Key distinguishing features of the most common diagnoses
|Pregnancy||Cyclical Mastalgia||Inflamed Nipple||Abscess||Mastitis|
Possible:Pregnancy test, mammography
Small Print:Swab of any nipple discharge, other investigations if non-breast causes suspected.
- Pregnancy test worthwhile in bilateral pain if a period has been missed.
- Mammography may help if pain is accompanied by a mass or ill-defined nodularity but this would normally be performed in secondary care after referral.
- If the aetiology is infective and the nipple is discharging, a swab may help guide treatment.
- Other investigations: If a non-breast cause is suspected, other tests may be required according to the pattern of the symptoms, e.g. cardiac tests (angina) or cervical spine X-ray (cervical spondylosis)
- Offer to examine the breasts even if you are sure from the history that there is no significant pathology – many women fear breast cancer and will find your reassurance hard to accept if they feel they haven’t been taken seriously.
- Don’t reflexly prescribe in cyclical mastalgia; the patient’s agenda is often to exclude serious disease rather than seek drug therapy.
- Remember pregnancy as a cause – the patient will not always volunteer this as a possibility, even if she has just missed a period.
- Unilateral breast pain with no other local signs may be an early symptom of shingles. Check the back in the T4/5 dermatomes for a rash.
- ‘Chest pain’ may be a euphemism used by a (frequently older) woman in denial. Don’t miss advanced tumour through not examining the breasts.
- Cancer rarely presents with breast pain but consider this possibility in a woman complaining of constant ‘pricking’ breast pain.
- A lactating woman with unilateral breast pain and flu-type symptoms is probably developing mastitis – treat early to avoid the development of an abscess.
- If the pain is related to exertion in a late middle-aged or elderly woman, consider angina as a possibility.