Breast Pain

by Christopher Yu, MD, PhD, and James Chalfant, MD

Breast pain is an extremely common symptom experienced by 70-80% of women within their lifetimes. Unfortunately, it can significantly impact quality of life and provoke fear of underlying malignancy, often resulting in referral for diagnostic imaging. Fortunately, the causes of  breast pain are typically benign and multiple studies have demonstrated a low association of pain with malignancy.

The imaging work up for breast pain should begin with identifying coexisting abnormalities such as a palpable mass, skin changes, edema, or nipple discharge. If present, then imaging is generally warranted and should be tailored to that abnormality with pain considered as a secondary non-specific symptom. Imaging workup for these abnormalities may be pursued according to the American College of Radiology (ACR) Appropriateness Criteria(1).

In the absence of additional symptoms, isolated breast pain should be categorized as either clinically significant (focal and persistent pain involving < 25% of the breast and axillary tissue) or clinically insignificant (cyclical/temporally associated with the menstrual cycle, non-focal/diffuse, and can be either unilateral or bilateral).

As per the ACR Appropriateness Criteria for breast pain, imaging evaluation is usually appropriate for clinically significant pain to exclude an unlikely cancer as the cause of pain, to determine a treatable benign etiology, or to reassure the patient that there is no imaging abnormality present(2). Imaging of clinically insignificant pain is usually not appropriate.

Common visualized etiologies of breast pain include cysts, fibroadenomas, fat necrosis, and duct ectasia with or without debris. Less common causes include Mondor disease and diabetic mastopathy. Treatment can then be tailored to the underlying findings with medical or surgical management. Particularly, cysts can be treated by aspiration.

Frequently, no cause for isolated pain is visualized. Some common etiologies in this setting are hormonal variations, large breast size, an ill-fitting or unsupportive bra, low levels of fitness or activity, sequela from prior surgery, and/or referred pain from another organ system. In these circumstances, it is prudent for the radiologist to advise the patient that if new signs or symptoms develop (e.g. a palpable abnormality) or the nature of the pain should change then they should alert their primary care physician to determine if repeat imaging is warranted.

In cases where imaging is normal, some patients remain anxious and concerned about a potential for underlying malignancy, leading to repeated clinical and imaging follow-up. According to one study, there was 100% negative predictive value and 100% sensitivity for detecting malignancy in isolated pain with both mammography and ultrasound(3). In a review across multiple studies, the incidence of detecting malignancy in patients presenting with isolated clinically significant breast pain was < 0.5%. Moreover, some studies have shown the incidence of detecting malignancy in those with breast pain was below the incidence in that of a general screening population (4). Thus, reassurance during the diagnostic consultation is important to help educate and minimize anxiety.

A few special cases of breast pain deserve special mention.

For transgender individuals, breast pain should be evaluated with consideration of the sex-assigned at birth and the transgender sex. Breast tissues in transgender females are subject to similar breast pathologies as cis-gendered females. Breast-related interventions (such as hormonal treatment and breast augmentation for transgender females and chest binding and mastectomy for transgender males) can also result in breast pain(5).

In male patients, breast pain is generally uncommon but may occur with gynecomastia and hormonal imbalances. If breast pain is an isolated finding and the exam is consistent with gynecomastia, breast imaging is usually not appropriate (6).

In breastfeeding women, breast pain is very common. Common causes include engorgement, milk stasis, candidiasis, nipple eczema, vasospasm of the nipple, ankyloglossia (tongue-tie) of the newborn, trauma, dermatitis, HSV outbreaks, or mastitis. Imaging is generally not necessary for isolated breast pain during lactation but is warranted if the pain is persistent or accompanied with other signs and symptoms such as inflammatory changes concerning for mastitis and abscess.

References

1. Holbrook AI, Moy L, Akin EA, et al. ACR Appropriateness Criteria^® Breast Pain. J Am Coll Radiol. 2018 Nov;15(11S):S276-S282. DOI: 10.1016/j.jacr.2018.09.014. PMID: 30392596.
2. Jokich PM, Bailey L, D'Orsi C, et al. ACR Appropriateness Criteria BreastPain. J Am Coll Radiol. 2017 May;14(5S):S25-S33. DOI:10.1016/j.jacr.2017.01.028. PMID: 28473081.
3. Leddy R, Irshad A, Zerwas E, et al. Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump. Breast J. 2013 Nov-Dec;19(6):582-9. DOI: 10.1111/tbj.12178. PMID: 24011215.
4. Holbrook AI. Breast Pain, A Common Grievance: Guidance to Radiologists. AJR Am J Roentgenol. 2020 Feb;214(2):259-264. DOI: 10.2214/AJR.19.21923. PMID: 31799872.
5. SivarajahR, WelkieJ, MackJ, et al. A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment, Journal of Breast Imaging, Volume 2, Issue 2, March/April 2020, Pages 101–111. DOI:10.1093/jbi/wbz082
6. Niell BL, Lourenco AP, Moy L, et al. ACR Appropriateness Criteria^® Evaluation of the Symptomatic Male Breast. J Am Coll Radiol. 2018 Nov;15(11S):S313-S320. DOI: 10.1016/j.jacr.2018.09.017. PMID: 30392600