Breast pain (mastalgia)

Most women will have experienced breast pain or tenderness at some point in their lives. Usually this is related to normal hormonal changes in the menstrual cycle. Breast tenderness may develop in the second half of the monthly cycle becoming worse in the days before the period starts. This is known as cyclical breast pain and it usually settles down again in the days following the period.

Cyclical breast pain usually occurs in both breasts, particularly in the upper outer region which is where the greatest concentration of glandular breast tissue is situated. The pain is often dull, heavy or aching and sometimes the breasts may appear swollen and feel “lumpy”.

Often the pain is mild and as long as there are no other concerning symptoms, no treatment is needed. Many women are concerned that the pain may be a symptom of an underlying cancer and visit their GP, so reassurance after a clinical breast examination may be all that is required. Pain alone is generally not a sign of breast cancer.

Wearing a supportive, well-fitted bra during the day, and at night if needed, may provide some relief. A sports bra should be used while exercising. For moderate pain, over-the-counter medications such as paracetamol or ibuprofen may help. Anti-inflammatory gels rubbed into the skin might provide some relief. If the pain is more severe, it may be useful to keep a diary for 1-2 months to help doctors see if there are patterns to the pain, or triggers which could be avoided.

The oral contraceptive pill, hormone replacement therapy (HRT) and some antidepressants can make some breast pain worse, so discuss this with your doctor. Some women have success using evening primrose oil* over a few months. This may change the balance of fatty acids in the body, although clinical trials haven’t clearly proven this to be beneficial.

*Evening primrose oil is thought to help the proper functioning of human tissues thanks to its anti-inflammatory properties, and supports healthy skin because it prevents loss of water and improves skin softness and elasticity.

Non-cyclical breast pain or tenderness has no relation to the menstrual cycle. It may be constant or come and go. It can be confined to one area, or felt over one or both breasts. It is more likely to affect women over the age of 40.

Pain in the breast tissue sometimes has no obvious cause or underlying abnormality.  Sometimes the pain, while felt in the breast, originates elsewhere. Referred pain from the chest wall is quite common and can be due to trauma, muscle strain after repeated upper body activity, chest infection or costochondritis* (Tietze’s Syndrome). Pain in the breast may also be referred from the neck. 

Early pregnancy may also be associated with breast non cyclic breast pain as the breasts often swell and become tender. Breastfeeding may also cause pain in some women. Mastitis, another cause of non-cyclic pain, is inflammation of breast tissue, usually due to infection and most commonly associated with breastfeeding.

Finally, large breasts can cause supportive ligaments to stretch, causing pain.

Non-cyclical breast pain that is ongoing for more than a week or two should be reported to a GP as they are able to prescribe pain relief medicines if needed and may also need to investigate the cause of the pain.

*Costochondritis is inflammation of the cartilage in the rib cage, usually in the area where the upper ribs attach to the sternum (breastbone). Costochondritis usually goes away on its own after about four to six weeks, and seldom comes back.

Periductal mastitis occurs when the ducts (tubes) under the nipple become swollen and infected.

Symptoms of periductal mastitis may include:

• a tender, hot or reddened breast
• liquid (discharge) from the nipple that is either bloody or non-bloody
• a lump that can be felt behind the nipple
• occasionally, a collection of pus (abscess) or an abnormal connection between a duct and the skin (fistula).

Treatment usually involves antibiotics, although the condition often recurs because the damaged ducts remain. In severe cases removal of the ducts is required. If the breast is painful, pain relief such as paracetamol can be effective.

A breast abscess occurs when a painful pus-filled lump develops under the skin of your breast, usually following mastitis. The lumps may be red and swollen, feel hot, have pus or discharge from the nipple.  A breast abscess may also be associated with a fever (high temperature), chills and a general feeling of being unwell.

Abscesses need to be drained, which is done with a syringe and needle if the abscess is small, but larger abscesses may require a small cut and drainage.

Mastitis or breast abscess in a non-breastfeeding woman requires investigation for an underlying clinical condition such as cancer.

Fibrocystic change is the most common cause of breast lumps in women aged 30–50. Changes occur because some of the breast tissue overreacts to normal monthly changes in hormonal levels. This can lead to scarring around the ducts, which can block the duct and cause tiny cysts to build up. The lumps feel smooth and mobile. Breast tenderness or aching is common, this may be generalised or felt particularly in the upper, outer area of the breasts (near the armpit).

Lumps may fluctuate in size during the menstrual cycle and in some cases, there may be a green or brown nipple discharge which occurs spontaneously (without squeezing).

If the discomfort is mild, no treatment is required for fibrocystic breast changes. Moderate discomfort can be managed by wearing a properly fitted bra and pain medications, like paracetamol. Occasionally, larger cysts causing more severe pain may require aspiration (a doctor uses a needle and syringe to remove the fluid).

Fibrocystic changes in the breast do not increase the risk of developing breast cancer.

Breast cysts are fluid-filled sacs. You may have a single cyst or a number of different sized cysts. Cysts may appear naturally as the breast alters with age, due to normal changes in the oestrogen hormone levels. During the menstrual cycle oestrogen causes fluid to be produced. Although you can develop breast cysts at any age, they’re most common in women over 35.

After the menopause (when your periods stop), as oestrogen levels fall, cysts usually stop forming. Women who have HRT may still get cysts. They may be too small to feel and only detected on imaging or they may be large enough to be felt as a lump. Large cysts may put pressure on other tissue in the breast and cause discomfort.

Cysts can’t be reliably diagnosed on clinical examination alone. Ultrasound will confirm whether the lump is solid or cystic (fluid-filled) and this should be performed before any cyst is drained.

Simple breast cysts are usually left alone. Sometimes the ultrasound will not show the typical appearance of simple breast cysts and a needle biopsy may be necessary to make sure they are breast cysts. If simple breast cysts are very uncomfortable, they may be drained to relieve pain. Occasionally, they can refill or return.