Mastalgia- Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

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

Epidemiology

Incidence

  • Predominant sex: Most common in women but occurs occasionally in men
  • Predominant age: Generally seen from adolescence through menopause
  • Frequency of breast cancer with those reporting breast pain ranges from 1.2–6.7% (1)[B].
  • Up to 70% of women report some degree of breast pain at some point in their lives (2)[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)
  • Exogenous hormones
  • Caffeine has not been shown to be a risk factor (3)[B].

Genetics

Familial tendency

General Prevention

  • Avoid exposure to risk factors.
  • Properly fitted bra support

Pathophysiology

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

Etiology

  • Benign breast disorders (e.g., fibrocystic changes)
  • Trauma (including sexual abuse/assault)
  • Diet and lifestyle
  • Lactation problems (e.g., 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 (e.g., pulmonary, cardiac, or gallbladder disease)
  • Ductal ectasia

Mammography, fibrocystic changes, lactation problems, breast pain, saturated fats, hormonal factors,

Diagnosis

History

  • Location, duration, frequency, severity, associated symptoms, related activities (e.g., trauma), and aggravating and ameliorating factors
  • Complete medical history with focus on gynecologic/obstetric history
  • Complete systematic review of systems
  • Diet/smoking history
  • Detailed family history for risk assessment for breast cancer

Physical Exam

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

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • If galactorrhea is found, check a fasting prolactin level.
  • Possibly thyroid-stimulating hormone

Imaging

  • Consider ultrasound in women with focal, persistent breast pain.
  • Mammogram ± ultrasound in women aged 30–35 years of age or older

Pediatric Considerations

  • Ultrasound is the imaging test of choice for children and adolescents. Mammogram is not useful.

Diagnostic Procedures/Surgery

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

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 also can worsen symptoms.
  • Chest wall pain or referred pain resulting from splenomegaly also must be differentiated from mastalgia.
  • Sometimes cyclic pain is concurrent with premenstrual syndrome.
  • Ductal ectasia of the breast

Treatment

Medication

First Line

Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (4)[B]

Second Line

  • Oral contraceptives may help some patients prevent fibrocystic disease but may worsen pain in some sensitive patients (5)[A].
  • If patient is on an oral contraceptive, switch to one that has a lower estrogen component.
  • In some patients with mastalgia only during their menses, menstrual suppression with continuous oral contraceptives may be of benefit.
  • Oral progesterone 10 mg PO daily
  • Other possibilities for patients with refractory symptoms, used infrequently because of potential side effects, include
    • Danazol 100 mg b.i.d. (possibly lower doses) may be the most effective; major adverse effects include menstrual irregularities, weight gain, acne, hirsutism, and voice change; may be used during luteal phase only; approved by the Food and Drug Administration (FDA) for this indication
    • Toremifene 30 mg PO daily (6)[A]
    • Bromocriptine 5 mg PO daily and cabergoline 0.5 mg PO weekly both during the 2nd half of the menstrual cycle are equally effective, but cabergoline has fewer side effects (7)[A].

Additional Treatment

If the patient is breast-feeding, correct any breast-feeding difficulties; treat underlying mastitis or breast abscess.

General Measures

  • Stop or modify current hormonal therapy.
  • Repeat examination may help to 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

Pediatric Considerations

Children and adolescents may require referral to a specialist.

Complementary and Alternative Medicine

  • Vitamin E and evening primrose oil have not been found to be of benefit for chronic mastalgia (1,8)[B].
  • Flax seed oil is not effective for the treatment of mastalgia (9)[C].

Surgery/Other Procedures

Some patients may need surgical breast reduction.

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Ongoing Care

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.
  • There is no strong evidence that reduction in caffeine intake may help to decrease the severity or incidence of the disease (10)[C].

Patient Education

Avoid or adjust of risk factors.

Prognosis

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

References

1. Smith RL, et al. Evaluation and management of breast pain. Mayo Clinic Proc. 2004;79:353.

2. Ader DN, Shriver CD. Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg. 1997;185:466–70.

3. Levinson W, Dunn PM. Nonassociation of caffeine and fibrocystic breast disease. Arch Intern Med. 1986;146:1773–5.

4. Colak T, Ipek T, Kanik A, et al. Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment. J Am Coll Surg. 2003;196:525–30.

5. Machado RB, de Melo NR, Maia H et al. Bleeding patterns and menstrual-related symptoms with the continuous use of a contraceptive combination of ethinylestradiol and drospirenone: a randomized study. Contraception. 2010;81:215–22.

6. Gong C, Song E, Jia W, et al. A double-blind randomized controlled trial of toremifene therapy for mastalgia. Arch Surg. 2006;141:43–7.

7. Aydin Y, Atis A, Kaleli S, et al. Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: A randomised, open-label study. European journal of obstetrics, gynecology, and reproductive biology. 2010

8. Pruthi S, Wahner-Roedler DL, Torkelson CJ, et al. Vitamin E and evening primrose oil for management of cyclical mastalgia: a randomized pilot study. Altern Med Rev. 2010;15:59–67.

9. Basch E, Bent S, Collins J, et al. Flax and Flaxseed Oil (Linum usitatissimum): A Review by the Natural Standard Research Collaboration. J Soc Integr Oncol. 2007;5:92–105.

10. Gumm R, Cunnick GH, Mokbel K. Evidence for the management of mastalgia. Curr Med Res Opin. 2004;20:681–4.

Additional Reading

Blommers J, de Lange-De Klerk ES, Kuik DJ, et al. Evening primrose oil and fish oil for severe chronic mastalgia: a randomized, double-blind, controlled trial. Am J Obstet Gynecol. 2002;187:1389–94.

12. Brennan M, Houssami N, French J. Management of benign breast conditions. Part 1–Painful breasts. Aust Fam Physician. 2005;34:143–4.

13. Campagnoli C, Ambroggio S, Lotano MR, Peris C et al. Progestogen use in women approaching the menopause and breast cancer risk. Maturitas. 2009;62:338–42.

14. McFadyen IJ, Chetty U, Setchell KD, et al. A randomized double blind-cross over trial of soya protein for the treatment of cyclical breast pain. Breast. 2000;9:271–6.

15. Miltenburg DM, Speights VO et al. Benign breast disease. Obstet Gynecol Clin North Am. 2008;35:285–300, ix

16. Olawaiye A, Withiam-Leitch M, Danakas G, et al. Mastalgia: a review of management. J Reprod Med. 2005;50:933–9.

17. Qureshi S, Sultan N. Topical nonsteroidal anti-inflammatory drugs versus oil of evening primrose in the treatment of mastalgia. Surgeon. 2005;3:7–10.

See Also (Topic, Algorithm, Electronic Media Element)

Premenstrual Syndrome (PMS); Premenstrual Dysphoric Disorder

Algorithms: Breast Discharge; Breast Pain

Codes

ICD9

611.71 Mastodynia

Snomed

53430007 pain of breast (finding)

Clinical Pearls

  • When evaluating a patient with breast pain, always rule out cancer first.
  • In the adolescent population, do not biopsy; instead, refer to a pediatric specialist.
  • Premenstrual mastalgia increases with age and then generally stops at menopause unless patient is receiving HT.

About the author

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