WHAT IS CAUSING MY BREAST PAIN?

Even though breast pain is usually not a sign of breast cancer, never ignore symptoms that your body may be trying to tell you. Do you experience breast pain? There are many causes of breast pain and we will explore them so that you can be “in the know” when it comes to your own breast health. I’ll also explore what you can expect when you go to a doctor through my own experience as a radiologist specializing in breast and other areas of women’s imaging. As a fellowship-trained physician specialist in women’s radiology, I see patients who have breast pain for many reasons: 

The good news is that most causes of breast pain are benign (non-cancerous). We can divide breast pain into several categories:

• Physiologic-related to such things as hormones, amount of sodium in our bodies, or your thyroid function
• Mechanical-related to overuse of sports bras, very tight underwire bras, ill-fitting bras
• Inflammation-underlying medical conditions such as allergic reaction, underlying autoimmune conditions
• Pathologic-such as a tumor situated on a nerve or several nerves that causes breast pain

Questions Your Doctor May Ask

Many questions that I ask my patients as a physician:

• How long has the pain been present?
• Is there an associated breast lump or redness of the skin of the breast?
• Does the breast look normal to you or is the nipple or skin retracted (pulled inwards)?
• Is it present in one or both breasts?
• Is it symmetric or asymmetric?
• Can you describe the intensity of the breast pain specifically?
• Is it a dull aching, throbbing, or sharp pain?
• Tell me about the frequency of your breast pain.
• Does it occur only before menstrual cycles or in the middle of the month (during ovulation)? If you are unsure about the duration of your menstrual cycle, you could always use an ovulation test to track when you are ovulating. This is also useful to know for women who are trying to get pregnant. 
• Is there nipple discharge, and if so, what color and does it occur spontaneously (versus you having to manually express the discharge)? 
• If the pain is completely new for you, is there anything you did in particular just preceding the onset of breast pain, such as a long flight (involving a time change)?
• What changes the circadian rhythm of many hormones in your body?
• Was there a significant social stressor such as the loss of a family member or caring for a close friend or family?
• Were you just starting a new workout regimen after being less physically active?

These questions help identify one of the most common causes of breast pain so it’s important that you pay close attention to the characteristics of the breast pain and to your body’s other signals which may be trying to tell you something. Your doctor should ask you some or many of these questions. 

Physiologic

Physiologic is usually the most common cause of breast pain as we cannot specifically change our hormones. This is usually the easiest to recognize when we usually find a rhythm to it, such as symptoms are worse during Mittelschmerz (time of ovulation) or right before or during our menstrual cycle. This pain typically gets better after the cycle.

Physiologic pain usually involves both breasts, more so in the upper-outer or the front of the breast behind the nipples.

There are some factors that you can change in order to try to balance out the hormonal issues.

• Knowing that the hormones are big molecules and cause large influxes of fluid, one can try to decrease the amount of fluid within the breasts by exercising. The movement of the breasts can increase lymphatic flow.
• Decreasing salt intake to a physiologically normal daily level can help as well.
• Eliminating extra sugars. Note that both sugars and salt are solutes and retain water, so you may want to minimize these as much as possible especially during certain times of your cycle. 
• Minimize the use of restrictive sports bras or tight underwire bras during this time.
• For my patients, I also introduce the new concept of lymphatic breast massage, which is a very light upwards motion massage starting from the bottom of the breast, moving upward towards the axilla or towards the clavicle on both sides.

All of these techniques may help to improve breast pain so you may want to try them before visiting your doctor.

Mechanical

If the pain is mechanical, it is one of the most idiosyncratic and hardest categories to diagnose. When women have breast pain, they tend to try to stay in tight clothing because they think that the restrictive movement makes them feel better. This may make the breast feel better, but this is a fallacy. The temporary relief that this provides actually makes the whole condition worse by compressing the lymphatics of the breast and skin, which is the main egress (way to get out) of fluid through tiny vessels just slightly larger than the size of a hair.

This lymphatic system drains the breasts instead of veins. The lymphatic structures are in a web-like configuration throughout the breasts following the nerves, arteries, and veins, as are in very large concentrations around the nipple/areola and skin of the breast. Tight compressive garments tend to impede the flow of fluids, therefore increasing the amount of fluid within the breast which typically causes breast pain in the front of the breast.

Again, using the same lymphatic breast massage techniques that we just discussed is the main remedy for this type of pain. We recommend removing the sports bra as soon as possible after exercise and replace with a comfortable supportive bra that is non-compressive and using the breast massage technique, as instructed above with a light touch starting from the lower breast to the axilla or the clavicle. Pretend like you are using “whisking stroke-like fluffing eggs” or “a light paint-brush type of technique” lightly like you are painting the landscape of a canvas. Other techniques include:

• Slight bouncing
• Moving your arms
• Lowering salt and sugar intake
• Try to minimize alcohol, which not only contains a large amount of sugar but is a diuretic and causes fluid disturbances.

Some women may have experienced more breast pain after a long day of work, especially in women with large breasts. In this case, there is usually a pulling sensation from the upper breast on both sides when the bra is taken off and the breast feels better when it is supported. This is a different kind of pain known as Cooper’s ligament stretch, often referred to as Cooper’s ligament breast pain. To ameliorate these symptoms, the use of a supportive bra that is not too compressive or tight may be helpful. Sleeping in a comfortable T-shirt or stretchy night shirt may help as well.

Inflammation

It is surprising how many conditions can affect the water content of the breast. Any process that causes inflammation in the body may cause breast inflammation. A moderate number of my patients have underlying autoimmune conditions such as celiac disease, gluten intolerance, Hashimoto’s thyroiditis, rosacea, inflammatory arthritis, and type 1 diabetes. All of these conditions associated with increased body inflammation will naturally increase breast inflammation. Increased breast inflammation beings in more water to the breasts and the tiny breast lymphatics may not be able to keep up draining the breast. 

There is an overall increase of fibrous tissue typically in the breast which may retain more water and cause more breast discomfort. Treating the underlying medical condition usually is the best way to improve breast health and decreasing extra fluids in the breasts (often called breast cysts), decrease breast pain. Note that the above techniques may also be helpful in this category as well. Pre-diabetes/hypoglycemia is a precursor to metabolic syndrome and is becoming much more common than when I started practicing. Our diet is more to blame probably than our sedentary lifestyle and genetics (and your family history) play a strong role as well. If you have had gestational diabetes or problems with hypoglycemia/hyperglycemia, you may want to watch out for this in your medical history. Good dietary and exercise habits are the primary treatment.

Pathologic (Breast Cancer)

Even though breast pain is usually not a sign of breast cancer, never ignore symptoms that your body may be trying to tell you.  If you have a focal persistent breast complaint that is reproducible, especially if it is associated with any change of the breast such as discoloration or thickening of breast tissue, breast lump, blood-colored discharge, or other signs that are a significant change for you, you should seek immediate medical attention. Workup, depending on your age, may at least include ultrasound and potentially a mammogram or MRI. If an abnormal finding on breast imaging is seen, then a breast biopsy may be performed. 

Although breast cysts are the most common reason for finding a breast lump, even the best physician cannot discern a solid breast lump or breast cyst by clinical examination alone, so further examination is necessary after clinical imaging in order to determine whether the breast lump is cystic or solid. A dominant breast cyst could be easily aspirated for immediate resolution of pain. A constellation of small cysts may be treated medically with the recommendations as above, as they may be too numerous to aspirate. A suspicious breast finding will be biopsied under ultrasound, mammography, or MRI. When additional procedures such as breast biopsy prove to be cancerous, The Women’s Imaging Center Team coordinates the patients’ care throughout the entire process including during treatment and follow-up afterward. 

Author Dr. Kelly McAleese is a fellowship-trained radiologist in Women’s radiology. She was one of the four original founders of the concept of Women’s Imaging and designed and developed the first Women’s Imaging Fellowship at the University of Colorado in 1995 which is still training new women’s imagers in Colorado. The concept of Women’s Imaging is unique and meeting the criteria to be a real Women’s Imaging Center is very difficult in which all services related to women’s health and women’s imaging could be performed in one Center with the radiologists who are specialized in this field AND physically examining or talking with patients regarding their imaging studies.

This specialty of Women’s Imaging uses an organ-based system wherein the radiologist specialized in Women’s Imaging is expert in several or all of these female organ systems including breast, gynecologic or reproductive, endocrine including thyroid and bone density. Dr. McAleese (Stanford and Dartmouth trained) is joined by other fellowship-trained radiologists from Harvard and Stanford Dr. John Lewin and Dr. Timothy Colt, respectively, who as a team provide unparalleled specialty knowledge and care in Women’s Imaging in our community and are nationally recognized in this field.

Dr. McAleese is a strong advocate for all women’s health issues and has served on multiple boards in Denver and our outlining communities to increase education, accessibility, and affordable imaging for breast cancer detection and treatment for all Coloradans. She has been active in making legislative changes in Colorado including the Reproductive Tax Check off and Dense Breast Tissue Notification laws. Follow Dr. McAleese or The Women’s Imaging Center on Facebook or Twitter for the latest news on breast imaging and breast cancer prevention. 

The Women’s Imaging Center uses the highest-rated digital mammography,  ultrasound, breast biopsies, and other women’s imaging services at our Women’s Imaging-Denver/Cherry Creek, Women’s Imaging -West/Lakewood, Women’s Imaging-South/Highlands Ranch, and Women’s Imaging-North/Westminster offices. We offer breast MRI and body MRI (MRI of knee, shoulder, spine, head, brain, abdomen, and pelvis) at The Women’s Imaging Center Denver-Cherry Creek location.

Call 303-321-CARE (2273) to schedule an appointment or make an online appointment request.

The Women’s Imaging Center is committed to providing individualized, innovative, state-of-the-art healthcare to women.