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Mastalgia
Eduardo Lara-Torre, MD
Amanda B. Murchison, MD
Patrice M. Weiss, MD, FACOG
image BASICS
DESCRIPTION
  • Painful breast tissue, often bilateral, which can be cyclic or noncyclic
    • 2/3 of breast pain is cyclic and 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 to menopause
  • Frequency of breast cancer with those reporting breast pain ranges from 1.2% to 6.7%.
  • Up to 70% of women report some degree of breast pain at some point in their lives.
  • Most describe mild pain, but 11% describe pain as moderate to severe.
  • Higher incidence in the older population, larger breasted individuals, and those who are less fit and active (1)[B].
ETIOLOGY AND PATHOPHYSIOLOGY
  • Causative pathophysiology remains unclear but is thought to be related to hormonal or nutritional factors.
  • When fibrocystic disease is the source, growth and distension of the cyst with hormonal fluctuation can 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.
  • Benign breast disorders (e.g., fibrocystic changes)
  • Trauma (including sexual abuse/assault)
  • Diet and lifestyle (e.g., poor-fitting exercise breast support)
  • 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
Genetics
Familial tendency
RISK FACTORS
  • Diet high in saturated fats
  • Cigarette smoking
  • Recent weight gain
  • Pregnancy
  • Large, pendulous breasts (caused by stretching of Cooper ligaments)
  • Exogenous hormones
  • Caffeine has been shown not to be a risk factor (2)[A].
GENERAL PREVENTION
  • Avoid exposure to risk factors.
  • Properly fitted bra support
image DIAGNOSIS
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 that are suggestive of breast malignancy.
DIFFERENTIAL DIAGNOSIS
  • The most important disease to rule out is breast cancer (although uncommon), 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
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • If galactorrhea is found, check a fasting prolactin level.
  • Consider thyroid-stimulating hormone (TSH).
  • Consider an ultrasound in women with focal, persistent breast pain.
  • Mammogram ± ultrasound in women aged ≥30 to 35 years
Pediatric Considerations
Ultrasound is the imaging test of choice for children and adolescents. A mammogram is not useful.
Diagnostic Procedures/Other
  • Cysts may need to be aspirated to relieve symptoms or verify diagnosis.
  • Biopsies may be indicated based on the results of examination, ultrasound, or mammography.
Pediatric Considerations
In children and adolescents, do not perform biopsies unless there is a suspicion for cancer. Refer to a specialist in pediatric breast disease.
Test Interpretation
  • 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
image TREATMENT
GENERAL MEASURES
  • Stop or modify the current hormonal therapy.
  • A repeat examination may help to establish any cyclic nodularity pattern.
  • Wear a properly fitted support bra (may be fitted by a professional).
  • Reassurance (sufficient for most patients)
  • Weight loss for obese patients
  • Smoking cessation
  • Relaxation training
MEDICATION
First Line
Acetaminophen or NSAIDs, either oral or topical (e.g., diclofenac sodium or piroxicam) (4)[B]
P.637

Second Line
  • Oral contraceptives may help some patients prevent fibrocystic disease but may worsen pain in some sensitive patients.
  • If the patient is on an oral contraceptive, switch to the 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 the following:
    • Danazol: 100 mg BID (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 FDA for this indication
    • Toremifene: 30 mg PO daily (5)[B]
    • 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 (6)[B].
    • Tamoxifen or Centchroman: Selective estrogen receptor modulators (SERM) may be used with a dose of 10 mg or 30 mg daily respectively (7)[A].
ADDITIONAL THERAPIES
If the patient is breastfeeding, correct any breastfeeding difficulties; treat underlying mastitis or breast abscess.
Pediatric Considerations
Children and adolescents may require referrals to a specialist.
SURGERY/OTHER PROCEDURES
Some patients may need surgical breast reduction.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Vitamin E and evening primrose oil have not been found to be of benefit for chronic mastalgia (2)[A].
  • Flaxseed oil is not effective for the treatment of mastalgia (2)[C].
image 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.
  • No evidence suggests that reduction in caffeine intake may help to decrease the severity or incidence of the disease (3)[A].
PATIENT EDUCATION
Avoid or adjust risk factors.
PROGNOSIS
  • Premenstrual mastalgia increases with age and then generally stops at menopause unless the 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. Scurr J, Hedger W, Morris P, et al. The prevalence, severity, and impact of breast pain in the general population. Breast J. 2014;20(5):508-513.
2. Chase C, Wells J, Eley S. Caffeine and breast pain: revisiting the connection. Nurs Womens Health. 2011;15(4):286-294.
3. Genc V, Genc A, Ustuner E, et al. Is there an association between mastalgia and fibromyalgia? Comparing prevalence and symptom severity. Breast. 2011;20(4):314-318.
4. Ahmadinejad M, Delfan B, Haghdani S, et al. Comparing the effect of diclofenac gel and piroxicam gel on mastalgia. Breast J. 2010;16(2):213-214.
5. Gong C, Song E, Jia W, et al. A double-blind randomized controlled trial of toremifen therapy for mastalgia. Arch Surg. 2006;141(1):43-47.
6. Aydin Y, Atis A, Kaleli S, et al. Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: a randomised, openlabel study. Eur J Obstet Gynecol Reprod Biol. 2010;150(2):203-206.
7. Jain BK, Bansal A, Choudhary D, et al. Centchroman vs tamoxifen for regression of mastalgia: a randomized controlled trial. Int J Surg. 2015;15:11-16.
Additional Reading
&NA;
  • Ader DN, Shriver CD. Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg. 1997;185(5):466-470.
  • 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(5):1389-1394.
  • Brennan M, Houssami N, French J. Management of benign breast conditions. Part 1—painful breasts. Aust Fam Physician. 2005;34(3):143-144.
  • Colak T, Ipek T, Kanik A, et al. Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment. J Am Coll Surg. 2003;196(4):525-530.
  • Miltenburg DM, Speights VO Jr. Benign breast disease. Obstet Gynecol Clin North Am. 2008;35(2):285-300.
  • Olawaiye A, Withiam-Leitch M, Danakas G, et al. Mastalgia: a review of management. J Reprod Med. 2005;50(12):933-939.
  • Rosolowich V, Saettler E, Szuck B. SOGC Clinical Practice Guideline: Mastalgia. Ottawa, Canada: Society of Obstetricians and Gynaecologists of Canada; 2006. http://sogc.org/guidelines/mastalgia/
  • Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clinic Proc. 2004;79(3):353-372.
See Also
&NA;
  • Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)
  • Algorithms: Breast Discharge; Breast Pain
Codes
&NA;
ICD10
N64.4 Mastodynia
Clinical Pearls
&NA;
  • 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 the patient is receiving HT.