Makindo Medical Notes

Breast pain (mastalgia) is a very common symptom in women, accounting for up to 70% of breast clinic referrals in the UK. Most cases are benign and non-cancerous, often related to hormonal fluctuations or benign breast disease. ⚠️ However, persistent, focal, or unexplained pain may rarely signal breast cancer. 🎯 For students: the aim is to take a clear history, identify red flags, and know when to reassure vs when to refer.

📝 Clinical History

1. ⏳ Onset & Duration: Acute, chronic, or cyclical (linked to menstrual cycle). ➡️ Rapid onset with fever/swelling → infection. ➡️ Chronic pain → cysts or fibrocystic change.
2. 📍 Location & Nature: Localised vs generalised; unilateral vs bilateral. Pain character: dull, sharp, throbbing, or burning 🔥 (neuropathic features = referred pain).
3. 📆 Timing & Pattern: 🌀 Cyclical mastalgia = common, bilateral, premenstrual. ⚠️ Non-cyclical, persistent pain → further evaluation.
4. 🔍 Associated Symptoms:
   • Breast lump, swelling, redness, warmth 🟥
   • Nipple changes: discharge 💧, inversion ↩️, ulceration
   • Systemic symptoms: fever 🤒 (infection), weight loss ⚖️ (malignancy)
5. 🧬 Risk Factors:
   • Family history 👩‍👩‍👧 of breast/ovarian cancer (BRCA genes).
   • Past breast problems: lumps, cysts, fibroadenomas.
   • Hormonal exposure 💊: contraceptives, HRT.
6. 💊 Medication History: Some drugs may cause mastalgia — SSRIs, contraceptives, HRT, antihypertensives (methyldopa, spironolactone).
7. 🌱 Lifestyle Factors: High caffeine ☕, smoking 🚬, alcohol 🍷, poorly fitting bras, trauma, or strenuous physical activity 🏋️.

👩‍⚕️ Physical Examination

1. 👀 Inspection: Asymmetry, skin dimpling, erythema, peau d’orange 🍊, nipple inversion/discharge.
2. ✋ Palpation: Examine all quadrants & axillary tail. Note size 📏, shape 🔺, mobility 🔄, and consistency 🧱 of any masses.
3. 🎯 Nipple & Skin Changes: Retraction, eczema (Paget’s disease), ulceration.
4. 🧾 Lymph Nodes: Palpate axillary & supraclavicular nodes for enlargement.

🧪 Investigations

1. 🩻 Mammography: Women >40 or suspicious mass.
2. 🔊 Ultrasound: Best for younger women; distinguishes cystic vs solid.
3. 🧲 MRI: If high suspicion or inconclusive findings.
4. 🧬 Hormones: Oestrogen/progesterone if imbalance suspected.
5. 🧫 FNA / Biopsy: Gold standard for suspicious lumps.

❓ Possible Causes of Breast Pain

• 🌀 Cyclical Mastalgia: Hormonal; bilateral, premenstrual.
• 📍 Non-Cyclical Mastalgia: Localised, persistent → cysts, fibroadenoma, mastitis.
• 👶 Hormonal States: Pregnancy 🤰, contraceptives 💊, HRT.
• 💊 Medication-Related: SSRIs, hormonal therapy.
• 💢 Costochondritis: Chest wall pain mimicking breast pain.
• 🤕 Trauma: Direct injury or strain.
• 🎗️ Breast Cancer: Rarely presents with pain — consider with red flag signs.

🛠️ Management

1. ✅ Reassurance: Benign pain is common. Encourage self-exam 🖐️.
2. 💊 Symptomatic Relief: Warm compresses, NSAIDs/Paracetamol, supportive bra 👙.
3. 🌱 Lifestyle Changes: Reduce caffeine ☕, limit smoking 🚭 & alcohol 🍷.
4. ⚖️ Hormonal Therapy Review: Adjust HRT/contraceptives if needed.
5. 📋 Referral: Breast clinic if suspicious mass, red flags 🚩, or persistent unexplained pain.