• 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
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