Approach to breast pain (mastalgia): Clinical sciences

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Introduction0:00–0:21

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.

H&P/Mastitis0:21–2:55

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.

Breast mass2:55–4:23

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.
Now, if the biopsy shows malignant cells, you can diagnose breast cancer. On the other hand, if it shows no evidence of in-situ or invasive malignant cells, you are dealing with a benign breast mass.
Moving on, let’s talk about another cause of an abnormal breast exam, gynecomastia. History reveals a biologically male patient presenting with a painful bilateral or unilateral retroareolar lump or breast enlargement.

Gynecomastia 4:23–5:05

They might also have a history of chronic liver or kidney disease, or take medications associated with gynecomastia such as spironolactone or anabolic steroids.
On physical exam, you’ll usually find a palpable, tender, rubbery, mobile disc of retroareolar glandular tissue. If you see these findings, that’s gynecomastia.
Alright, let’s go back a step and talk about patients with a normal breast exam, starting with cyclic mastalgia or mastodynia.

Cyclic mastalgia 5:05–5:48

These patients present with diffuse, bilateral, cyclic breast pain, and symptom onset related to the menstrual cycle. Typically, breast pain will start during the luteal phase and become progressively worse until the onset of menses.
The patient might report that the pain is worse in the upper, outer quadrants. If the physical exam does not reveal any abnormalities like masses, skin, or nipple changes you can diagnose cyclic mastalgia or mastodynia.
Next up is non-cyclic breast pain. History typically reveals focal and unilateral breast pain that is not cyclic in nature, or related to the patient's menstrual cycle.

Non-cyclic mastalgia5:48–6:36

Additionally, they might have a history of hormone replacement therapy. Physical exam will not reveal any masses, skin, or nipple changes, but the patient might have large pendulous breasts.
With these findings, consider non-cyclic breast pain. Your next step is to order a breast ultrasound, plus a diagnostic mammogram if the patient has risk factors for breast cancer.
If the ultrasound and mammogram are normal, you can diagnose non-cyclic mastalgia or mastodynia. Lastly, let’s talk about extramammary chest wall pain.

Extramammary chest wall pain6:36–7:19

In this case, the pain isn’t from the breasts, but from adjacent structures of the chest wall like the muscles, bone, or cartilage.
History might reveal breast pain with concurrent neck, back, or shoulder pain. Additionally, patients might report pain with repetitive upper body physical activities, or a history of chest wall trauma or surgery.
On exam, you’ll be able to reproduce the pain with active or passive motion of the upper body or chest, or by palpation of the chest wall.
These features strongly support the diagnosis of extramammary chest wall pain. Alright as a quick recap… Breast pain can be caused by conditions affecting the breast or the chest wall.

Review7:19–7:43

Patients with abnormal breast exam might have mastitis with or without an abscess, malignant or benign breast mass, or gynecomastia.
On the flip side, if the breast exam is normal, consider cyclic or non-cyclic mastalgia as well as extramammary chest