Sore Nipples and Sore Breasts

Sore breasts or mastalgia is a common complaint that nearly two thirds of women will experience during their lifetime. Sore nipples frequently occur in mothers who are breastfeeding their infants. Breast pain is referred to as cyclical if it occurs or becomes more severe before the start of a new menstrual cycle. Breast pain that is unrelated to the menstrual cycle is referred to as noncyclical breast pain. There are many causes of breast pain and sore nipples, and the most common are listed in the table below.

General Approach to Management of Mastalgias

Treatment of breast pain usually involves symptomatic pain relief and treatment of the underlying cause of the breast pain. It is critical to have a breast cancer evaluation to rule it out. Topical NSAIDs (Nonsteroidal anti-inflammatory drugs) like diclofenac gel and supportive bra are key to symptomatic management of breast pain. If the underlying cause is treatable, then additional treatment will be prescribed. In the case of mastalgias, this involves antibiotics. If there is no obvious cause for severe breast pain that is not relieved by NSAIDs, various hormone analogues or antagonists such as Danazol, Tamoxifen and Bromocriptine are prescribed. However, long-term use carries a significant risk of severe adverse effects, so they are therefore best avoided if possible Danazol is the preferred first-line drug for severe breast pain that is not relieved by NSAIDs. Evening primrose oil is a famous home remedy for breast pain, but its effectiveness for mastalgia treatment is unclear due to conflicting reports. Furthermore, additional measures including cutting down on coffee, tea, soda, etc. have not been shown effective. Many women report that these measures are in fact effective, but it is not clear whether their breast pain resolved by itself or from these interventions.

Table: Most common causes of Sore nipple/Sore breast

Cause

Comments

Treatment and Course

Mastitis

Inflammation of the breast tissue resulting in swollen, red, and painful breasts.

Treated with antibiotics, but about a quarter of cases progress to form an abscess.

Breast Cancer

Inflammatory Locally Advanced Breast Cancer. Also in other types, though rare.

Medical/Surgery depending upon the stage.

Fibrocystic Breast Changes

May present with breast pain as the only symptom or with other symptoms.

Main focus is to exclude cancer.

Pregnancy and Lactation

Can be due to numerous causes. Both breast pain and/or nipple pain can occur

General symptomatic treatment plus treatment depending upon cause.

Hormonal changes

Cyclical breast pains occurring before the start of new menstrual cycle. Also peri-menopausal breast pain.

NSAIDs. Danazol etc. for severe refractory causes

Cervical Radiculopathy

Causes referred pain in the breast. Breasts are normal.

Treatment depending upon the cause of cervical radiculopathy.

Tietze's Syndrome / Costochondritis

Inflammation of the cartilage connecting the breastbone and the ribs.

Cured by conservative treatment and NSAIDs.

Mondor's Disease (Superficial Thrombophlebitis)

Inflammation of superficial veins of the breast associated with blood clot.

NSAIDs and hot compresses.

Trauma

Any injury to the breast. Also injury associated with biopsy.

Symptomatic Therapy. Usually resolves after sometime.

Psychogenic

No abnormality in the breasts.

Addressing the cause of mental distress.

Idiopathic

No cause could be found.

General Symptomatic Treatment.

Mastitis and Abscess Formation

Lactational mastitis occurs in nursing mothers. It is a bacterial infection that results in red, swollen, and tender breasts. Fever may or may not be present. Lactational mastitis is treated with antibiotics, and the affected woman should increase the frequency of nursing or pumping. There is no need to stop breastfeeding the baby if the mother has mastitis. Most of the cases of lactational mastitis are completely cured by antibiotics, but almost a quarter of them may progress to form breast abscesses, which requires the cessation of nursing and surgical drainage of the abscess. Rarely, mastitis can occur in a non-lactating woman. This may also lead to abscess formation. Not all breast pain in a nursing mother is lactational mastitis. It could also be due to engorgement of the breasts, clogging of the ducts, and injury to the areola or nipple due to breast feeding. Similarly, engorgement of breasts may cause breast pain even before the birth of the baby. Some nursing mothers might develop sore nipples, which are often not due to the frequency of breastfeeding, but instead to improper technique.

Breast Pain and Cancers

Although pain is not a common symptom of breast cancers, general pain in any part of the breast can occur in some patients. Ruling out breast cancer is a priority in the evaluation of breast pain. Pain associated with cancer does not change with the menstrual cycle. It is usually confined to a particular area and might be associated with a mass or bloody nipple discharge. The probability of breast cancer being the cause of breast pain is increased if the woman is postmenopausal, or if the pain is associated with a palpable mass or skin abnormalities. A special subtype of breast cancer, inflammatory locally advanced breast cancer often has pain, tenderness, and skin changes as the main presenting symptoms. This type of cancer is frequently confused with mastitis.

Side Effect of Hormonal Changes

Hormonal changes associated with the progression of the menstrual cycle are believed to be a cause behind cyclical mastalgia, although it remains inconclusive. As previously mentioned, cyclical breast pain occurs or increases in severity before the start of a new menstrual cycle. Some women might perceive this pain as radiating to the inner surface of the upper arm. Hormonal changes are also implicated in causing breast pain during pregnancy and in the peri-menopausal period. Many drugs can cause breast pain by affecting the hormonal milieu (e.g. Oral Contraceptive Pills and Hormone Replacement Therapy).

Other Conditions

Fibrocystic Breast Changes are common disorders that may present with a variety of symptoms, and breast pain is one of them. The breast pain might be the sole symptom, or it may also be associated with other symptoms such as a breast lump (these lumps are not cancers) and nipple discharge. Excluding the presence of cancer is the most important step in diagnosing this condition.

Chest pain or costochondritis (or its more severe form, Tietze's Syndrome) might be perceived as breast pain. Costochondritis is the inflammation of the cartilage connecting the ribs with the breastbone. This condition usually resolves itself, and symptomatic pain relief using NSAIDs is often the only necessary treatment.

Rarely, cervical radiculopathy may result in breast pain. This pain is a 'referred pain.' There is no abnormality in the breasts, but the dysfunction lies in the nerve roots near the spinal cord. A herniated disk is a common cause of cervical radiculopathy, but there are also many other causes.

Mondor's disease is another cause of breast or nipple pain. It is a thrombophlebitis (inflammation of a vein caused by a blood clot) of the superficial veins of the breast. Sometimes these veins can be palpated as 'cord' like.

Injury

Any injury to the breast may cause breast pain. Biopsy of breast tissue for a suspected lesion may also cause breast pain. Also, large breast size might be responsible for breast pain for some women. Others might have psychogenic breast pain. In a large number of cases, especially in the non-pregnant and non-lactating women, no abnormality is found in the breast or any other region that may result in breast pain. Such cases are referred to as idiopathic cases and the treatment in such cases is often symptomatic. Some cases resolve in time, but many require prolonged treatment.

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