Mastalgia

Aka: Mastalgia, Breast Pain, Mastodynia

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II. Epidemiology

  1. Severe Breast Pain occurs in up to 11% of women

III. Pathophysiology

  1. Breast Pain thought to be related to Estrogen excess

IV. Causes

  1. See Medication Causes of Mastalgia
  2. Cyclic Breast Pain (responsible for two thirds of all Breast Pain, esp. age 20-40 years old)
    1. Pain related to Menses (typically during Luteal Phase, second half of cycle)
    2. Diffuse, bilateral Breast Pain radiating into the axilla
  3. Non-cyclic Breast Pain (inflammatory)
    1. See Chest Wall Pain
    2. See Chest Pain
    3. Costochondritis
    4. Chest Trauma
    5. Sclerosing adenosis
    6. Large pendulous Breasts
    7. Medication Causes of Mastalgia
    8. Breast Cancer (represents under 5% of Breast Pain)
      1. Associated with focal Breast Pain (contrast with diffuse Breast Pain in benign Mastalgia)

V. History

  1. Location: Focal or Diffuse
    1. Focal Breast Pain more concerning for malignancy than diffuse pain
  2. Duration of Breast Pain
  3. Unilateral or Bilateral
  4. Changes with Menstrual Cycle
  5. Relationship to hormonal replacement therapy
  6. Rank Breast Pain on a 10 point scale
  7. Altered life style
  8. Excessive Worry or emotional stress

VI. Exam

  1. Clinical Breast Exam
  2. Heart and Lung Exam
  3. Abdominal exam
  4. Musculoskeletal Exam (e.g. chest wall, Shoulder, thoracic back)

VII. Labs

  1. No specific lab testing is indicated in Mastalgia

VIII. Differential Diagnosis

  1. See Chest Wall Pain
  2. Non-cyclical Breast Pain causes (as above)
  3. Referred pain (cardiopulmonary, gastrointestinal)

IX. Evaluation

  1. Breast Mass present
    1. Evaluate as Breast Mass (imaging, possible biopsy, consider Breast surgeon referral)
    2. Simple Breast cyst may undergo Breast Cyst Aspiration
  2. Diffuse Breast Pain, no Breast Mass present, and no significant Breast Cancer Risk Factors
    1. Diagnostic Mammography starting at age 40 years (or age 30 years if Breast Cancer Risk Factors)
    2. Low risk for malignancy
      1. Risk of malignancy 0.5% after negative Mammography and Clinical Breast Exam
      2. Holbrook (2018) J Am Coll Radiol 15(115): S276-82 [PubMed]
  3. Focal Breast Pain and no Breast Mass present
    1. Precautions
      1. Consider referred pain sources from the chest and Abdomen
    2. Younger than age 30 years
      1. Consider targeted breast Ultrasound
      2. Consider repeat Breast Exam in 1-2 months
    3. Older than age 30 years
      1. Step 1: Breast Imaging
        1. Diagnostic Mammogram AND
        2. Targeted breast Ultrasound
      2. Step 2a: Negative Breast imaging
        1. Breast Cancer Risk Factors
          1. Consider subspecialist referral
          2. Routine Mammography starting at age 30 years
        2. No Breast Cancer Risk Factors
          1. Very reassuring as low risk for malignancy
          2. Routine Mammography starting at age 40 years
      3. Step 2b: Abnormal Breast imaging
        1. Breast FNA or Breast core biopsy

X. Associated Conditions

  1. Premenstrual Dysphoric Disorder (PMDD or PMS)

XI. Management: Measures with best efficacy

  1. Expect spontaneous resolution in up to 80-90% of patients
  2. General measures
    1. Wear supportive Brassiere or Sports Bra
    2. Arrange formal bra fitting
      1. Poorly fitting bra identified in up to 70% of women
      2. Properly fitting bra should reduce tension on the Cooper ligaments (esp. in large Breasted women)
      3. Reduced Breast Pain in up to 85% of women who adjust the bra fit
    3. Manage stress, anxiety and depressed mood
  3. First-line preparations
    1. NSAIDs
    2. Topical Diclofenac (Solaraze)
  4. Moderate persistent symptoms
    1. Tamoxifen (first-line)
      1. Dose: 10 mg daily for 3 months (may extend for an additional 3 months if effective)
      2. Highly effective (in up to 90% of patients), but symptoms return after discontinuation
      3. Anti-Estrogenic effects (Hot Flashes) and itfvctygvgc ncreased Venous Thromboembolism Risk
    2. Danazol
      1. Anterior pituitary suppressant that is FDA approved for Mastalgia
      2. Dose: Start at 200 mg daily and reduce to 100 mg daily after pain decreases
      3. Less effective than Tamoxifen and with increased androgenic effects, Menorrhagia, myalgias
  5. Severe, refractory symptoms
    1. Goserelin (Zoladex)
      1. Marked, but reversible ovarian suppression to post-menopausal levels
      2. Menopause symptoms
      3. May be used for up to 6 months

XII. Management: Other measures with less supporting evidence

  1. Eliminate Caffeine
  2. Vitamin E Supplementation up to 800 IU qd
  3. Herbal therapies with variable efficacy
    1. Evening Primrose Oil 1500-3000 mg orally daily
    2. Chaste Tree Berry 30 to 40 mg orally daily (PMS)
    3. References
      1. Hardy (2000) J Am Pharm Assoc 40:234-42 [PubMed]
  4. Medroxyprogesterone
    1. Dose: 150 mg IM q3 months
    2. Very effective in pre-menopausal women
      1. Marked reduction in Mastalgia
    3. Reference
      1. Euhus (1997) J Am Coll Surg 184:596-604 [PubMed]

XIII. Resources

  1. Breast Pain (BMJ)
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200534/pdf/2014-0812.pdf

XIV. References

  1. Belieu (1994) Obstet Gynecol Clin North Am 21:461-77 [PubMed]
  2. Conry (1994) Am Fam Physician 49(2): 445-50 [PubMed]
  3. Goyal (2014) BMJ Clin Evid 2014:0812 [PubMed]
  4. Salzman (2019) Am Fam Physician 99(8): 505-14 [PubMed]
  5. Salzman (2012) Am Fam Physician 86(4): 343-9 [PubMed]
  6. Smith (2004) Mayo Clin Proc 79(3): 353-72 [PubMed]
  7. Srivastava (2007) Breast 16(5): 503-12 [PubMed]

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