Breast series • CLINICAL PRACTICE

Management of benign
breast conditions
Part 1 – painful breasts

Meagan Brennan, BMed, FRACGP, DFM, is a breast physician, NSW Breast Cancer Institute, Westmead Hospital,
New South Wales. [email protected]
Nehmat Houssami, MBBS, FAFPHM, FASBP, PhD, is Associate Clinical Director, NSW Breast Cancer Institute,
Westmead Hospital, Honorary Senior Lecturer, Screening and Test Evaluation Program, School of Public Health,
The University of Sydney, New South Wales.
James French, MBBS, FRACS, is Breast and Endocrine Surgeon, NSW Breast Cancer Institute, Westmead Hospital,
New South Wales.

This is the first article in a series on breast disorders with an emphasis on

B reast symptoms are a frequent reason for • early clinical review Mastalgia
women to consult their general practitioner. • breast imaging: breast ultrasound and/or
While breast cancer is a common disease, mammography depending on the clinical Mastalgia (breast pain) affects up to 77% of
affecting up to one in 11 Australian women in findings and age of the patient, and women at some time in their lives,4 and is so
their lifetime,1 the overwhelming majority of • breast biopsy: fine needle aspiration common it is considered part of a normal
breast symptoms are caused by physiological biopsy, core biopsy, vacuum assisted core bodily process rather than a disease.
or benign, rather than malignant processes in biopsy (VACB), or open surgical biopsy. Mastalgia may be accompanied by breast ten-
the breast. For many women, a great deal of Note that triple testing (a combination of clini- derness, lumpiness, fullness, heaviness, or a
anxiety is associated with experiencing a cal examination, imaging, and nonsurgical noticeable increase in breast size. Mastalgia is
breast symptom. Much of the GP’s role biopsy) is essential for all women who have a not usually a sign of breast cancer or other
therefore, is to exclude cancer, provide an significant clinical finding such as an asym- breast disease. Doctors often think it a trivial
explanation of the nature of the condition, metrical thickening or a discrete palpable symptom, but for many women it causes sig-
and educate and reassure the patient that the mass.2 Interpretation of the triple test result nificant discomfort and anxiety.
symptom is not dangerous. is also critical. If there is any inconsistency, or Mastalgia is classified as cyclical, ie.
all three parts of the triple test are not defi- varying during the menstrual cycle, or non-
Investigation of a breast nitely benign, referral for further assessment cyclical. Cyclical mastalgia accounts for the
symptom is required. majority of breast pain and is most common
A thorough history and physical examination Further information about investigation of in premenopausal women in their 30s.
is required for any woman presenting with a breast symptoms and the use of the triple test Cyclical mastalgia:
breast symptom. This will guide further can be found in the National Breast Cancer • varies with the menstrual cycle, increases
appropriate investigation that may include: Centre’s guide for general practitioners.3 progressively from mid cycle and is usually

AReprinted from Australian Family Physician Vol. 34, No. 3, March 2005  143
Clinical practice: Management of benign breast conditions

relieved with the onset of menstruation the breast or behind the nipple and clinical findings. Ultrasound may not be
• is usually located in the upper outer quad- • is described as having a burning, stabbing, useful in the evaluation of generalised mastal-
rants of the breasts or throbbing quality gia, but may contribute information for very
• is often bilateral • is more likely than cyclical mastalgia to be localised areas of pain. If imaging is normal
• is often described as discomfort, fullness, or associated with breast pathology such as and there are no worrying clinical findings, the
heaviness with a dragging or aching quality. a cyst, fibroadenoma or duct ectasia, and patient should be reassured and given infor-
Noncyclical mastalgia is defined as pain that • may be caused by chest wall problems mation on managing breast pain (see Patient
does not vary with the menstrual cycle. such as costochondritis. education page 145 this issue). Further treat-
It may be continuous or intermittent. It is less ment options are listed in Table 1.
common than cyclical mastalgia and more
Investigation and management
common in women in their 40s. Noncyclical Any woman with a breast symptom, including
Conclusion
mastalgia: significant mastalgia, requires breast imaging. For many women, mastalgia is a cause of sig-
• is usually unilateral, localised to one part Ultrasound and/or mammography are indi- nificant discomfort and anxiety, but it is not
of the breast; commonly the inner part of cated depending on the age of the woman usually a sign of breast cancer or other breast
disease. Cyclical mastalgia accounts for the
Table 1. Management of mastalgia majority of breast pain and is most common
in premenopausal women.
• Reassure the patient that her symptoms are not dangerous and not caused by Noncyclical mastalgia is more common in
breast cancer older women and more likely than cyclical
• Ask the patient to complete a pain chart mastalgia to be associated with breast pathol-
– it will help to characterise the pattern of pain: cyclical or noncyclical ogy. In most cases, explanation that the pain
• Advise the patient to wear a well fitting bra is not caused by breast cancer, reassurance,
– a supportive bra (eg. sports bra) has been shown to reduce breast discomfort and simple measures are all that is required.
• Evening primrose oil There is a trend for all mastalgia to improve
– there is some evidence in randomised trials that evening primrose oil, taken over time, regardless of the treatment given.
orally on a regular basis, may reduce mastalgia in some women5,6 This should be stressed to the patient.
– a dose of 1000 mg 2–3 times per day for 2–3 months is usually required for relief
of symptoms Conflict of interest: none declared.
• Other dietary changes and vitamin supplements
– evidence does not support the recommendation of vitamins B1, B6, E, or special
References
diets for breast pain 1. Available at: www.aihw.gov.au. Accessed June
2004.
• Pain medication 2. Irwig L, Macaskill P, Houssami N. Evidence rele-
– simple analgesics such as paracetamol are useful for women who only vant to the investigation of breast symptoms:
experience mastalgia for a few days each menstrual cycle the triple test. Breast 2002;11:215–20.
3. The investigation of a new breast symptom: a
– there is some evidence to support the use of topical nonsteroidal anti-
guide for general practitioners. National Breast
inflammatory medication for breast pain7 Cancer Centre, 1997.
• Oral contraceptive pill (OCP) 4. Mansel RE. Breast pain. In: Dixon JM, editor.
– some women find their mastalgia improves on the OCP, while others find it ABC of Breast Diseases. 2nd ed. London: BMJ
Publishing Group 2000;16–20.
exacerbates symptoms
5. Gateley CA, Miers M, Mansel RE, Hughes LE.
– high dose oestrogen OCPs are more likely than others to exacerbate mastalgia Drug treatments for mastalgia: 17 years experi-
• Other hormonal medications ence in the Cardiff Mastalgia Clinic. J R Soc Med
1992;85:12–5.
– for severe cases of mastalgia, medications such as danazol, tamoxifen, and
6. Pye JK, Mansel RE, Hughes LE. Clinical experi-
bromocriptine are of use (although their use is limited by side effects)5,6 ence of drug treatments for mastalgia. Lancet
– patients being considered for these medications should be referred to a 1985;17:373–7.
specialist breast surgeon, gynaecologist, or endocrinologist for discussion 7. Tahsin C, Turgut I, Arzu K, Zekai O, Suha A.
Efficacy of topical nonsteroidal anti-inflamma-
• Complementary therapies
tory drugs in mastalgia treatment. J Am Col
– some women get relief from relaxation therapy, acupuncture, and applied Surgeons 2003;196:525–30.
kinesiology, but their role remains unclear
• In uncommon cases where breast pain is caused by large cysts or fibroadenomas, AFP

aspirating or removing these can relieve the discomfort Correspondence

144Reprinted from Australian Family Physician Vol. 34, No. 3, March 2005
 Patient education • CLINICAL PRACTICE

Breast pain
The New South Wales Breast Cancer Institute.

B reast pain (mastalgia) is so common it is Chest wall pain Oral contraceptive pill
considered to be a normal bodily process Pain that is felt in the breast doesn’t always Some women with cyclical mastalgia find
rather than a disease. Some women experi- originate from the breast tissue. Nonbreast their symptoms improve on a low dose oral
ence severe discomfort due to the causes of breast pain include chest wall pain contraceptive pill. Other women find that
extremes of these normal changes. Breast from muscles, ribs, and ligaments. This pain the contraceptive pill worsens their symp-
pain may be accompanied by breast tender- may occur after an injury or physical activity, toms. You may wish to discuss a trial of the
ness, lumpiness, fullness, heaviness, or a or it may be unexplained. Treatment consists pill with your GP.
noticeable increase in breast size. It is not of rest and pain medication eg. paracetamol
Complementary therapies
usually a sign of breast cancer or other or anti-inflammatory tablets. Heat treatment
breast disease. It is important to see your and physiotherapy may also help. Other treatments such as relaxation
GP to exclude causes of breast pain that therapy, acupuncture, and applied kinesiol-
require specific treatment.
Managing breast pain ogy have been tried, but their role remains
Keep a pain chart unclear.
Breast pain related to your menstrual
Mapping the pattern of pain will determine
cycle Other medication
whether the pain is cyclical, and on which
Most breast pain varies in its intensity days symptomatic relief may be required. For severe cases of mastalgia that interfere
with the menstrual cycle (it is ‘cyclical’). with lifestyle, there are strong hormonal
Wear a well fitting bra
It can cause discomfort, fullness, and medications such as danazol and tamoxifen.
heaviness in the breasts, increasing pro- A well fitting and supportive bra (eg. a sports These may have significant side effects and
gressively from the middle of the menstrual bra) can significantly reduce breast pain. their use needs to be strictly monitored by
cycle and peaking 3–7 days before each Have a bra specially fitted by trained staff. your GP in consultation with a specialist.
period. The pain is relieved when the Diet and vitamin supplements Pain caused by benign (noncancerous)
period begins. While there is no strong evidence that spe- breast disease
cific dietary changes such as reducing If breast pain is caused by cysts or fibroade-
Breast pain not related to your
caffeine intake and the use of supplements nomas, aspirating or removing these can
menstrual cycle
such as vitamins B1, B6, and E improve relieve the discomfort.
Breast pain that doesn’t vary with the symptoms, some women may find them
menstrual cycle is called ‘noncyclical’. beneficial. Evening primrose oil is helpful for
Most women find that their pain
The pain can be random and intermittent, many women. Your doctor can discuss the
improves over some months with the
or continuous. It can have a burning, appropriate dose and length of treatment.
measures discussed above.
stabbing, or throbbing characteristic. Often Your GP will discuss the best
Pain medication
no cause can be identified for this type treatment options with you and
of breast pain. In some cases it can Simple pain medication such as paracetamol monitor your symptoms.
be caused by benign breast changes such can reduce mastalgia. This is of particular
as cysts, fibroadenomas, and age related benefit for women who get cyclical mastal-
changes in the milk ducts under the nipple. gia that is only present for a few days each
Symptoms such as a breast lump or nipple month. Topical anti-inflammatory medica-
discharge, especially if bloodstained, need tion in the form of gel applied over the Adapted from: ‘Mastalgia’ fact sheet. The NSW
to be investigated promptly. tender areas may be effective. Breast Cancer Institute www.bci.org.au

Reprinted from Australian Family Physician Vol. 34, No. 3, March 2005  145