Initial Approach

History is very important in the assessment:

• Cyclical exacerbation
• Frequency
• Duration
• Exacerbating or relieving factors (night pain? Analgesic use?)
• Lifestyle alterations (caffeine intake, bra fitting, night support bra)
• Beliefs: what has caused them to present? Often it is a false worry of cancer and can be reassured

Examination assesses the cause and need for imaging. Check for infection. Often the pain is found to be coming from the rib cage or costochondral junction. Imaging should be used according to Algorithm B attached. Focal signs indicating imaging are

• Localised tenderness
• Nodularity
• Swelling
• Lump

And Algorithm A should be followed.

True Breast Pain

Cyclical – this may be persistent throughout the cycle but will still have a pre-menstrual exacerbation. Confounding factors such as mirena coil and injectable contraception may co-exist.

Treatment:

• Reassure
• Lifestyle measures (reduce caffeine, reduce dietary animal fats)
• 2 week course paracetamol +/- Ibuprofen or ibuprofen gel over tender areas
• Carefully measured Bra (Bravissimo, M&S, Debenhams)
• Evening Primrose Oil – works in 50% ? placebo!

Give written information and refer back to GP. Offer option of Danazol 100mg BD if other measures do not work, but warn them of side effects (hirsuitism, deep voice) which may not be reversible. Hardly anyone wants it!

Mondor’s Disease

Superficial thrombophlebitis. This may occur spontaneously or secondary to trauma or surgery. A groove is usually visible in the breast and the vein felt as a cord like structure. NSAIDS are the appropriate treatment.

Non Breast Pain

This is usually muscloskeletal. There might be point tenderness arising from the chest wall. Lie the patient on their side and move the breast out of the way and the tenderness stays fixed. There may well be still some pain the breast but most of the tenderness arises from the chest wall. Medially and inferiorly this is attributed to Teitze’s syndrome or costochondritis whereas laterally it is referred to as lateral chest wall syndrome. Some musculoskeletal pain in the breast is infact referred to the breast from the shoulder neck or thoracic spine: the history will suggest this and there will be no local tenderness. Treatment is symptomatic and reassurance that this does not represent serious breast pathology. A 2-4 week course of anti-inflammatories as above usually sorts the problem.