Mastalgia

From: 5 minutes consult


Description
Painful breast tissue, often bilateral, that can be cyclic or noncyclic (1)[B]:
2/3 of breast pain is cyclical and is usually associated with hormonal changes related to menses, external hormones, pregnancy, or menopause.
1/3 is noncyclical and is often related to breast and chest wall lesion.
Synonym(s): Mastodynia; Breast pain


Epidemiology
Most common in women but occasionally occurs in men.
Generally seen from adolescence through menopause.
Frequency of breast cancer with those reporting breast pain ranges from 1.2–6.7% (2)[B].

Incidence
Up to 70% of women report some degree of breast pain at some point in their lives (3,4)[B].
Most describe mild pain, but 11% describe pain as moderate to severe.


Risk Factors
Diet high in saturated fats
Cigarette smoking
Recent weight gain
Pregnancy
Large pendulous breasts (caused by stretching of Cooper ligament)
Caffeine has not been shown to be a risk factor (5)[B].

Genetics
Familial tendency

General Prevention
Avoid exposure to risk factors.
Properly fitted bra support

Pathophysiology
Causative pathophysiology remains unclear but thought to be related to hormonal and/or nutritional factors. When fibrocystic disease is the source, growth and distention of the cyst with hormonal fluctuation causes pain. Hormonal factors (e.g., hormone replacement therapy, oral contraceptives, pregnancy, menses, puberty, menopause) may influence the diverse conditions that cause mastalgia, or may themselves cause breast tenderness and pain.

Etiology
Multiple disorders present with breast pain and may include:
Benign breast disorders (i.e., fibrocystic changes)
Trauma (including sexual abuse/assault)
Diet and lifestyle
Lactation problems (engorgement, mastitis, breast abscess)
Breast masses, including breast cancer
Hidradenitis suppurativa
Costochondritis (Tietze syndrome)
Postthoracotomy syndrome
Spinal and paraspinal disorders
Potential side effects of medications
Postradiation effects
Referred pain (i.e., pulmonary, cardiac, or gallbladder disease)
Ductal ectasia (6)[A]

History
Location, duration, frequency, severity, associated symptoms, related activities (i.e., trauma), and aggravating and ameliorating factors.
Complete medical history with focus on Gyn/OB history
Complete systematic review of systems
Diet/Smoking history
Detailed family history for risk assessment for breast cancer

Physical Exam
Look for signs suggestive of breast malignancy.
Examine breasts systematically in both lying and sitting positions.
Assess for skin changes, breast symmetry and contour, dimpling, localized tenderness, bruising, mass, nipple discharge, and lymphadenopathy.

Diagnostic Tests and Interpretation
Lab
Initial Labs
Prolactin test if galactorrhea is found
Possibly TSH test
Imaging
Consider ultrasound in women with focal, persistent breast pain.
Mammogram +/− ultrasound in women >age 30–35.

ALERT
Pediatric Considerations
In children and adolescents do not perform mammogram. Always ultrasound first.

Diagnostic Procedures/Other
Cysts may need to be aspirated to relieve symptoms and verify diagnosis.
Biopsies may be indicated based on results of examination ultrasound or mammography.

ALERT
Pediatric Considerations
In children and adolescents, do not perform biopsies unless suspicion for cancer. Refer to specialist in pediatric breast disease.

Pathological Findings
Normal breast tissue
Benign: Fibrocystic changes, duct ectasia, solitary papillomas, simple fibroadenomas
Small increased risk of breast cancer: Ductal hyperplasia without atypia, sclerosing adenosis, diffuse papillomatosis, complex fibroadenomas
Moderate increased risk: Atypical ductal hyperplasia, atypical lobular hyperplasia
Breast cancer

Differential Diagnosis
The major alternate disease to consider is breast cancer, particularly if pain is localized.
Manipulation or trauma can also worsen symptoms.
Chest-wall pain or referred pain resulting from splenomegaly must also be differentiated from mastalgia.
Sometimes flare-up is concurrent with PMS.
Ductal ectasia of the breast

Medication (Drugs)
First Line
Acetaminophen, NSAIDs (7)[B]
Second Line
Oral contraceptives may help some patients prevent fibrocystic disease but may worsen pain.
If on oral contraceptive, switch to one that has a lower estrogen component.
Oral progesterone
Other possibilities for patients with refractory symptoms, used infrequently because of potential side effects:
Danazol: 100 mg b.i.d. (possibly lower doses). May be the most effective. Major adverse effects: Menstrual irregularities, weight gain, acne, hirsutism, and voice change. May be used during luteal phase only. Approved by FDA for this indication.
Toremifene (8)[A]


Additional Treatment
General Measures
Stop or modify current hormonal therapy.
Repeat examination may help establish any cyclic nodularity pattern.
Wear properly fitted support bra (may be fitted by a professional).
Reassurance (sufficient for most patients)
Weight loss for obese patients
Smoking cessation
Relaxation training

ALERT
Pediatric Considerations
Children and adolescents may require referral to specialist.

Complementary and Alternative Therapies
Vitamin E and evening primrose oil has not been found to be of benefit for chronic mastalgia (2,9)[B].


Surgery/Other Procedures
Some patients may need breast reduction surgical procedure.


In-Patient Consideratons
Nursing
Correct any breast-feeding difficulties; treat underlying mastitis or breast abscess.

Follow-Up Recommendations
As needed

Patient Monitoring
As needed for patients not receiving pharmacotherapy
Time of follow-up will vary by type of pharmacotherapy and patient's particular problems.

Diet
Decrease fat intake to 20% of total calories.

Patient Education
Avoid or adjust of risk factors.

Prognosis
Premenstrual mastalgia increases with age, and then generally stops at menopause unless patient is receiving HRT.
Most patients can control symptoms without receiving hormone treatment.
Several months of hormone treatment may provide several more months of relief, but mastalgia may recur.
Cyclic mastalgia responds better than noncyclic mastalgia to treatment.
Effects of long-term hormonal treatment are unknown.

[General]
Blommers, et al. Evening primrose oil and fish oil for severe chronic mastalgia: A randomized, double-blind, controlled trial. Am J Obstet Gynecol 2002;187:1389.
Love S, et al. Dr. Susan Love's Breast Book, 4th ed. New York: Perseus Publishing, 2005.
McFadyen, et al. A randomized double blind-cross over trial of soya protein for the treatment of cyclical breast pain. Breast 2000;9:271.
Qureshi S, et al. Topical nonsteroidal anti-inflammatory drugs versus oil of evening primrose in the treatment of mastalgia. Surgeon 2005;3:7–10.
Other

See Also (Topic, Algorithm, Electronic Media Element)
Premenstrual Syndrome (PMS)
Algorithm(s): Breast Discharge; Breast Pain
ICD-9
611.71 Mastodynia

SNOMED

53430007 pain of breast (finding)


CLINICAL PEARLS


Always rule out cancer first when evaluating a patient with breast pain.
In the adolescent population, do not biopsy; refer to a pediatric specialist.


AUTHOR

Leon N. Plowright, MD
Eduardo Lara-Torre, MD


BIBLIOGRAPHY


Davies EL, et al. The long-term course of mastalgia. J R Soc Med 1998;91:462. [PMID:9849515]
Smith RL, et al. Evaluation and management of breast pain. Mayo Clinic Proc 2004;79:353.
Ader DN, et al. Cyclical mastalgia: Prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg 1997;185:466. [PMID:9358091]
Maddox PR, et al. Management of breast pain and nodularity. World J Surg 1989;13(6):699–705. [PMID:2696222]
Levinson W, et al. Nonassociation of caffeine and fibrocystic breast disease. Arch Intern Med 1986;146:1773. [PMID:3530165]
Peters F, et al. Severity of mastalgia in relation to milk duct dilation. Obstet Gynecol 2003;101:54. [PMID:12517645]
Colak, et al. Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment. J Am Coll Surg 2003;196:525. [PMID:12691925]
Gong C, et al. A double-blind randomized controlled trial of toremifene therapy for mastalgia. Arch Surg 2006;141(1):43–47. [PMID:16415410]
Bespalov, et al. [Study of an antioxidant dietary supplement “Karinat” in patients with benign breast disease]. Voprosy Onkologii 2004;50:467. [PMID:15605774]