Breast Pain
Division of the breast anatomically into various components is
interesting but not worthwhile in the differential diagnosis of breast pain.
It is rather more instructive and practical to use VINDICATE in
developing a list of causes of this symptom.
V—Vascular infarction in this area is rare, although a pulmonary or
myocardial infarction may refer pain to the breast, and congestive heart
failure may distend the veins of the breast sufficiently to cause mastitis.
I—Inflammation in the form of acute bacterial mastitis occurs in
breastfeeding mothers, but it is infrequent. Under other circumstances,
chronic cystic mastitis is a common cause of unilateral or bilateral breast
pain. A breast abscess may develop during lactation. Herpes zoster may
affect the skin and nerve roots supplying the breast.
N—Neoplasms of the breast, like neoplasms elsewhere, are an unlikely
cause of breast pain, but if they infiltrate the skin (i.e., in Paget
disease) or axillary nerves or obstruct the ducts they may cause pain.
D—Degenerative conditions are rarely a cause of breast pain.
I—Intoxication. A number of drugs (e.g., chlorpromazine and α -methyldopa)
may cause gynecomastia and pain. Alcoholism, estrogen, and birth control
pills are probably more frequent causes.
C—Congenital anomalies are not a significant cause of breast pain.
A—Allergic-autoimmune conditions are also unlikely causes of breast
pain.
T—Trauma from a bite on the breast by a feeding infant is a common
cause of acute mastitis and pain. Frequent sexual relations and masturbation
of the breasts may induce pain, although some women are reluctant to admit
that their breasts have been traumatized this way.
E—Endocrine causes of breast pain are numerous. Menstruation,
menarche, pregnancy, and menopause are associated with bilateral swollen and
painful breasts. Hyperestrogenemia from
endogenous or exogenous sources is also a frequent cause. Estrogen from
birth control pills, estrogen therapy for menopause, and the increase of
blood estrogen in chronic liver disease and ovarian tumors are a few of the
etiologies in this group. Any pituitary condition associated with an
increased output of prolactin may cause swollen, painful, and, of course,
lactating breasts. The Chiari–Frommel syndrome is one of these
conditions.
Approach to the Diagnosis
The diagnosis of a painful breast is usually made by taking a careful
history. What drugs is the patient taking? Associated symptoms and signs
(see sections on bloody discharge, page 306 and swelling, page 74) are
also important. A culture of the discharge, mammography, and determination
of serum, estrogen, and prolactin levels
may be important, but referral to an endocrinologist is wise when the
history does not provide a simple solution, especially when the pain is
bilateral. Biopsy (frozen section) is necessary when tumor is suspected and
mammography is equivocal, because faith in mammography has declined somewhat
in recent
years.
Other Useful Tests
-
CBC (infection)
-
Sedimentation rate (infection)
-
Chest x-ray (metastasis)
-
CT scan of the brain (pituitary adenoma)
-
Sonogram (cyst)
-
Aspiration (cyst)
-
Discontinuation of suspicious drugs
-
Pregnancy test
-
Surgery consult
