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Postmenopausal breast tenderness

Q - What causes postmenopausal breast tenderness?

A - Around 80 per cent of breast pain in postmenopausal women is non-cyclical pain usually caused by chest wall pain located over either the costal cartilages medially (Tietze's syndrome) or lateral chest wall pain. Another 10-13 per cent of patients presenting with breast pain will be found to have referred pain due to a cause outside the breast, such as cervical spondylosis or occasionally gallstones.

Postmenopausal women not on HRT often get pain in the serratus anterior muscle area, which can be elicited by turning the patient into the lateral position dropping the breast away from the chest. It is then possible to identify tender areas over the lateral chest wall, which are musculoskeletal trigger spots for the pain. Women with musculoskeletal pain have usually not had premenopausal cyclical mastalgia previously.

Non-steroidal anti-inflammatory drug gels rubbed into the area two or three times daily for a month relieve the pain compared with placebo; oral NSAIDs are also helpful in chest wall pain syndrome. If a localised tender area is found on the chest wall, infiltration with local anaesthetic and steroid injection (bupivacaine combined with 40mg of methylprednisolone) often relieves the pain.

Occasionally, true non-cyclical breast pain is seen and mammograms may show radiological evidence of duct ectasia with typical coarse calcification. This pain tends to be behind the nipple or in the peri-areolar area.

Rarer causes of pain include breast biopsy scar pain, sclerosing adenosis and, if the pain is particularly well localised, breast cancer.

Dr Nigel Bundred is professor of surgical oncology at South Manchester University Hospital

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