Breast Pain

Overview

Breast pain is thought to affect up to 70% of women at some point in their life and is most commonly noted in women aged 30-50. It is very unlikely to be a presenting symptom of breast cancer but can cause women significant distress and so requires thorough primary care assessment and support.

This guide is intended as a tool to help primary care clinicians manage breast /chest wall pain with supportive and interventional measures initially.

 Types of breast pain

Who to refer

Breast Pain with a PMH of Breast Cancer

Breast pain is not uncommon in women who have had breast cancer and is very likely to be benign. If it is not responding to simple measures and persists beyond 8 weeks then these patients should be referred to breast clinic for assessment using the USC (2WW) referral form.

Breast Pain without PMH of Breast Cancer

If breast pain has not resolved with simple measures after 3 months AND is affecting quality of life or sleep. These patients should be referred to the breast care on the 2WW referral form and anti-oestrogen medication may be prescribed by the breast team.

Straight to mammogram pathway  

This is a ‘direct to investigation’ pathway, currently as a pilot, at the Bristol (NBT) Breast Care Centre for GPs to use for women with breast pain only who meet the strict criteria below.

• Over 40 years old
• Nil else found on clinical examination, and musculoskeletal pain excluded
• Breast pain for more than 8 weeks which is not musculoskeletal.
• Trial of analgesia (ideally NSAIDs) for 2 weeks has not helped symptoms
• Patient has been asked to watch the You Tube video below

Through this pathway, GPs can request a mammogram. Both breasts will be imaged (if appropriate) so there can be an assessment of symmetry of breast tissue. If the results are normal, an automated letter will be sent to the patient and GP. If the results are abnormal, further investigations will be arranged by the NBT Breast Care Centre and this will include further imaging and possibly a biopsy.

GPs can request the straight to mammogram pathway on NBT ICE (not available by any other route). Choose the 'XR Mammogram (GP only)' option.If your Practice does not have access to NBT ICE please email: gplinks@nbt.nhs.uk to arrange ICE access.

Red Flag

If other symptoms/abnormalities are found on examination; mass, nipple change or unilateral discharge. Please review Nipple Conditions information on Remedy for this symptom and then refer on 2WW referral form if appropriate

Signs consistent with infection or an abscess - See Mastitis and Breast Abscess page

Before referral

Clinical Examination

Careful examination of breasts is important to exclude palpable masses, skin changes, nipple signs. Displacement of breast tissue off chest wall will help to differentiate musculoskeletal tenderness from mastalgia (examine the women sitting up at 45 degrees, with the breast tissue lifted off the chest wall and bimanually palpated with no pressure on the chest wall. In mastalgia, this will be painful, in musculoskeletal pain it won’t).

Reassurance

Taking the patient’s concerns seriously, discussing the glandular and hormonally sensitive nature of breast tissue and reassuring them that their pain is unlikely to be the result of breast cancer can often help to reduce the stress and anxiety that can increase the severity of breast pain.

The following are useful resources for patients;

Breast Cancer Now Breast pain information 

Breast pain | Breast Cancer Now

Video developed by GP network in London

Understanding Breast Pain - YouTube

Self Care

Well-fitting bra;

If breast tissue is not adequately supported then breast pain may result so weight loss/gain, changes to the breast shape with age, underwear that has lost its elasticity or is not supportive enough for exercise can all result in breast pain. Women may also find their breast pain improves if they wear support at night.

Caffeine and alcohol;

Can both exacerbate hormonal breast pain and so reducing quantities consumed can improve symptoms. Reducing alcohol consumption also reduces breast cancer risk.

HRT/Hormonal contraception;

Exogenous hormones may exacerbate/cause breast pain.

Evening Primrose/ Starflower Oil;

The traditional advice has been to try evening primrose or star flower oil for breast pain. In essence these are herbal remedies that contain a substance called gammalenic acid. This is a naturally occurring free fatty acid. It is thought that if one takes this in sufficient quantities it may help to reduce the severity of breast pain. It can be bought over the counter in many health food shops or supermarkets. It is well tolerated by most women and has few side effects. The normal capsule strength is in the region of 500mg. It is thought that for this remedy to be effective one needs to take a high dose of the compound; perhaps 2-3g per day (or 4-6 capsules a day). It is important to understand that this therapy may well not work for everybody. Clinical studies have failed to prove its effectiveness conclusively and some experts feel that it is no more effective than a placebo. However, it is a harmless and well tolerated drug and has few side effects so that it is a quite reasonable step to take in the first instance to see if benefit can be achieved.

Analgesia;

If a musculoskeletal cause of pain is thought likely, regular NSAIDs for 2 weeks will often help to reduce inflammation and therefore pain.  Topical treatments can be used as if tablets are not tolerated.

Paracetamol can be helpful if the patient is finding the discomfort severe.

Services

For patients suitable for direct access mammogram use NBT ICE (as detailed in Who to Refer section above).

For patients meeting USC (2WW) criteria or not meeting criteria for direct access mammogram, refer to the Bristol Breast Care Centre using the 2WW referral form (available in EMIS).

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.