• Pain in the breast

Mastalgia

• Mastodynia affects up to 70% of women at some time in their lives.
• Severe cyclic mastodynia lasting more than 5 days/mo and of sufficient intensity to interfere with sexual, physical, social, and work-related activities is reported among 30% of premenopausal women.
• Risk factors include increasing age, larger breast size, and physical inactivity.
• Approximately 15% of women with mastodynia require pain-relieving therapy.

• Usually the breasts are normal on exam bilaterally.
• Generalized breast nodularity without discrete lumps.
• Extramammary breast pain: Chest wall tenderness, unilateral, aggravated by activity.
  1. If pain is extramammary, with the patient lying on her side so that the breast tissue falls away from the chest wall, tenderness can then be reproduced by direct pressure over the offending site.
• Cyclic mastodynia presents in the luteal phase of the menstrual cycle 1 wk prior to onset of menses and resolves with menstruation. Most commonly in upper outer quadrant.
• Women with cyclic mastodynia tend to have abdominal bloating, leg swelling, and other symptoms of premenstrual syndrome.
• Noncyclic mastodynia is unrelated to the menstrual cycle.
• Extramammary breast pain simulates noncyclic mastodynia.

• Hormonal imbalance: Theories include increased estrogen, decreased progesterone, and increased prolactin
• Abnormal lipid metabolism, increased saturated fatty acids
• Premenstrual syndrome (20%)
• Fibrocystic breast disease, breast cysts, ductal ectasia
• Emotional abuse and anxiety
• Excessive caffeine intake has not been proven

• See “Etiology”
• Breast cancer
  1. Discrete breast lumps need full evaluation to rule out malignancy
• Mastitis
• Tietze syndrome usually unilateral and may be associated with chest wall swelling

Although hormonal imbalance and abnormal lipid metabolism have been implicated in the etiopathogenesis of mastodynia, there is no good evidence to support any consistent pattern of serum hormonal or lipid profile in women with mastodynia. These tests are therefore not recommended.

• Cyclical, bilateral, or nonfocal: Usually does not require imaging.
• Ultrasound is helpful in the assessment of cystic breast lesions.
• Unilateral, noncyclical, or focal: Mammogram vs. breast ultrasound based on age.
• Consideration of family history for breast disease is important.
• There are no radiologic features associated with mastodynia: Rather, radiologic investigations are performed to exclude the rare presence of a subclinical carcinoma.

• 78% to 85% of women with mastodynia can be reassured after full clinical evaluation. In fact, reassurance can be considered first-line therapy for mastodynia since many women who present are concerned about significant pathology, especially cancer.
• A firm, supportive brassiere designed for postpartum use is particularly helpful if mastodynia is associated with breast swelling.
• Hot or cold compresses.
• Reducing caffeine intake and smoking cessation have not been proven effective but may help some women.

• First line: Oral NSAIDs/acetaminophen
• There is limited evidence supporting the use of evening primrose oil, which contains gamma-linolenic acid, but this may be offered to patients as it is generally benign.
• Topical NSAID preparations (diclofenac, salicylate) may confer some benefit and can be prescribed for these women.
• Hormonal therapy is the mainstay of treatment and may include progesterone-only oral contraceptives or cyclic Provera.
• Tamoxifen, a synthetic antiestrogen, has also been shown to be effective in the treatment of mastodynia. Although effective in relieving symptoms, its use is extremely limited because of side effects, although it has fewer than Danazol. When used, it should be at a low dosage of 10 mg/day and duration should be limited to 6 mo at a time.
• Danazol has some androgenic and peripheral antiestrogenic effects. Its efficacy is well established, with significant relief of mastodynia in 70% to 93% of cases.
  1. Widespread use of danazol is limited because of its adverse side effects. These include menstrual irregularities, depression, acne, hirsutism, and, in severe cases, voice deepening. Women should be advised to use effective nonhormonal contraception because of the drug’s potential adverse effects on the fetus. It is imperative to rule out pregnancy prior to drug initiation.
  2. The side effects of danazol can be significantly reduced by using a low dose (100 mg daily) and confining treatment to 2 wk preceding menstruation. However, alternatives should be explored.
• Bromocriptine is a dopamine-receptor agonist whose primary action is inhibition of prolactin release. It has been used extensively in the treatment of severe cyclic mastodynia and is effective. Again, side effects such as headache and light-headedness have limited its use, and it is less effective than Danazol.
• Lisuride maleate was recently found to be effective by one study.
• Other hormonal agents that have been reported to be effective in small studies cannot be recommended. Either they have unacceptable side effect profiles or their efficacy is not established. These agents include gestrinone, gonadotropin-releasing hormone analogues, progesterone, and hormone replacement therapy.
• Investigational treatments: Phytoestrogens, agnus-castus, chamomile.

• Longstanding cases of mastodynia can be managed with intermittent low-dose danazol therapy to limit side effects. In between these courses of hormone, nonpharmacologic and nonhormonal therapy can be used.
• Severe, unremitting mastodynia that does not respond to medical treatment may require mastectomy; this is rare.

• Cyclic mastodynia resolves spontaneously in 20% to 30% of women.
• Noncyclic mastodynia responds poorly to treatment but may resolve spontaneously in up to 50% of women.

Breast Pain (Patient Information)

Fibrocystic Breast Disease (Related Key Topic)