Sore breasts and nipples – the ultimate guide

Burning questions

• What is the most common cause of sore breasts and nipples?
• Why do my breasts (boobs) hurt?
• Are tender nipples a sign of PMS?
• Are sore breasts and nipples a sign of cancer?
• Why do I have sensitive nipples during my period?
• Why does one breast hurt and not the other?
• My breasts are sore – am I pregnant?
• Is it normal to have sore breasts with mood swings?
• Why are my breasts sore? I’m menopausal.
• Are sore breasts after ovulation a sign of low progesterone?
• Can HRT cream cause breast soreness?
• What are the causes of tender breasts and nipples apart from pregnancy?

These are just some of the questions I get asked about breasts when I talk to other women. I used to be completely baffled by this because I couldn’t understand why they didn’t ask their own doctors all these questions. When I asked them the answers I got usually went something like:

• I felt too embarrassed to bring it up.
• I felt silly asking him these questions.
• He is usually in a bit of a hurry so I didn’t bother asking.
• He said my mammogram was normal and prescribed some painkillers.
• He said there was nothing to worry about, but I’m still worried.
• I saw my doctor about the pain but it was a complete waste of time.

I hope what you’re about to read will give you some answers and help you to understand more about breast pain.

What is breast pain and what causes it?

Breast pain is the most common breast complaint affecting women of all ages. If you’re reading this, the chances are that you are among the 70 percent of women who will experience sore breasts to some degree, at some time in their lives. Breast pain is also known as mastalgia or mastodynia.

Structure of the breast

The female breast is also known as the mammary gland. Several different types of tissue make up the breast. They can be broadly divided into two groups:

• Tissues involved in milk production and transport – the lobes, ducts and alveoli; and
• Tissues which support and feed the breast – connective tissue, ligaments, fat, blood vessels, lymph vessels and nerves. The amount of fat in the breasts determines how large they are.

Types of breast pain

Pain in the breast can basically be divided into two groups:

• Cyclic breast pain; and
• Non-cyclic breast pain.

Cyclic breast pain

Cyclic breast pain may start up to two weeks before your period
Cyclic breast pain is the most common type of breast pain. About two-thirds of breast pain is cyclic, and it occurs in relation to your menstrual cycle. It can occur at any age once you start having periods, but it is most common between the ages of 30 and 50. For this reason, it doesn’t occur naturally in women who have gone through menopause and are no longer having periods. If you have gone through menopause and you are using hormone replacement therapy (HRT), you may also experience cyclic breast pain.

How will you feel if you have cyclic sore breasts?

• You may experience mild discomfort in both breasts as your period approaches. One in ten women has pain that is severe enough to interfere with their day-to-day activities. The pain may start up to two weeks before the onset of the period. The few days before the period are usually the worst, and the pain gradually subsides after your period starts. For some women, the pain may last throughout the cycle and then worsen as the period gets closer.
• The severity of the pain may be different from month to month. In some months you may experience mild discomfort, and in others you may have severe pain.
• The pain in your breast may be constant or on and off. Your breasts may feel very full or heavy, aching or sore, or you may feel as if you have a fever in your breast. The pain may extend into your armpits and down your arm. You may find it uncomfortable to sleep on your tummy, wear a bra, hug someone or have your breasts touched while you are making love.
• Your breasts may feel generally lumpy, but you may not be able to identify a single, specific, large lump. The texture of your breasts usually returns to normal after your period starts.
• Your nipples may feel very hard and sore and uncomfortable to touch.
• You may feel the pain in only one breast.
• Pain usually stops during pregnancy and after menopause. However, some women still have breast pain during pregnancy and menopause, but it is non-cyclic.

What causes and/or worsens cyclic breast and nipple pain?

Various theories have been suggested as to the cause of cyclic breast pain. The most popular ones are:

• Low progesterone levels compared to estrogen in the second half of the menstrual cycle: It has been suggested that there is an imbalance between the levels of progesterone and estrogen after ovulation, with the effects of the estrogen outweighing those of progesterone. This idea is known as estrogen dominance and was made popular by Dr. John Lee, a Harvard-trained medical doctor and strong advocate for the use of natural, bio-identical hormones. Apart from sore breasts, other symptoms of estrogen dominance are said to be:
  • irregular periods,
  • irritability,
  • mood swings,
  • bloating,
  • low sex drive,
  • memory loss,
  • migraine headaches,
  • hair loss,
  • weight gain,
  • tiredness and
  • sleeplessness
• Abnormalities in prolactin levels: Prolactin is a hormone that is produced in very large quantities in pregnant and nursing mothers. It stimulates the breasts to produce milk. Abnormalities in the prolactin levels in the body can lead to breast pain.
• Stress: Several hormones in the body are made from progesterone, including cortisol. When you are under a lot of stress, your body converts more progesterone into cortisol to help you handle the stress. This leaves your body lacking in progesterone. This is known as the “progesterone steal.” The more stress you’re under, the less progesterone you have to take care of your other body functions.
• Over-sensitivity: It is possible that the breasts of some women are more sensitive to hormonal changes than others. This may be due to an imbalance in the fatty acids in the breasts.
• Drugs: Breast pain may be worsened by hormones (birth-control pills and injections, hormone replacement therapy, drugs used for infertility), drugs used for hypertension and heart conditions (digoxin, spironolactone, and methyldopa) and antidepressants (chlorpromazine).

Cyclic breast pain and Premenstrual Syndrome

Cyclic breast pain is usually one of a group of symptoms collectively known as Premenstrual Syndrome or PMS. PMS can be grouped into several different types based on the group of symptoms you experience each month.

TABLE

If you have cyclic sore breasts then your symptoms may belong to the PMS H (hydration) group with breast tenderness, bloating, weight gain and excessive storage of water in the body. It is possible to have symptoms from more than one group in this classification e.g. groups H and C.

Non-cyclic breast pain

Non-cyclic breast pain is pain in the breast and/or nipple that is not related to your period and that doesn’t have any particular pattern. About a third of women who have breast pain have the non-cyclic kind.

How will you feel if you have non-cyclic sore breasts?

• The pain may be continuous or may come and go.
• The pain may be felt in both breasts, one breast or even a specific part of one breast.
• Pain may extend into the armpit and down the arm.
• The pain may be described as burning, aching, drawing or pulling, or as heaviness in the breast.

Causes of non-cyclic breast pain

The source of the pain may be from within the breast itself or from structures close to the breast.

Pain from the breast

• Puberty: During puberty, breast pain may occur in both boys and girls, due to hormonal changes.
• Pregnancy,
• Breast feeding,
• Menopause,
• Breast cysts: A cyst is a localized collection of fluid. Pressure from the cyst pressing on surrounding tissues and nerves may lead to pain.
• Infections of the breast (mastitis): Mastitis may occur during breast-feeding (breast-feeding mastitis), or at other times. If you have mastitis, you may experience the following symptoms:
  • Pain in the breast,
  • Redness of the skin,
  • Warmth in the breast,
  • Breast swelling,
  • Body aches,
  • Extreme tiredness, or
  • Fever and chills.
• Breast abscess: This is a collection of pus in the breast and is usually a result of infection. You may experience the following:
  • A painful, mobile lump in the breast (if the abscess is very deep within the breast, you may not be able to feel it),
  • Pus draining from the nipple, or
  • Fever and other symptoms that have not improved 72 hours after starting treatment for mastitis.
• Tumors of the breast: Non-cancerous growths in the breast may cause pain due to compression. The most common non-cancerous growth is fibroadenoma.
• Shingles may cause breast pain before the rash appears.
• Previous breast surgery: This may leave scar tissue that causes persistent pain

Pain from outside the breast

• Tietz’s syndrome: This causes inflammation of the joints where the ribs meet the breastbone (costochondral junction). Pain is felt deep within the breast.
• Gastro-esophageal reflux disease (GERD): Acid that is regurgitated back into the lower esophagus (food tube) from the stomach can cause pain that may be felt in the breast.
• Angina
• Arthritis of the spine
• Hiatus hernia
• Nerve entrapment syndromes, such as carpal tunnel or cervical rib, where the nerve is compressed against bone leading to persistent pain.
• Gallstones
• Chest infection

Sore breasts in pregnancy

Many women experience breast pain in pregnancy
Many women will complain of discomfort in the breasts when they are pregnant. It is possible to start feeling pain, tingling or swelling in the breasts even before you confirm that you are pregnant. When you are pregnant, a lot of hormonal changes take place in your body. You produce large amounts of estrogen and progesterone. This is similar to what happens between ovulation and your period. The difference is that in pregnancy the hormone levels are much, much higher. This helps to prepare the body for pregnancy and nursing.

Changes in the breasts during pregnancy

The breasts usually get bigger, increasing by several cup sizes for some women. The increase in size is due to:

• Fat being stored in the breast,
• Milk glands becoming larger and more developed, and
• Blood vessels increasing in number and becoming larger. This accounts for the blue or green lines (which are actually veins) that you may see just under the skin on your breasts.

Your nipples become larger and darker, and you may also notice small bumps on the areola or flat part of the nipple; these are called Montgomery’s tubercles. You may also notice a yellowish fluid leaking from your nipples towards the end of your pregnancy; this is called colostrum or the first milk. On the other hand, you may find that your breasts change very little during pregnancy.

This does not mean that you are abnormal or that you won’t be able to breastfeed your baby. Every woman’s body is unique and different. Breast and nipple soreness tend to be worse in the first three months (first trimester) of pregnancy, causing some women to avoid lovemaking at this time. For some women, the discomfort may appear on and off at the beginning of pregnancy, whereas for others, sore breasts may persist throughout pregnancy.

Sore breasts during breast-feeding

Sore breasts and nipples can be very alarming and may give rise to a lot of anxiety, even if you have nursed before. The commonest causes of sore breasts during breastfeeding include:

• Milk let-down reflex: In the first few days of breast feeding a new baby, you may feel pain deep inside the breast when your baby is feeding. This may be felt as a tingling, or a feeling of heaviness or pain. This is a result of the milk let-down reflex or milk ejaculation reflex. When your baby suckles, the hormone oxytocin is released. This makes the muscles lining the ducts of your breast squeeze out milk.
• Breast engorgement: In the first few days after your baby is born, your breasts may feel swollen, hot and painful. Large amounts of milk are produced to make sure the baby is well fed. Large amounts of blood flow to the breast, and the milk producing cells become enlarged. All this makes it difficult for the milk to leave the breasts. As the baby starts to nurse and the breast empties, milk production stabilizes and the engorgement subsides.
• Plugged milk ducts: Milk flows through passages in the breasts called ducts. Sometimes a duct becomes blocked and milk cannot flow freely. The skin over the affected area may or may not be red, and you may feel a lump where the milk has accumulated.
• Infection of the breast, or mastitis: This usually arises from a blocked milk duct that has not been treated. Symptoms include:
  • generally feeling unwell or feeling run down,
  • fever,
  • chills,
  • redness of the skin over the breast and
  • severe pain in the breast.

You should see your healthcare provider if pain and fever lasts for more than 24 hours.

Sore Breasts and Nipples after Menopause

Hot flashes and night sweats are common menopause symptoms but you may also experience sore breasts.Sore breasts and nipples are a very common complaint in women who have gone through menopause. With the prominence given to hot flushes and night sweats in particular, sore breasts don’t get much attention. To make things worse, you may not find much information on breast and nipple soreness after menopause.

What causes sore breasts after menopause?

The exact cause is unknown, but it is most likely linked to hormonal imbalance. A large part of the progesterone in your body is produced by the corpus luteum after ovulation. When there is no ovulation and you are no longer menstruating after menopause, your body no longer gets progesterone from that particular source; in fact, your progesterone levels may be as low as 1 percent of the pre-menopausal level.

In contrast, estrogen is produced in the ovaries, adrenal glands and fat cells. This means that even when you go through menopause, your estrogen levels may be as high as 50 percent of the levels before menopause. Even though both progesterone and estrogen are reduced after menopause, there is an imbalance because progesterone levels are so low. Without a corresponding level of progesterone to oppose its action, the body is set to be in a state of estrogen dominance.

Visiting your doctor or healthcare provider

If you have sore breasts make sure you see your doctor or healthcare provider
If you have any doubts whatsoever about your health, you should always see your healthcare provider. However, you should visit your healthcare provider as soon as possible if you experience any of the following symptoms:

• A suspicious lump in your breast,
• Abnormal discharge from the nipples,
• Redness,
• Swelling,
• Severe pain, or
• Changes in the skin over the breast.

To help your healthcare provider to make a diagnosis, it’s usually a good idea to keep a pain diary or a pain chart, on which you should mark the days when you experienced breast pain and the days when it was worse than others. You should also record anything else you notice about your health. This will help guide your healthcare provider in making a diagnosis.

Questions your doctor may ask you

• Which part of the breast you feel the pain in,
• How long you have had the pain,
• What the pain feels like,
• Times when the pain gets better or worse in relation to your period and in relation to anything else,
• Your menstrual history,
  • How often you see your period,
  • How many days it lasts,
  • Whether your flow is heavy or light,
  • Whether you have period pains and
  • Whether you have noticed any changes in your cycle recently.

These questions are usually asked to determine if your pain is cyclic or non-cyclic. The doctor will also ask you about:

• Any medication you are taking,
• History of illness in your family and
• Your personal habits (e.g., smoking, your alcohol consumption, etc.).

Other things your doctor may do

Always see your doctor for persistent breast pain
After doing a general examination, your doctor will examine your breasts. She will look for:

• Differences in size and shape, and abnormalities of the skin over the breast,
• Redness or pitting of the skin,
• Differences in the levels of the nipples,
• Warmth of the breast,
• Lumps in the breast,
• Discharge from the nipple, and
• Tenderness of underlying muscle or the surrounding ribs and breastbone.

If she cannot find any specific condition that is making your breasts sore, she will tend to reassure you. She might also prescribe some pain killers and orders some tests. These will usually include:

• a mammogram (an x-ray of the breast),
• an ultrasound scan, and possibly
• a pregnancy test