Experiencing Breast Pain? It May Mot be as Scary as You Might Think

Breast Pain Explained 

Breast pain is a common complaint and often leads to a high level of anxiety in women concerned they are developing breast cancer.  Fortunately, symptoms of breast pain are almost always related to non-cancerous causes.  Although breast pain is rarely associated with breast cancer, all new breast symptoms, including breast pain, should be evaluated by your primary care physician with a clinical breast exam.  As discussed for evaluation of new breast lumps, your primary care physician will likely send you to an imaging center for a diagnostic mammogram and possible ultrasound evaluation of the breast pain.  Diagnostic breast imaging to evaluate breast pain is similar to the imaging performed when a woman feels a new lump in the breast or is called back for further evaluation of an abnormal screening mammogram.

Causes and Types of Breast Pain

Common Causes of Breast Pain

I use breast pain as a general term to include sharp breast pain, breast discomfort, and breast tenderness.  As I said before, most cases of breast pain are not related to breast cancer.  In my practice, the most common causes of breast pain are related to changing hormone levels (estrogen and progesterone).  In order for the female body to menstruate, the hormones in our body go through a cycle every month.  These fluctuating hormones may also stimulate breast tissue, resulting in pain.

The most common time that a woman will experience breast pain associated with her menstrual cycle is the week before menstruation.   The amount of pain, the location of the pain, and the type of pain may vary from month to month.  Being aware of when the breast pain occurs in regard to your menstrual cycle can go a long way in reassuring you that the breast pain is likely hormone-related, even if the quality of the pain changes over time.

Breast Pain During Perimenopause and Menopause

Other Causes of Breast Pain

In addition to hormones, a few of the more common causes of breast pain include caffeine consumption and certain medications.  Finally, breast cancer may very rarely present with breast pain.  In the case of breast cancer, the breast pain is often noticed in conjunction with other symptoms, including a breast lump or skin changes. However, breast pain is generally not felt at all until cancer grows past 2 cm in size (0.8 inches).  Even in cases of breast cancer greater than 2 cm in size, breast cancer is most often pain-free.

Evaluation and Workup of Breast Pain

As a breast radiologist, my primary focus is to ensure that breast pain is not caused by breast cancer. Given this, I approach breast pain differently depending on the location and quality of the breast pain.

Focal vs. Non-Focal Breast Pain

• Focal breast pain: you can place one finger to localize the site of pain.
• Non-focal breast pain: Any breast pain described as intermittent, involving a larger than the pinpoint area of the breast, shooting pain, pain involving both breasts or migratory pain (pain that moves around).

Why the distinction?

Non-focal breast pain is most commonly associated with hormonal changes (menstrual cycle or menopause).   My level of suspicion for breast cancer with this type of pain is minimal, therefore I limit the amount of imaging I will perform to evaluate the breast pain.

Although rare, if there is breast pain associated with breast cancer, it is most likely going to be focal breast pain.  Therefore, I evaluate focal breast pain in the same way I evaluate breast lumps.

Guidelines for Breast Pain Evaluation

Here is a general guideline of how I may approach a workup of breast pain based on age and the quality of breast pain.  Please note that this is meant to serve as a general guide, and evaluation of breast pain will likely vary between facilities depending on the protocols of the imaging facility.

• Female < 30 years old with NON-focal breast pain:

  • Targeted breast ultrasound to evaluate the quadrant of the breast where the breast pain is most concentrated.

• Female < 30 years old with FOCAL breast pain:

  • Targeted breast ultrasound at the site of focal breast pain.
  • If a finding suspicious for cancer is seen by ultrasound, mammography will be performed to completely evaluate both breasts.

• Female 30-39 years old with NON-focal breast pain:

  • Mammogram of both breasts to provide a baseline mammogram which will serve as a comparison for future mammograms.
  • Targeted breast ultrasound will only be performed if a suspicious finding is seen on the mammogram.

• Female 30-39 years old with FOCAL breast pain:

  • Mammogram of both breasts to provide a baseline mammogram which will serve as a comparison for future mammograms.
  • Additional mammogram images including 3D mammography and/or “spot compression” views may also be obtained.
  • Targeted breast ultrasound at the site of focal pain. At my facilities, we do not evaluate the entire breast with ultrasound, we only evaluate the area of the breast at and around the area of focal pain.

• Female > 40 years old with NON-focal breast pain:

  • > 12 months since the last screening mammogram, a mammogram of both breasts will be obtained to keep you on track for annual screening.
  • < 12 months since the last screening mammogram, only the symptomatic breast will be evaluated with a mammogram.
  • Targeted breast ultrasound will only be performed if a suspicious finding is seen on the mammogram.

• Female > 40 years old with FOCAL breast pain:

  • > 12 months after the last screening mammogram, a mammogram of both breasts will be obtained to keep you on track for annual screening.
  • < 12 months since the last screening mammogram, only the breast with focal pain will be evaluated with a mammogram.
  • Additional mammogram images, including 3D mammography and/or “spot compression” views, may also be obtained.
  • Targeted breast ultrasound at the site of focal pain.
• Men of all ages who have new breast pain will be evaluated with a mammogram of both breasts, along with an ultrasound of the area only if focal pain is present.

Rest assured, the most common causes of breast pain are not related to breast cancer. That being said, I strongly encourage all patients to discuss any new breast symptoms, including breast pain, with their primary care physician. Although your doctor may be able to determine the most likely cause of breast pain based on your age and the timing of the symptoms, exclusion of breast cancer as the cause is also recommended with breast imaging.

Written by Danielle Carroll, M.D.

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