Breast Pain

In this episode of PodMD, Breast and Endocrine Surgeon, Susannah Graham discusses the topic of Breast Pain- she discusses how to identify the signs and symptoms of different breast pain and what to do next.

  • Transcript

    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Dr Sean Mackay “Today I’d like to welcome to the PodMd studio Dr Susannah Graham is an Australian trained breast and endocrine surgeon, with a special interest in oncoplastic breast surgery, breast reconstruction, thyroid surgery, parathyroid surgery and minimally invasive parathyroid surgery. 

    Today, we’ll be discussing the topic of breast pain

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Susannah, thanks for talking with us on Pod MD today.

    Answer Thank you for having me, Sean.

    Question 1 “The topic of today’s discussion is breast pain
    Susannah, can you describe for our listeners in general sense what breast pain actually is?”

    “Absolutely Sean. So, breast pain, really is what we commonly refer to in the medical literature as mastalgia and it is as simple as pain in the breasts. There’s really nothing more complicated to it than that. It is exceptionally common. Up to 70% of women at some stage in their lives will have breast pain in some form or another. It probably should be considered a normal function of the body rather than a disease process. It can, however, sometimes be severe for some women despite being within the spectrum of normal change, and can be accompanied by other symptoms like breast heaviness, lumpiness fullness, or an increase in breast size.

”

    Question 2 What are the most common causes of breast pain?

    So, I think, it’s important to differentiate between probably the three most common types of breast pain or mastalgia. So cyclical mastalgia, non-cyclical mastalgia and chest wall pain. The reason for differentiating between those three different types are really because of the treatments that we use. Cyclical and non-cyclical, most algebra probably treated similar art, sorry, the cyclical and non-cyclical mastalgia are treated similarly, whereas chest wall pain is another common cause of perceived breast pain but is treated differently. So cyclical mastalgia is pain that varies with the menstrual cycle. It’s more common in younger women, usually women in their twenties and thirties. And it’s that sort of increased sensitivity and sensation that women describe, in their breasts that usually relates to their period. They can be symptoms of heaviness, tenderness, discomfort, fullness, and that usually increases from the middle of their cycle and peaks at about three to four, three to seven days before each period. And usually the pain settles. Once women have their period. Women taking hormone replacement therapy can have similar pain after menopause. Non-cyclical mastalgia is more common in older women. It can be confined to one breast and even localized to one part of the breast. Often no real cause is identified, but it can relate to some underlying benign breast changes like cysts or fibroadenomas or other age-related changes in the dots. It’s particularly common around menopause. So perimenopausal women often describe more severe breast pain but it’s always important to remember that if any woman has pain in association with lump or nipple discharge or any other skin changes, they should be investigated promptly. So, chest wall pain is another common cause of pain that’s perceived as breast pain. But it’s due to underlying chest wall structures like muscles, ribs, ligaments. And in this case, analgesia, heat treatment and physio can help. The way to differentiate between breast and chest wall pain is often by displacing the breast, I’m sorry, elevating the breast on examination and palpating the underlying chest wall which will often elicit the pain that women that the woman is describing rather than tenderness in the breast itself. On palpation.

    Question 3 What are the risks of breast pain, worst case scenerio?

    So, Sean, I think everyone’s greatest concern with any breasts symptom is cancer. I think the important thing to remember here though is that breast pain in isolation is very, very rarely a symptom of cancer. It’s often a symptom that does prompt women to seek medical attention and is a good opportunity to ensure that breast cancer screening is up to date and has been performed. So, women who present with breast pain but have normal clinical examination and normal imaging studies can be reasonably reassured that their risk of breast cancer is similar to that of a woman without breast pain. Women that have non-cyclical unilateral or focal breast pain that is not related to an underlying chest wall structure should have breast imaging though to elucidate the underlying cause and exclude a breast cancer.

    Question 4 Have there been any developments in treatment of breast pain in the last years or are there any in trials or development now?

    “No, unfortunately studies looking into breast pain and messed algebra are really limited, this small in number and they’re not well designed. A lot of the treatments that we use for mast algia are based really not on good evidence. The treatments that we do use, uh, things like wearing a well-fitting and supportive bra. There is some, some limited evidence really for diet and vitamin supplements. So for some women reducing caffeine intake, taking vitamin B, one basics and vitamin E can improve symptoms. Evening Primrose oil is probably the thing that’s most helpful for many women and that’s at high dose. So a thousand milligrams two to three times a day, and it needs to be taken regularly for two to three months for best results. It’s not backed by rigorous evidence, but often we use these treatments in the first instance as they’re not considered.

Simple analgesia can also be used to reduce severity of breast pain and a lot of women actually find topical antiinflammatory gel is really helpful in alleviating some of the severity of their pain. I would consider that they should be used as first line therapy. The oral contraceptive pill can be helpful in some women with cyclical breast pain, but in other women it makes the pain worse. So often it’s a bit of trial and error in order to work out what treatments will work for which woman women with really severe breast pain that’s interfering with their lifestyle can trial hormonal medications like bromocriptine, Danazol, and Tamoxifen, but they should really be prescribed in consultation with a specialist because they have quite significant side effects and shouldn’t be started without serious counseling and consideration.”

    Question 5 Are there any warning signs a GP or their patient can look out for?

    “I think the key point here is to ensure that there are no symptoms or signs of cancer or malignancy. Um, so specific questions to exclude concerning symptoms. Like do you have a lump, have you noticed any skin changes? Do you have any nipple retraction or nipple discharge? Must always be asked. And I think really importantly, patients need to be examined to make sure that there’s no mass skin or nipple changes or any nipple discharge evident on physical examination. Any patient with suspicious physical findings should be referred for imaging. So usually in the form of a bilateral breast ultrasound and mammogram and then referred for specialist review. Women without suspicious physical findings who are up to date with their breast cancer screening should really undergo breast imaging selectively based on their presentation and age. So, breast imaging, even with a negative result is often helpful in alleviating patient anxiety. And so, the most common reason that women really go to the doctor for breast pain is so that they can have some reassurance that the pain is not a symptom of breast cancer rather than there actually being any underlying abnormality.
”

    Question 6 What is the likelihood that a patient who has already sought medical attention will seek it again?

    “So I think so most women following reassurance that the pain is not due to cancer, do not seek further medical attention and do not require really any other treatment. I think provision of patient education about the condition is really important in reassuring them that the breast pain is considered part of the normal spectrum of change in the breast. It’s definitely the minority of patients that require ongoing, uh, treatment and specialists review, uh, to manage their symptoms. And also to provide another level of reassurance that these are not symptoms that should be investigated even further or warrant any other treatment or investigation.
”

    Question 7 When should a GP refer?

    So, any patient with suspicious symptoms, physical findings or imaging findings should be referred. And I think any patient where there’s any concern that the that there is discordance or that, you know, the history examination and imaging findings don’t match up. So that’s a that’s a really important thing to remember with the triple assessment that unless the clinical evaluation, the imaging findings and any tissue biopsies that are performed all correlate, otherwise it’s considered a triple assessment. That words further review.

    Question 8 What role does the GP play in the treatment of the condition?

    So, I think the most important thing really is ensuring that any concerning symptoms and signs aren’t missed. And following that, providing assurance that the lady doesn’t have any PR, does not have breast cancer. And as I said, most women once provided that assurance don’t require any further treatment.

    Summary/Take Home Message – Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on breast pain.

    ” Absolutely, Sean.
    So, I think the first one is that breast pain is very common but rarely a symptom of cancer in the absence of physical or imaging abnormalities.
    Number two, that women who present with breast pain should undergo a thorough history and physical examination to determine whether further imaging or other investigations are required and if specialist referral is necessary.
    The third thing is the assurance that the patient does not have breast cancer is most commonly the only treatment that is required.”

    Thank you – Thanks for your time and the insights you’ve provided.

    My pleasure.

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.