Mastalgia

Mastodynia, mastalgia or mammalgia are names for a medical symptom that means - pain in the breast (from the Greek masto-, breast and algos, pain).

Mastalgia is usually a benign disorder in young women due to hormonal imbalance during their menstrual cycle. During a menstrual cycle the breasts swell and become lumpy and tender. During a period, the breasts reabsorb the extra fluid inside instead of discharging it, causing breast pain. A breast exam and a breast ultrasound should be performed to make sure nothing is hidden.

Epidemiology and Demographics

 * Most common breast symptom leading to office visit
 * More common in premenopausal women
 * Rarely a presenting symptom of cancer
 * Study of women with known breast cancer: 7% presented with mastalgia alone
 * Women referred for mammogram because of mastalgia:
 * 0.4% had breast cancer (same as controls)
 * 87% had normal mammogram
 * 9% had benign abnormalities

Types
It can be subdivided into 2 main clinical patterns:
 * cyclical when the pain is worse prior to each menstrual cycle
 * This may occur with a woman's natural menstrual cycles and is not due to any hormone or breast disease.
 * It may be caused by use of hormonal contraception


 * non-cyclical when the pain is unrelated to periods.
 * It may be related to the underlying muscle
 * Trauma and resulting haematoma
 * Infection is sometimes responsible, particularly during times of breast feeding.
 * Breast engorgement during breast feeding (mastitis)
 * Arthritis pain in the chest or neck felt as if it is coming from the breast.

Associations
Breast cancer is, in 19 out of 20 cases, not normally painful in the early stages. New onset of a painless lump should therefore be promptly assessed.

History and Symptoms

 * Timing of Pain
 * Cyclic
 * Associated with menstrual cycle, worst before the menses
 * Tends to occur in younger women, usually resolves spontaneously
 * Noncyclic
 * Unrelated to menses or in post-menopausal patient
 * Most common in women ages 40-50
 * Can be due to underlying fibroadenoma or cyst
 * May resolve with therapy of underlying lesion
 * Location of Pain
 * Cyclic pain tends to be bilateral, poorly localized, +/- radiation to arm/axilla
 * Noncyclic tends to be unilateral, sharp, well localized
 * Menstrual Irregularities
 * Medications
 * Changes in medications may exacerbate mastalgia

Physical Examination

 * Thorough Breast Exam
 * Best performed 7-9 days after onset of menses in premenopausal patients
 * Should be performed with patient in both lying and sitting positions
 * Goals
 * Note any masses
 * Identify any localized areas of tenderness – correlation to patient symptoms
 * Identify any axillary or supraclavicular LAN
 * Detect skin changes, edema, erythema, or nipple discharge
 * Fibrocystic Changes
 * Lumpy or doughy consistency with no well-defined masses
 * Fibroadenoma
 * Well-defined, mobile mass
 * May be multiple
 * Suspicious Characteristics of a Palpable Mass
 * Single lesion
 * Hard, immobile
 * Irregular border
 * Size > 2 cm

Echocardiography or Ultrasound

 * Women < 35 years old
 * No imaging indicated if normal physical exam
 * Women 35 years old and older
 * If focal pain, can start with ultrasound – rule out focal cystic or solid lesion

Mammogram

 * Women 35 years old and older
 * If global unilateral or bilateral pain, start with bilateral mammogram
 * If ultrasound unrevealing, proceed to mammogram

Causes Related to the Breast

 * Fibrocystic Changes
 * Increased number of cysts or fibrous tissue in otherwise normal breasts
 * Can be associated with pain or nipple discharge – “fibrocystic disease”
 * If fibrocystic changes are cause of pain- found in 50-90% asymptomatic women
 * Hormonal etiology – pain often cyclic; most severe during luteal phase
 * Tissue edema/water retention with dilated/blocked ducts – not proven
 * Mastitis or Breast Abscess
 * Acute onset, usually due to Staphylococcus aureus (S. aureus) or streptococci
 * Erythema, local tenderness induration
 * Most common in lactating women
 * Pendulous Breasts
 * Pain due to stretching of Cooper’s ligaments
 * Hidradenitis Suppurativa
 * Can involve the breast
 * Presents with painful breast nodules

Causes Unrelated to the Breast

 * Trauma to Chest Wall
 * Fat Necrosis
 * Usually induced by trauma
 * Tender, firm mass, +/- calcification on mammogram
 * Costochondritis
 * Intercostal Neuralgia
 * Usually due to a respiratory infection
 * Pleuritic Pain from Underlying Pulmonary/Pleural Disease
 * Thoracic Spine Arthritis
 * Referred Chest Pain
 * Gallbladder disease
 * Ischemic heart disease

Risk Stratification and Prognosis

 * Referral
 * Abnormal findings on exam, mammogram or ultrasound
 * Persistent pain unresponsive to symptomatic treatment

Treatment

 * Reassurance
 * Pain resolves spontaneously in 60-80% and will not require further therapy in 90% of patients
 * Pain, fibrocystic changes, and simple fibroadenomas pose no increase in breast cancer risk
 * Pendulous breasts: soft bra with adequate support

Acute Pharmacotherapies

 * Symptomatic Treatment
 * Indicated for severe pain or pain lasting > a few days each month
 * Analgesia: acetaminophen or NSAIDs (nonsteriodal anti-inflammatory drugs)
 * Premenstrual engorgement: thiazide diuretic for several days during premenstrual symptoms
 * Other potentially beneficial treatments
 * Avoidance of caffeine: no efficacy in randomized controlled trials (RCTs), but some patients report relief
 * Vitamin E: 400 IU bid beneficial in some studies but not others (2 negative RCTs)
 * Primrose oil (linoleic acid): 1.5-3 g qd effective in 40-60%; may take 3 months for results
 * Danazol
 * Only FDA approved therapy for breast pain
 * Inhibits luteinizing hormone/follicle stimulating hormone (LH/FSH) secretion (decreased exocrine secretion); blocks exocrine effects on breast
 * 100-200 mg qd reduces pain and nodularity in patients with fibrocystic disease
 * Response rate 50-75% for both cyclic and noncyclic breast pain
 * Significant side effects in 20% (weight gain, acne, irregular menses, hirsutism)
 * Tamoxifen: 10 mg bid reduces pain in ~70% via antiestrogen effect
 * Bromocriptine: 1.25-5 mg qd may reduce pain via inhibition of prolactin secretion; +/- data
 * Oral contraceptive pills (OCPs): can reduce fibrocystic changes via progestin component; efficacy for pain uncertain
 * Reduction in hormone replacement therapy (HRT) dose: for postmenopausal women, lower E dose may reduce pain

Treatments for cyclical breast pain
Specific treatment for cyclical breast pain will be determined by your physician(s) based on:
 * your overall health and medical history
 * extent of the condition
 * your tolerance for specific medications, procedures, or therapies
 * expectations for the course of the condition

Treatments vary significantly and may include the following:
 * caffeine avoidance
 * a low-fat diet
 * evening primrose oil
 * vitamin E
 * any over-the-counter pain-reliever

In some cases, various supplemental hormones and hormone blockers are also prescribed. These may include:
 * birth control pills
 * Bromocriptin (which blocks prolactin in the hypothalamus)
 * Danazol, a male hormone
 * thyroid hormones
 * Tamoxifen, an estrogen blocker

Supplemental hormones and hormone blockers may have side effects. In addition, the risks and benefits of such treatment should be carefully discussed with your physician.

Treatments for non-cyclical breast pain
Determining the appropriate treatment for noncyclical breast pain is more difficult, not only because it is hard to pinpoint where the pain is coming from, but also because the pain is not hormonal. Specific treatment for noncyclical breast pain will be determined by your physician(s) based on:
 * your overall health and medical history
 * extent of the condition
 * your tolerance for specific medications, procedures, or therapies
 * expectations for the course of the condition

Generally, physicians will perform a physical examination and may order a mammogram. In some cases, a biopsy of the area is also necessary. If it is determined that the pain is caused by a cyst, the cyst will be aspirated. Depending on where the pain originates, treatment may include analgesics, anti-inflammatory drugs, and compresses.

Acknowledgements
The content on this page was first contributed by: Rebecca Cunningham, M.D.,