cyclical breast pain

• most common

• associated with menstruation

  • last 5 days

• premenopausal 30-50yo

  • hormonal

• HRT

  • post menopausal

• progesterone

  • breasts often diffusely nodular or lumpy

• >7/7 per month

• 1/5 women

• can be anywhere in breast

• upper outer quadrant - most marked pain

  • dull

  • aching

  • heavy

• may have had fibrocystic changes in the past

noncylcial

• isolated to one breast

• less diffuse

• one quadrangt of one breast women who are older

• less common compared to cyclical

• most not diagnosed

  • pregnancy,

  • truama

  • breast cancer

  • mastitis/cysts

• check what hormones

• drugs

  • antidepressants

  • spironolactone

  • antipsychotics

  • digoxin

examination

• external appearance

  • by sides

  • hands on hip

  • arms above head

• nipples

  • eczema

  • peau d’orange

  • nipple d/c -> blood stained

• quadrants

  • including up to the axilla

• supraclavicular lymphadenopathy

single diffuse lump -> fast track referral

Tietze’s syndrome = costochonditis compared to mammary pain

Investigations

cyclical

• not usually

Management

cyclical

• simple analgesic

• better fitting bra

• topical NSAID

  • quite a lot of benefit

• very limited evidence for evening primrose oil

• stopping/changing pill

  • change to more oestrogen dominant

• no diuretics

• limited evidecne that lowering caffeine

• ?food diary

• danazol

  • anti-gonadotrophin