Breast Tenderness (Mastalgia): Causes, Relief & When to Seek Care

Breast tenderness (mastalgia) affects up to 70% of women. Understanding patterns guides appropriate management.

Types & Causes

Cyclical Mastalgia (Most Common: 2/3 of cases)

• Timing: Luteal phase (1-2 weeks pre-menses), resolves with menses
• Mechanism: Estrogen/progesterone → ductal/glandular proliferation, edema, inflammation
• Features: Bilateral, diffuse, heavy/aching, upper outer quadrants
• Age: 20s-40s; resolves at menopause

Non-Cyclical Mastalgia

• Pregnancy: Early sign (4-6 weeks); bilateral, intense, with nipple sensitivity
• Breastfeeding: Engorgement, latch issues, mastitis, plugged ducts
• Medications: OCPs, HRT, SSRIs, digitalis, spironolactone, methyldopa
• Structural: Cysts, fibroadenomas, duct ectasia, Mondor's disease
• Trauma: Injury, surgery, biopsy site
• Referred: Costochondritis (Tietze), cervical radiculopathy, thoracic outlet
• Lifestyle: Caffeine, high-fat diet, ill-fitting bras, stress

Red Flags (Require Prompt Evaluation)

• Unilateral, persistent, localized pain
• Palpable mass, skin dimpling, nipple retraction/discharge (esp. bloody)
• Progressive worsening unrelated to cycle
• Age >40 without recent imaging
• Male breast pain (always evaluate)

Management Strategies

Conservative (First-Line)

• Supportive bra: Professional fitting; sports bra for exercise; sleep bra if nocturnal pain
• Dietary: Reduce caffeine, methylxanthines; low-fat, high-fiber; omega-3 supplementation
• Supplements (evidence varies): Evening primrose oil (GLA) 3g/day; Vitamin E 400-800 IU; Vitamin B6 100-200mg
• Topical NSAID: Diclofenac gel 1% TID
• Oral NSAIDs: Ibuprofen 400mg q6h prn
• Warm/cool compresses

Medical (If Conservative Fails ≥3 months)

• OCP adjustment/change (if cyclical)
• Dopamine agonists (bromocriptine, cabergoline) - specialist only, side effects
• Danazol (androgenic) - second-line, significant SEs
• Tamoxifen (low-dose) - refractory cases, off-label

Diagnostic Imaging

• Diagnostic mammogram + targeted ultrasound: For focal pain, mass, age >30, or abnormal exam
• Screening mammogram: Per age/risk guidelines (not for pain alone)

When to See a Provider

New lump, skin/nipple changes, bloody discharge, unilateral persistent pain, pain interfering with sleep/ADLs, or anxiety about cancer. Most mastalgia is benign, but evaluation provides reassurance and targeted treatment.