• Painful breast tissue that can be cyclic and usually associated with hormonal changes related to menses, hormones, pregnancy, or menopause.
• Noncyclical pain can be constant or intermittent.
• Pain is often bilateral.
System(s) Affected: Skin/Exocrine
Synonym(s): Mastalgia, Breast pain


  • Predominant age   - Generally adolescence through menopause
  • Predominant sex   - Most common in women, rarely men   - May occur in adolescent males during puberty

Most mild, but 11% report mild to severe pain


  • Diet high in saturated fats
  • Cigarette smoking
  • Recent weight gain
  • Pregnancy
  • Large pendulous breasts (caused by stretching of Cooper’s ligament)
  • Caffeine has not been shown to be a risk factor

Familial tendency


  • Hormonal influences (i.e., hormone replacement therapy, OCPs, pregnancy, menses, puberty, menopause)
  • Benign breast disorders (i.e., fibrocystic changes)
  • Lactation problems (engorgement, mastitis, breast abscess)
  • Extramammary tissue
  • Hidradenitis suppurativa
  • Breast masses, including breast cancer
  • Postthoracotomy syndrome
  • Spinal and paraspinal disorders
  • Potential side effects of medications
  • Postradiation effects
  • Costochondritis (Tietze syndrome)
  • Trauma (including sexual abuse/assault)


  • Premenstrual syndrome
  • Pregnancy


  • Breasts aching, heavy, or tender
  • Breasts enlarged


  • Duration, frequency, associated symptoms, related activities
  • Past medical history with focus on Gyn/OB history
  • Diet/smoking
  • Family history (especially of breast cancer)

Physical Exam
Examine for nipple discharge, skin changes, lymphadenopathy, breast mass


  • Possibly thyroid-stimulating hormone test
  • Prolactin test if galactorrhea is found
  • Papanicolaou test of discharge, if any present

No relevant findings

Mammography and/or ultrasound (if <35 years) to rule out cancer

Diagnostic Procedures/Surgery

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

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


  • 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




  • 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

Decrease fat intake to 20% of total calories.

No restrictions

Correct any breastfeeding difficulties; treat underlying mastitis or breast abscess


Complementary and Alternative Medicine
Vitamin E and evening primrose oil has not been found to be of benefit for chronic mastalgia


First Line

  • No drugs are needed unless required by severity of symptoms.
  • Reassurance, acetaminophen, ibuprofen, or topical NSAIDs .

Second Line

  • Frequently used agents (limited evidence to support their effectiveness)   - Diuretics (usually spironolactone) before 5 days prior to menses   - Oral contraceptives may help some patients.   - If on oral contraceptive, switch to one that has a slightly higher progesterone 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.   - Bromocriptine: 2.5-5.0 mg/d. Major adverse effects: Nausea, dizziness, orthostatic hypotension   - Tamoxifen: 10 mg/d. Major adverse effects: Cataracts, hepatocellular carcinoma, endometrial carcinoma. May be used during luteal phase only.   - Toremifene   - Gonadotropin-releasing hormone agonists: Induces menopause

Patient may need reduction mammoplasty if cause is macromastia.


  • Premenstrual mastalgia increases with age, then generally stops at menopause unless patient is receiving hormone replacement therapy.
  • 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.
  • If other treatment fails, a final possibility is subcutaneous mastectomy (used rarely).
  • Oophorectomy is drastic, but may also provide relief for some patients.


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

611.71 Mastodynia

1. Davies EL, Gateley CA, Miers M, Mansel RE. The long-term course of mastalgia. J R Soc Med. 1998;91:462.
2. Ader DN, Shriver CD. Cyclical mastalgia: Prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg. 1997;185:466.
3. Levinson W, Dunn PM. Nonassociation of caffeine and fibrocystic breast disease. Arch Intern Med. 1986;146:1773.
4. Colak et al. Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment. J Am Coll Surg. 2003;196:525.
5. Bespalov et al. [Study of an antioxidant dietary supplement “Karinat” in patients with benign breast disease]. Voprosy onkologii. 2004;50:467.
6. 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.
7. McFadyen et al. A randomized double blind-cross over trial of soya protein for the treatment of cyclical breast pain. Breast. 2000;9:271.
8. Gong C, Song E, Jia W, et al. A double-blind randomized controlled trial of toremifene therapy for mastalgia. Arch Surg. 2006;141(1):43-47.

Anya S.Koutras, MD

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