Subcutaneous and retromammary fat surrounds the glandular tissue and constitutes most of the bulk of the breast.3 Stimulation of breast tissue by hormone fluctuations during the menstrual cycle may cause breast pain. Hormonal changes associated with ovulation can stimulate the proliferation of glandular breast tissue, resulting in breast swelling during the luteal phase of the menstrual cycle. For most women, this causes minor discomfort. Typically, breast pain is categorized as cyclical, noncyclical, or musculoskeletal (Table 1).

Cyclical mastalgia is more severe and persistent.4 Women with cyclical mastalgia have higher mean luteal levels of luteinizing hormone and follicle-stimulating hormone,5,6 but research has not found a consistent abnormality of estradiol levels in these women.7,8 Breast pain can also arise from the myofacia.

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Evaluation of breast pain begins with a comprehensive health history, which should include type of pain, relationship to menses, duration, location, impact on activities of daily living, factors that aggravate and alleviate pain, and any other medical problems and comorbidities. Check the patient’s medications carefully, including use of alternative therapies and herbal remedies.

Physical examination should include a thorough evaluation, taking into consideration any medical conditions that might contribute to breast pain. A complete breast examination begins with the patient in a seated position. Look for symmetry, skin changes (i.e., dimpling, retraction, or lesions), architectural distortion, and changes in upper-extremity mobility. This is a good time to check underneath the breasts for yeast infections and skin nodules as well.

Palpation is usually performed with the patient in a supine position. Start with gentle palpation or a sweeping technique before moving on to deeper palpation using a vertical stripping method. Be sure to check the underlying ribs and costal cartilage.9 Additional information regarding breast examination is available at the American Cancer Society website.

Using the findings from the health history and breast examination, the practitioner is now guided by the algorithm to manage breast pain.

In the absence of a discrete mass and in younger women, mammography is not routinely used in clinical evaluation. Ultrasound is also unlikely to provide useful information. Clinicians in our practice, however, use focused ultrasound at the area of point tenderness to check for an incidental finding that may be causing the mastalgia (e.g., a cyst) and to reassure the patient. MRI is not ordered to evaluate breast pain. Of course, any palpable breast lump requires triple assessment (clinical breast exam, diagnostic study and biopsy for pathology).

If clinical breast examination and diagnostic studies fail to identify an abnormal lesion, treatment options for breast pain can be employed.

The initial approach begins with reassurance. 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.10 Other recommendations include alteration of dietary factors, such as reducing caffeine, salt and saturated fat intake. Broad lifestyle recommendations can also improve comfort and overall quality of life.11-14