• 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
- Large pendulous breasts (caused by stretching of Cooper’s ligament)
- Caffeine has not been shown to be a risk factor
- 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
SIGNS AND SYMPTOMS
- Breasts aching, heavy, or tender
- Breasts enlarged
- Duration, frequency, associated symptoms, related activities
- Past medical history with focus on Gyn/OB history
- Family history (especially of breast cancer)
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
- Cysts may need to be aspirated to relieve symptoms and verify diagnosis.
- Biopsies may be indicated based on results of examination or mammography.
- 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.
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
- No drugs are needed unless required by severity of symptoms.
- Reassurance, acetaminophen, ibuprofen, or topical NSAIDs .
- 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.
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
|Comments||[ + Post Your Own ]|
Now you're in the public comment zone. What follows is not Armenian Medical Network's stuff; it comes from other people and we don't vouch for it. A reminder: By using this Web site you agree to accept our Terms of Service. Click here to read the Rules of Engagement.
There are no comments for this entry yet. [ + Comment here + ]
We are pleased to let readers post comments about an article. Please increase the credibility of your post by including your full name and email.
All comments are reviewed by our editors before they are posted on the site. Just keep it clean, kids.