Breast Lumps and Pain

Lumps and pain in the breast are common and can have numerous causes.

Breast changes are common. From the time a girl begins to develop breasts, begins menstruating and throughout life, women may experience various kinds of breast pain and other breast changes. Some of these changes normally occur during the menstrual cycle, during pregnancy, and with aging. Breast lumps, tenderness, and other changes may occur. Most breast lumps and other changes are not cancer.

The breast is composed of several glands and ducts that lead to the nipple and the surrounding colored area called the areola. The milk-carrying ducts extend from the nipple into the underlying breast tissue like the spokes of a wheel. Under the areola are lactiferous ducts. These fill with milk during lactation after a woman has a baby. When a girl reaches puberty, changing levels of hormones cause the ducts to grow and cause fat deposits in the breast tissue to increase. The glands that produce milk (mammary glands) that are connected to the surface of the breast by the lactiferous ducts may extend to the armpit area (axilla).

There are no muscles in the breasts, but muscles lie under each breast and cover the ribs. These normal structures inside the breasts can sometimes make them feel lumpy. Such lumpiness may be especially noticeable in women who are thin or who have small breasts.

• Lumps within breast tissue are usually found unexpectedly or during a routine monthly breast self-exam. Most lumps are not cancer but represent changes within the breast tissue. As your breasts develop, changes occur. These changes are influenced by normal hormonal variations.
• Breast pain is a common breast problem in younger women who are still having their periods, and happens less often in older women. Although pain is a concern, breast pain is rarely the only symptom of breast cancer. Most breast cancers involve a mass or lump.
• Cyclic mastalgia: About two-thirds of women with breast pain have a problem called cyclic mastalgia. This pain typically is worse before your menstrual cycle and usually is relieved at the time your period begins. The pain may also happen in varying degrees throughout the cycle. Because of its relationship to the menstrual cycle, it is believed to be caused by hormonal changes. This type of breast pain usually happens in younger women, although the condition has been reported in postmenopausal women who take hormone replacement therapy.
• Noncyclic mastalgia: Breast pain that is not associated with the menstrual cycle is called noncyclic mastalgia. It occurs less often than the cyclic form. It typically occurs in women older than 40 years and is not related to the menstrual cycle. It is sometimes linked to a fibrous mass (called a fibroadenoma) or a cyst.
• Breast pain or tenderness may also occur in a teenage boy. The condition, called gynecomastia, is an enlargement of the male breast which may occur as a normal part of development, often during puberty.
• Breast infection: The breast is made up of hundreds of tiny milk-producing sacs called alveoli. They are arranged in grapelike clusters throughout the breast. Once breastfeeding begins, milk is produced in the alveoli and secreted into tube-shaped milk ducts that empty through the nipple. Mastitis is an infection of the tissue of the breast that occurs most frequently during the time of breastfeeding. This infection causes pain, swelling, redness, and increased temperature of the breast. It can occur when bacteria, often from the baby's mouth, enter a milk duct. This causes infection and painful inflammation of the breast.

Many possible causes exist for pain or tenderness in one of your breasts or both breasts. Most often the pain can be attributed to harmless causes such as puberty or pregnancy. It can also be a recurrent problem for women with cyclical pain associated with the menstrual cycle. Although cancer is a major concern for most women, it is rarely the cause of isolated breast pain.

Some causes of breast pain are:

• Fibrocystic breast disease
• Premenstrual syndrome, cyclic mastalgia
• Normal hormonal fluctuations
• The onset of puberty or menopause
• Pregnancy
• Breastfeeding (nursing)
• Estrogen therapy
• Chest wall tenderness (costochondritis)
• Injury to the breast (trauma, after breast surgery)
• Shingles (pain is only in one breast, usually accompanied by a rash)
• Use of certain medications such as digoxin (Lanoxin), methyldopa (Aldomet), spironolactone (Aldactone), oxymetholone (Anadrol), and chlorpromazine (Thorazine)
• An infection in the breast (breast abscess, mastitis)
• Breast cancer

If you lump your breast, your doctor will check for the following:

• Fibrocystic changes: Fibrocystic changes, previously called Fibrocystic Disease, are the most common benign or harmless (does not threaten health or life) condition of the breast. Changes can occur in one or both breasts, most commonly in the upper and outer sections. You may feel a thickening of the fibrous tissue that supports your breasts. Common lumps, called fibroadenomas, occur during the reproductive years. They feel rubbery and moveable. They often occur with fibrocystic changes.
• Cysts: Breast cysts are fluid-filled lumps. They can be tender, especially before your period.
• Breast cancer: Some lumps may be cancer. Breast cancer is usually associated with the risk factors of age, genetics, or hormones. About 75% of breast cancers occur in women older than 50 years, 23% occur in women ages 30 to 50 years, and 2% occur in women under 30 years of age.
  • Genetics is believed to play a role if your mother or sister (referred to as first-degree relatives) were diagnosed with breast cancer before menopause. You have a two to three times higher risk than the general population of developing breast cancer.
  • Hormonal factors may play a role. If you have had the following conditions, you may have an increased incidence of breast cancer (possibly because of longer exposure to a hormone called estrogen).
    • Had your first period at an early age
    • Had menopause at a later age
    • Have never had a child or your first pregnancy after the age of 30
  • Cancer may also be explained by one of many theories including exposure to viruses, chemicals, radiation, dietary factors, and genes (for example, BRCA-1). No single theory explains all types of breast cancer.

• Breast lump: Although alarming when you find one, most breast lumps are not cancer.
• Breast pain: Most commonly associated with fibrocystic changes, pain may occur in both breasts, though one may be more painful than the other. With fibrocystic changes, the pain occurs about a week before your menstrual period. The pain usually goes away gradually with the onset of your period.
  • Cyclic breast pain is typically most severe before your period and gets better during your period.
    • It is usually described as bilateral (in both breasts), in the upper outer areas of your breast, and is often associated with lumpiness.
    • Women tend to describe this pain as dull, aching, heavy, or sore, and it can radiate to your armpit or even down your arm.
    • The intensity of pain can vary widely with the range of severity from mild to severe enough to limit clothing selections, sleep positions, or hugging.
  • Noncyclic breast pain is typically unilateral (only on one side) with no relationship to your menstrual cycle.
    • This pain may be constant or on and off and irregular. It is described as a sharp, stabbing, burning pain that appears to be right below the area around your nipple.
    • If it is localized and persistent, it may be due to the presence of a fibroadenoma or cyst. But other more serious causes must be ruled out.
• Nipple discharge: May occur from an infection, or cancer, or from very small tumors within a part of the brain called the pituitary gland, which influences secretions from the breast. In cases of infection, the discharge is usually brown or greenish. The color and characteristics of nipple discharge, however, cannot be used reliably as an indicator for, or against, the diagnosis of cancer. Your health care professional can make this assessment.
• Skin changes: In cancer, there is fibrosis (scarring) of underlying breast structures (small ligaments) causing retraction (pulling) of the breast that can lead to dimpling of the skin or flattened or deviated nipples. Cancer may block up the drainage (lymphatics) of the breast, and your skin may take on the appearance of the peel of an orange. Take these symptoms very seriously and see your health care professional if they occur.
• Mastitis: Such breast infections may cause pain, redness, and warmth of the breast along with these symptoms:
  • Tenderness and swelling
  • Body aches
  • Fatigue
  • Breast engorgement
  • Fever and chills
• Abscess: Sometimes a breast abscess can complicate mastitis. Harmless, noncancerous masses such as abscesses are more often tender and frequently feel mobile beneath the skin. The edge of the mass is usually regular and well-defined. Signs and symptoms that this more serious infection has occurred include the following:
  • A tender lump in the breast that does not get smaller after breastfeeding a newborn (If the abscess is deep in the breast, you may not be able to feel it.)
  • Pus draining from the nipple
  • Persistent fever and no improvement of symptoms within 48 to 72 hours of treatment

Call your health care professional as soon as you feel any suspicious lump. You should also consult your doctor if you detect a significant change while doing a monthly breast self-exam.

Breast lumps ideally should be checked about one week after your period starts. Fibrocystic changes in the breast are usually irregular and mobile, and you may find more than one lump. Cancerous tumors are usually hard and firm and do not typically move a great deal.

Call your health care professional if you experience the following:

• You have any abnormal discharge from your nipples.
• Breast pain is making it difficult for you to function each day.
• You have prolonged, unexplained breast pain.
• You have any other associated symptoms that you are worried about. You should see a doctor if you experience any changes in your breasts.
  • Redness
  • Swelling
  • Pain, especially pain that interferes with nursing
  • Drainage from the nipple
  • A mass or tender lump in the breast that does not disappear after nursing
  • Changes in the skin
  • Any of these symptoms with or without fever
• If you are breastfeeding, you should call your doctor if you develop any symptoms of breast infection so that treatment may be started promptly.

If you find a breast mass or lump, you should schedule an appointment with your health care professional who will do a breast examination to check your breasts for irregularities, dimpling, tightened skin, lumps, inflamed or tender areas, and nipple discharge. The areas of each breast and underarms will be examined.

If your doctor finds a lump at this time, you may have a re-examination in two to three weeks. If it is still present, then your doctor may recommend some further testing. The ideal time for the breast examination is seven to nine days after your period.

If the physical examination is normal and no mass is found, laboratory and imaging tests are not usually necessary in women younger than 35 years. Women older than 35 years should probably still have a mammogram unless they have had a mammogram in the past 12 months.

• Mammography is an X-ray technique that looks for changes in the breast. These appear as changes in the shape of the breast or calcifications. Mammograms can see abnormalities that you may not be aware of or that the doctor cannot feel or identify by physical exam.
  • Mammograms are the best tool for the early detection of breast cancer.
  • The test is more sensitive in women over the age of 30. Mammograms detect 85% of cancers, but up to 15% can be missed. Thus, if a suspicious lump is found, and mammography is normal or the doctor cannot distinguish the lesion as having a cancerous appearance, then the doctor may order an ultrasound or fine needle aspiration to be performed. An alternative would be to repeat the mammogram in another 6 to 12 months.
• Ultrasound: If a lump is found, an ultrasound scan helps distinguish between a fluid-filled sac (cyst) in the breast and a solid lump. This distinction is important because cysts are usually not treated, but a solid lump must be biopsied to rule out cancer. In a breast biopsy, a piece of the lump is taken out and tested for cancer.
• Aspiration: If a cyst-like lump is found, fluid may be drawn out of it by suction (aspiration) with a syringe and needle. Examination of the fluid and repeat exams will help your doctor decide what other tests to do.
• Fine needle aspiration: Special techniques of aspiration (drawing out a sample of fluid or tissue with a needle) may be used on certain masses.
• Excisional biopsy: Occasionally, the surgeon may prefer to remove the whole lump and send it for analysis in a lab. In this case, you will be scheduled for surgery to remove the lump.
• If you have a family history of breast cancer, your doctor may also suggest genetic testing to see if you have any genes known to put you at higher risk for breast cancer.

Your doctor will be able to classify your breast pain is cyclic or noncyclic by taking a thorough history. After performing a physical examination, the different causes of noncyclic breast pain can be found. Both components of your visit to the doctor will determine an appropriate management strategy for you.

• Questions that your doctor will ask you to help decide if you have cyclic or noncyclic breast pain include your age, the position of the pain, the character of the pain, and the relation of the pain to your menstrual cycle.
• You should inform your doctor if you have a history of taking hormone replacement therapy or oral contraceptives, previous history of breast problems, breast surgery, or a family history of breast cancer.
• It is also important to tell your doctor if you have any other breast symptoms such as nipple discharge or a lump that you can feel.

The diagnosis of mastitis and breast abscess can usually be made based on physical examination.

• If it is unclear whether a mass is due to a fluid-filled abscess or a solid mass such as a tumor, a test such as ultrasound may be done. An ultrasound may also help distinguish between simple mastitis and abscess or in diagnosing an abscess deep in the breast. This noninvasive test allows your doctor to directly visualize the abscess by placing an ultrasound probe over your breast. If an abscess is confirmed, aspiration or surgical drainage, and IV antibiotics, are often required.
• Cultures may be taken, either of breast milk or material aspirated (taken out through a syringe) from an abscess, to determine the type of organism causing the infection. This information can help your doctor decide what kind of antibiotic to use.
• Non-breastfeeding women with mastitis, or those who do not respond to treatment, may have a mammogram or breast biopsy. This is a precautionary measure because a rare type of breast cancer can produce symptoms of mastitis.

• Limit your intake of caffeine in coffee and soft drinks, theophyllines in tea, and theobromine in chocolate. Although the role of these methylxanthines is controversial, some women report improvement in pain when they limit these.
• Daily vitamin E can reduce fibrocystic changes. Avoid doses higher than 600 mg per day.
• Wear a well-fitted bra or sports bra for support, especially if you have large breasts. You may want to wear a comfortable bra to bed.
• Apply warm compresses to your breasts for pain relief.
• Over-the-counter pain medication may help.
• Make note, and avoid, any foods that may seem to cause the pain.
• Keep a diary of pain, documenting frequency and severity for at least 2 months. This may be enough to convince you and your doctor that the pain is cyclic and not severe enough to warrant medications that may have bothersome side effects.
• Injury: If you suffer an injury to your breast, apply an ice pack for 20 minutes just as you would for any other bruise. Do not let the ice touch your skin directly. You can use a bag of frozen vegetables wrapped in a towel. You may take a pain reliever such as ibuprofen (Advil, for example).
• Mastitis: Breast infections require treatment by a doctor. After you see a doctor, try pain medication, frequent feedings of your infant, and warm compresses.

• When your breast pain is severe enough to interfere with your lifestyle and when it occurs for more than a few days each month, you may be treated with medications.
• Before treatment is begun, document the frequency and severity of your pain daily for at least one to two menstrual cycles.
• This pain diary will also help check your response to treatment.

When nonmedical treatment fails to control cyclic breast pain, your health care professional may prescribe birth control pills or danazol (Danocrine). Be sure to ask about possible side effects of these medications and report them to your doctor if you experience them.

• Many other drugs have been tried in the treatment of cyclic breast pain and are not useful or are generally not recommended because of their side effects.
• Noncyclic breast pain is managed by treating the underlying cause. If a mass or lump is found, it is checked and treated. When your breast pain is caused by chest wall tenderness, it is treated with anti-inflammatory medication or rarely by steroid injections.
• If no cause for the noncyclic pain is found, a pain treatment protocol for cyclic pain is usually tried and often found to be successful.
• For simple mastitis without an abscess, oral antibiotics are prescribed. The antibiotic chosen will depend on the clinical situation, your doctor's preference, and your medication allergies, if any. This medicine is safe to use while breastfeeding and will not harm the baby.
• Chronic mastitis in nonbreastfeeding women is more complicated. Recurrent episodes of mastitis are common. Occasionally this type of infection responds poorly to antibiotics. Therefore, close follow-up with your doctor is mandatory.

• In general, surgery is not necessary to treat breast pain unless a mass is found. Surgery is performed to remove a lump.
• If an abscess is present, it must be drained. After injection of local anesthetic, the doctor may drain an abscess near the surface of the skin either by aspiration with a needle and syringe or by using a small incision. This can be done in the doctor's office or Emergency Department.
• If the abscess is deep in the breast, it may require surgical drainage in the operating room. This is usually done under general anesthesia to minimize pain and completely drain the abscess. If your infection worsens despite oral antibiotics or if you have a deep abscess requiring surgical treatment, you may be admitted to the hospital for IV antibiotics.

• Avoid the use of home remedies or herbal remedies until you discuss the idea with your health care professional.
• In one study in England, positive effects were found with evening primrose oil in 44% of women with cyclical pain, although danazol was more effective (70% benefitted).

Recommended mammograms should be part of your routine health maintenance screening. Keep track of when your last mammogram was done and inform your doctor when you are due for another, based on your doctor's recommendations. Be aware of your body and the changes you notice on examining yourself. If you notice a mass, this should also be reported to your health care professional.

• Follow-up care will vary depending on the cause of your breast pain, severity of symptoms, and treatment strategy. You should discuss a follow-up plan with your doctor. Regular and routine mammograms are an excellent investment in your future well-being.
• If you have a breast infection, you will usually be seen for a recheck in 24-48 hours. Take all antibiotics as prescribed.
• Close follow-up of any breast lump or infection is also important to rule out breast cancer. Mastitis does not cause cancer, but some cancers can mimic mastitis in appearance. If a breast infection is slow to go away, your health care professional may recommend a mammogram or other tests to rule out cancer.

Once you reach age 20, you should begin to do a monthly breast self-exam. The best time to examine yourself is about seven to eight days after your period begins. If you have passed menopause, do it at the same time each month. If you find any suspicious masses, report them immediately to your health care professional for testing. Tumors found during your monthly self-exam are usually in an early stage. You have a better outcome and a higher long-term survival in these cases if cancer is found. Most lumps are not cancer.

• Performing regular breast self-exams will allow you to familiarize yourself with your body and alert you when a change in your usual breast tissue is found.
• Repeating the breast exam and completing a pain diary for a few consecutive menstrual cycles will also help establish whether your breast pain is cyclic or not.
• The American Cancer Society Guidelines for the Early Detection of Cancer recommend yearly mammograms starting at age 40. Also, Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic health exam by a health professional, preferably every three years. After age 40, women should have a breast exam by a health professional every year.
• If you are younger than 40 and in a high-risk category (for example, many women in your family have breast cancer), you should ask your doctor about how early you should have your first mammogram.
• Sometimes mastitis is unavoidable. Some women are more susceptible than others, especially those who are breastfeeding for the first time.

• Premenstrual breast pain usually increases with age and then generally stops at menopause.
• Most women can control their symptoms without hormonal treatment.
• When treated promptly, the majority of breast infections go away quickly without serious complications.