Mastodynia

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• 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

EPIDEMIOLOGY

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

Incidence
Most mild, but 11% report mild to severe pain

RISK FACTORS

• 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

Genetics
Familial tendency

ETIOLOGY

• 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)

ASSOCIATED CONDITIONS

• Premenstrual syndrome
  
• Pregnancy

SIGNS AND SYMPTOMS

• Breasts aching, heavy, or tender
  
• Breasts enlarged

History

• 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

TESTS

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

Lab
No relevant findings

Imaging
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

DIFFERENTIAL DIAGNOSIS

• 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

TREATMENT

STABILIZATION
Outpatient

GENERAL MEASURES

• 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

Diet
Decrease fat intake to 20% of total calories.

Activity
No restrictions

Nursing
Correct any breastfeeding difficulties; treat underlying mastitis or breast abscess

SPECIAL THERAPY

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

MEDICATION (DRUGS)

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

SURGERY
Patient may need reduction mammoplasty if cause is macromastia.

PROGNOSIS

• 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.

PATIENT MONITORING

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

CODES
ICD9-CM
611.71 Mastodynia

REFERENCES
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

RELATED STORIES:
Diagnostic Mammography   Using Breast Density to Predict Breast Cancer Risk   Radiation treatment for breast cancer   Fibroadenoma   Assessment of Risk and Choice of Adjuvant Therapy   Chemotherapy - Breast Cancer Palliative Treatment   Fat Necrosis   Epithelial Hyperplasia   The Mammogram Report: The Breast Imaging Reporting and Data System (BI-RADS™) Lexicon   Quality Assurance   Nipple Problems and Discharge   Needle Localization   Disease Burden - Screening for Breast Cancer   Breast Pain   Sclerosing Lymphocytic Lobulitis / Diabetic Mastopathy   The Breast Cancer Alternative Hypothesis   Uterine or Ovarian Enlargement in patients with breast cancer   Sexuality and Breast Cancer Survivorship - Key Practice Points   Molecular Biology of Preliferative Breast Disease   Radiation Therapy for Axillary Control   Sensitivity, Specificity, and Positive Predictive Value   Surveillance Options for Individuals with BRCA1 or BRCA2 Mutations

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