Figure 1. Algorithm for managing breast pain

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At a glance

  • The etiology of breast pain is multifactorial. An understanding of breast anatomy and physiology is essential to the management of mastalgia.
  • During a breast examination, look for symmetry, skin changes (i.e., dimpling, retraction, or lesions), architectural distortion, and changes in upper-extremity mobility.
  • When breast cancer is ruled out, reassurance alone will result in resolution of the symptom in 86% of women with mild pain and in 52% of women with severe pain.
  • Side effects associated with the various pharmacologic approaches to the management of breast pain make them a less appealing treatment option.

Breast pain is one of the most common problems for which women consult primary-care providers, gynecologists, and breast specialists. Women often think that breast pain indicates cancer, causing them significant anxiety. In reality, the prevalence of women presenting with mastalgia who actually have breast cancer is 1.2%-6.7%.1 In our breast-specialty practice, an estimated one third of the women referred have breast pain.

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Unfortunately, options for evidence-based practice for the management of breast pain is sparse in the literature.2 To better serve this patient population, we have created a comprehensive algorithm to guide clinicians in the management of breast pain (download Figure 1 PDF). This algorithm is based on research, personal practice, and anecdotal literature.

Since the etiology of breast pain is multifactorial, an understanding of breast anatomy and physiology (Figure 2) is essential to the management of mastalgia. The breasts are paired mammary glands located on the anterior chest wall, superficial to the pectoralis major and serratus anterior muscles. The female breast is composed of glandular and fibrous tissue and subcutaneous and retromammary fat. The glandular tissue of each breast is arranged into 15 to 20 lobes that radiate around the nipple. Each lobe is composed of 20 to 40 lobules. A lactiferous duct drains milk from each lobe to the surface of the nipple.

What treatment are you most likely to recommend for breast pain that does not resolve on its own?

Vascular supply to the breast is provided primarily through branches of the internal mammary artery and the lateral thoracic artery. These branches supply blood to the deeper tissues of the breast and nipple. The intercostal arteries help supply the superficial tissues.