential diagnoses.

When a patient presents with breast pain, the first step is to perform a focused history and physical examination, including a breast exam. First let’s talk about an abnormal breast exam, starting with mastitis.

These patients usually have a history of fever, breast skin swelling and redness, and sometimes discharge from the nipple. If the patient is currently lactating, they may report incomplete emptying of breast milk. Non-lactating patients may have risk factors like smoking, diabetes, obesity, a prior history of radiation to the breast or chest, or a history of ductal ectasia or periductal mastitis.

Physical exam will typically reveal erythema, induration, and tenderness of the breast. You may also see nipple retraction or purulent nipple drainage. In some cases, a fluctuant mass may be palpable. If these features are present, consider mastitis, with or without the presence of an abscess.

Next order a CBC. If the patient is not lactating, consider imaging with a breast ultrasound and mammogram to look for an abscess or an underlying malignancy. Also, If there is drainage from the nipple, send it for gram stain and culture.

CBC might reveal leukocytosis, while the ultrasound of the breast shows soft tissue inflammation, and possibly ductal dilation, or the presence of an abscess or fistula. The mammogram will show ill-defined, non-specific regions of increased density and skin thickening. Lastly, gram stain and culture may show bacterial growth. If these features are present, you can diagnose mastitis with or without an abscess.

Here’s a clinical pearl. Inflammatory breast cancer is a form of locally advanced breast cancer that can sometimes mimic mastitis. Think about inflammatory breast cancer in patients who do not respond to treatment for mastitis, or have a skin finding called peau d’orange, which is when portions of the breast become edematous and have a dimpled orange-peel appearance.

Okay, let’s move on to the next possibility. Some patients might report noticing a mass or asymmetry of one of the breasts. History might also reveal age over 40, a personal or family history of breast or ovarian cancer, and a history of exogenous hormone use. On exam, you can expect to find a palpable breast mass and possibly nipple or skin changes, nipple discharge, and lymphadenopathy. With these findings, consider a malignant or benign breast mass.

Your next step is to order a breast ultrasound, as well as a diagnostic mammogram in patients over the age of 30. If the ultrasound reveals a solid or cystic mass, and the mammogram shows an asymmetric density, you should proceed with a core needle biopsy.

Here’s another clinical pearl. Some breast mass features on mammogram are suggestive of malignancy. These include a spiculated or irregular mass, the presence of microcalcifications, and architectural distortion of the breast.