A guide to breast pain
Autore:I frequently consult with women across the UK who experience breast pain (BP), and over the years, my understanding of how to explain its causes and treatment has evolved. In a one-stop breast clinic, my primary objectives are to communicate effectively and offer reassurance grounded in the most up-to-date medical evidence.
Breast pain (BP) is often compared to the ‘common cold.’ It affects around 70-80% of women who visit a one-stop breast clinic, yet in the majority of cases, a specific cause is not identifiable. This is because BP is multifactorial. While we do not yet fully understand whether certain genes predispose individuals to benign breast conditions, it is likely that other female members of a person’s family have experienced similar symptoms. BP is not considered a risk factor for breast cancer, and the condition is extremely rare in association with cancer, occurring in approximately 0.4–0.8% of cases. Breast density (increased amounts of breast tissue) is a recognised risk factor for breast cancer and may also be linked to chronic BP that lasts between three to eight years. Additionally, a larger breast volume may contribute to BP due to the increased strain it places on the connective tissue ligaments. BP can begin suddenly in women in their 30s or 40s, with only 15% of cases occurring in post-menopausal women.
Overall, breast pain is a benign condition with no obvious singular cause. However, it still warrants evaluation by a healthcare professional.
Cyclical BP – 70% of women (onset in 30s)
This type of BP is described as “coming and going” (cyclical) and serves as an indicator of recurring BP later in life, typically until menopause. It tends to affect the entire breast, presenting in multiple locations. This form of BP is believed to result from the increased hormonal sensitivity of normal breast tissue, though the exact cause remains unclear. Blood hormone levels are typically normal, and there is no evidence of breast disease.
Possible contributing factors include:
- Hormonal stimuli: Hormonal medications, oral contraceptives, infertility treatments, pregnancy, breastfeeding, and hormone replacement therapy (HRT)
- Medications: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs)
Up to 20% of BP will resolve within three months, and 60% of BP will recur within three years.
Older onset BP – 25% of women (onset in 40s)
This type of BP is more constant and usually localised to a specific ‘trigger spot’ or a single area, particularly in the central nipple region and lower inner breast. It is more likely to be ‘inflammatory,’ not due to bacterial infection but as a result of a ‘chemical phenomenon’ that occurs in ageing breast ducts. As the walls of the breast ducts (milk ducts) thin, they can dilate, causing ‘duct ectasia.’ Chemical inflammation in the ducts, caused by stagnant secretions, may lead to localised BP.
Constant BP is generally not hormonal, and 50% of cases resolve on their own.
Why might BP occur in only one breast?
Embryology, or the development of the human embryo, provides a logical explanation. Our bodies develop in two symmetrical halves, extending from the spine to the front and joining at the midline. However, perfect symmetry is rare—this is true for our face, hands, feet and breasts! Each milk duct line is developmentally separate, extending from the armpit to the groin on the right and left sides, respectively. Consequently, our breasts are not identical in size, shape, or the amount of tissue they contain, nor are they always identical in their biochemical responses to certain triggers.
In fact, most BP occurs in one breast only—76% of cases, with 24% affecting both breasts.
Treatments
A thorough review of all randomised trials on treatments for BP has provided clear evidence supporting the following recommendations:
First-line treatment for BP: Topical Voltarol gel, a non-steroidal anti-inflammatory, has proven far more beneficial compared to unwanted side effects. One clinical trial showed that its use resulted in a 70-92% reduction in pain.
Second-line treatment: Selective Oestrogen Receptor Modulators (SERMs). Raloxifene, which has been shown in trials to prevent breast cancer and treat osteoporosis, acts by selectively blocking the oestrogen receptor. The recommended dose for BP is half the dosage used in osteoporosis treatment (30 mg orally, daily) for six months, with BP reduction of up to 92%.
Another SERM option is Tamoxifen, commonly used to treat breast cancer. It can be administered at half the usual dose (10 mg orally, daily) for six months. However, Tamoxifen is less effective than Raloxifene (45% versus 92%) and has more potential side effects.
Neither Raloxifene nor Tamoxifen is officially registered for the treatment of BP, despite their effectiveness in clinical trials. Raloxifene is the preferred second-line choice for severe BP, as it is associated with fewer side effects than Tamoxifen.
Both treatments should only be considered under the supervision of a surgeon and only in cases where Voltarol gel is ineffective or BP is severe enough to affect a woman’s quality of life.
If you are experiencing breast pain, it’s important to consult a doctor or healthcare professional for further evaluation.
References
- Goyal A BMJ Clin. Evid. 2011 Jan 17; 2011: 0812.
https://pubmed.ncbi.nlm.nih.gov/21477394/ - Jokich P J Am Coll Radiol. 2017 May; 14(5S): S25-S33.
https://pubmed.ncbi.nlm.nih.gov/28473081/ - Hafiz SP, Barnes NLP, Kirwan CC. Clinical management of idiopathic mastalgia: a systematic review. J Prim Health Care. 2018 Dec;10(4):312-323.
https://pubmed.ncbi.nlm.nih.gov/31039960/
