Breast pain: Not just a premenopausal complaint

Menopause has come and gone. Why do I still have breast pain?

In most cases, breast pain is a by-product of reproductive life: Like breast swelling, it waxes and wanes during the menstrual cycle, and it's one of the first symptoms of pregnancy. Many women expect breast pain to go away after menopause. When it doesn't, they may fear they have breast cancer. Fortunately, breast pain is rarely a symptom of cancer, regardless of age. Still, that possibility should be considered, along with a number of noncancerous conditions that affect the breasts.

Types of breast pain

Breast pain, sometimes referred to as mastalgia, is either cyclical (the most common type) or noncyclical.

Cyclical breast pain. This is the kind that's linked to menstruation and apparently results from monthly fluctuations of the hormones estrogen and progesterone. Although studies have not found any hormonal abnormality that explains cyclical breast pain, we know that estrogen and progesterone have a stimulating effect, increasing the size and number of ducts and milk glands (lobules) and causing the breast to retain water.

A few days before menstruation, both breasts may swell and become tender, painful, or lumpy. The pain may extend to the upper and outer portions of the breast, the armpit, and the arm. The symptoms subside when menstruation ends. Cyclical pain may worsen during perimenopause, when hormones can surge and drop erratically, and linger into menopause, especially in women who use oral contraceptives or hormone therapy.

Noncyclical breast pain. This type of breast pain isn't obviously linked to menstruation and doesn't follow any predictable pattern. It may be constant or intermittent, may affect one breast or both, and may involve the whole breast or just a small part. Noncyclical pain is usually a symptom of a specific problem, such as a cyst, trauma, or a benign tumor. Several conditions affecting the chest wall, esophagus, neck and upper back, and even the heart can produce symptoms that are felt as breast pain.

Some research suggests that an imbalance in fatty acids within cells plays a role in breast pain, perhaps by sensitizing breast tissue to hormonal changes.

Fibrocystic changes in breast tissue may cause cyclical or noncyclical pain in one or both breasts. Women with this very common condition have thickened tissue or an increased number of cysts in otherwise normal breasts.

Anatomy of the breast area

Breast pain unrelated to menstrual cycles may be caused by conditions that affect the pectoralis major muscle, structures within the breast, and the ribs or sternum.

Causes of noncyclical breast pain

Several other conditions can cause breast pain that's not related to the menstrual cycle.

Infection. Infection of the breast (mastitis) or an abscess can cause severe pain. Mastitis is most common in lactating women, but it can occur at any age. Nursing or chafing from clothes can irritate the skin overlying the nipple — possibly allowing bacteria to enter and infect the breast. Mastitis causes fever and breast swelling, redness, and tenderness.

Injury. Any trauma to the breast (including breast biopsy or surgery) can cause localized pain that may last for weeks or months. Occasionally, trauma causes inflammation and a clot in a superficial vein of a breast (thrombophlebitis) that results in pain and swelling but rarely anything more serious.

Medications. Some prescription medications can also cause breast pain. Apart from hormone drugs, the most common culprits are certain cardiovascular and psychiatric medications.

Cancer. Breast pain is rarely a symptom of cancer. Only 2%–7% of women with noncyclical pain at one spot on the breast will receive a cancer diagnosis related to breast pain.

Support problems. Heavy, pendulous breasts may stretch ligaments and tissues in the breast, causing pain in the shoulders, back, neck, and breasts. Breast reduction surgery may ease these symptoms in some women, but it can also cause breast pain if tissue is injured during the procedure.

Conditions outside the breast. Strain in the pectoralis major muscle, which lies directly beneath and around the breast, can cause pain that feels as if it's coming from inside the breast. Activities that strain the pectoralis muscle include raking, shoveling, and lifting.

Costochondritis — an inflammation of the costal cartilages which join the ribs to the breastbone — can cause a burning sensation in the breast. (Tietze's syndrome, a variation of costochondritis, causes painful swelling near the sternum.) Breast pain may be a symptom of connective tissue disease, such as Ehlers-Danlos syndrome, an inherited disorder. Arthritis in the neck or upper back may affect sensory nerves exiting the upper spinal cord and cause numbness or pain in the breast.

Shingles is an outbreak of a painful rash on one side of the body caused by reactivation of the chicken pox virus (herpes zoster). Breast pain can occur if the rash affects a breast.

Occasionally, pain arising from heart disease or inflammation of the heart muscle, gastroesophageal reflux disease (GERD), or inflammation of the tissues lining the lungs (pleuritis) may be felt as breast pain.

How breast pain is evaluated

It's important to discuss any breast pain with your clinician. She or he will take a careful history to try to rule out any conditions outside the breast. Your risk for breast cancer will also be assessed, including a breast examination and a check of your chest wall and underarms. Your neck, shoulders, and upper back may also be evaluated. If you haven't had a recent mammogram, your clinician may order one, as well as an ultrasound if a lump is found.

Treating breast pain

Breast pain can be treated when it's severe and debilitating or, if you're premenopausal, when it occurs more often than a few days each month.

Treating conditions. For breast pain arising from pectoralis muscle strain, costochondritis, or arthritis in the spine, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) may help, along with stretching, yoga, or neck rotation exercises. Mastitis requires antibiotics, as does an abscess, which will also need to be drained. Draining may also relieve a painful breast cyst (a benign, fluid-filled sac).

Lifestyle approaches. It usually helps to wear a well-fitting, supportive bra and a sports bra for exercise (and, when the pain is particularly severe, for sleep). Although there is no proof that caffeine or nicotine causes breast pain, many women report relief from avoiding both. Some research has shown that a very-low-fat diet (15%–20% of daily calories from fat) can reduce breast tenderness and swelling. Other local treatments include ice packs, warm compresses, or massage, and occasional use of NSAIDs or acetaminophen.

Supplements and medications. Although the data are inconsistent, there's some evidence that both cyclic and noncyclic mastalgia are modestly improved by evening primrose oil, which contains gamma-linolenic acid (an essential fatty acid). Some women report symptom relief from fish oil supplements, which contain other fatty acids. Vitamin E has demonstrated no benefit in controlled trials.

Three medications — danazol, tamoxifen, and bromocriptine — have been shown to relieve breast pain, but these drugs can cause serious side effects and are typically reserved for breast pain that is severe and doesn't respond to more conservative treatments.