Event 2: Mastalgia

Introduction

Illustration that shows a woman's breasts circled with the words, "Breast pain, slight swelling, and tenderness"
Mastalgia symptoms
  • General mastalgia (breast pain) is a common complaint by many women
  • Mastalgia can be caused by multiple factors
  • Breast pain rarely is a symptom of breast cancer

Mastalgia Categories

Mastalgia is divided into 3 categories:

  1. Cyclic
  2. Non-Cyclic
  3. Extramammary

Causation should be established

  • Some women may experience a change in quality of life and need to explore treatment options

Incidence Rate

Up to 70% of women will experience breast pain at some point in their life

Pie chart illustration showing 70% of women reporting breast pain with 10% of that 70% have daily lives affected and require pain treatment
Percentage of women experiencing breast pain

10% of women with breast pain may experience change of life and will require some type of pain-relieving treatment.

Reference

Crochetiere C, 2005

Etiology of General Mastalgia in Normal Breasts

Physical Activity: (Cause for Non Cyclic and Extramammary Breast Pain)

  1. Trauma to breast (breast blow)
  2. Costochondritis

Medications

  1. Antipsychotics 
  2. Oxymetholone
  3. Chlorpromazine
  4. Diuretics
  5. Digitalis preparations
  6. Methyldopa
  7. Spironolactone

Hormones

  1. Estrogen 
  2. Progesterone 
  3. Oral contraception 
  4. Clomiphene

Reference

Rodden  AM, 2009; Smith RL et al., 2004; Breast Pain, 2014

Exam for Mastalgia

  1. Patient History
  2. Patient describes pain, location of pain, relation to their menstrual cycle or any physical activity, interference with their daily living and any family/personal history of breast cancer
  3. Obtain medication history, medical conditions, caffeine intake, stress level, smoking status
  4. Physical breast examination (Click for more information on next slide)
    • Entire breast area should be examined (lymph nodes, cervical and thoracic spine, chest wall, and arm pits)
    • Patient should be in supine position in an effort to determine if pain is extramammary or breast pain
    • If breast mass is felt during the examination – refer for radiographic  work

Breast or Extramammary Pain

It can be difficult to determine if the pain is in the breast or if extramammary or musculoskeletal pain.

Illustration showing highlight box on a woman's breast with the words, "True breast pain" and a highlight box over the rib cage area with the words, "Musculoskeletal pain."
Breast or extramammary pain

Reference

© Iddon J, & Dixon JM (2013). Used by permission
http://www.bmj.com/content/347/bmj.f3288?variant=long&sso=

Differentiating Breast or Extramammary Pain

  • Have patient lay on her side so the breast falls from chest
  • Examine discomfort in muscles of the chest wall and question if pain during exam is similar to usual pain experienced
  • If there is pain in the lower part of the breast, underlying chest wall is examined
    • Lift the breast with one hand and exam the chest wall with the other hand
    • Have the patient confirm if that is the area for maximal pain and tenderness
    • This will help determine if the pain is in the breast or if it is extramammary

Treatment for Mastalgia

Treatment for mastalgia typically consists of:

  • Medical Treatment
  • Reassurance for the Patient
  • Alternative Treatments
Pie chart illustration showing 85% of women do not require medical treatment for mastalgia
Percentage of women who require medical treatment for mastalgia

A majority of patients are treated with simple reassurance. 85% do not require medical treatment. Only 15% require medical treatment for mastalgia.

Treatment Steps

  1. Etiologic treatment
  2. Symptomatic treatment
  3. Reassurance
  4. Follow-up

Hormone-Related Treatment

Mastalgia Treatment (Hormone-Related)
Hormonal Treatment Discussion
Danazol
  • Synthetic Androgen 
  • Only current medication approved by FDA for treatment of mastalgia
  • 200 mg/day starting on 2nd day of menstrual cycle
  • 100mg-400mg can be used for moderate to severe cases
  • Shown to cause serious side effects and are usually only used for severe breast pain
Tamoxifen
  • Not FDA approved
  • Selective estrogen receptor modulator
  • 10-20mg/daily
  • Shown to cause serious side effects and are usually only used for severe breast pain
Bromcriptine
  • Not FDA approved
  • Dopamine agonist
  • Goal of 2.5mg twice daily (start with 1.25 mg and increase by 1.25 mg daily)
  • Shown to cause serious side effects and are usually only used for severe breast pain
Centchroman
  • Has been found to be safe and effective alternative to Danazol for treatment of mastalgia
Lisuride
  • Dopamine agent
Goserelin (Zoladex)
  • Luteinizing hormone-releasing hormone
  • 3.6mg by injection each month
  • Side effects associated

Medication-Related Treatment

Mastalgia Treatment (Medication-Related)
Pain Treatments Discussion
Nonsteroidal anti-inflammatory drugs (NSAIDS)
  • Used for pain and bruising. Reduce pain quickly. Effective for both cyclic and non-cyclic mastalgia 
  • Non-serious side effects associated: such as irritation and skin eruption, and gastrointestinal side effects.
  • Used as symptomatic treatment
Acetaminophen
  • Used as symptomatic treatment

Reference

Breast pain, 2005; Onstad M, & Stuckey A, 2013; Amin  AL, et al., 2013; Colak T, et al., 2003; Tejwani PK, et al., 2010; Rodden AM, 2009

Considerations for Mastalgia Treatment

Reassurance for The Patient

  • Women sometimes fear breast pain may indicate breast cancer
  • Women just need simple reassurance
  • Non-randomized studies have found reassurance is effective in 70% of women 
  • Breast pain is not a major symptom of breast cancer
    • In a study conducted at symptomatic breast unit in Ireland, 5,841 patients were referred with mastalgia
      • 3,331 (57%) of those 5,841 reported mastalgia as their only symptom
      • Patients who reported their only symptom was mastalgia had a breast cancer incidence rate of 1.2%
      • Of those diagnosed with beast cancer, all were over the age of 35
  • Overall prevalence of breast cancer in women with mastalgia is 0-3.2%

Alternative Treatments

Mastalgia Treatment (Alternative Treatments)
Supportive bra
  • May help to wear a well-fitting bra, especially for exercise and sleep
  • Limits breast movement which can help with breast pain
Avoid caffeine and nicotine
  • No proof that caffeine or nicotine affects breast pain, but some women have reported a sense of relief while avoiding both
Very low-fat and reduced sodium diet
  • No studies have provided significant evidence to support this treatment 
  • However, it is still thought that a diet containing 15%-20% of daily calories from fat can help to reduce breast tenderness and swelling
Massage with Ice packs/heat compress
  • Can help to massage cold compress onto breast
Primrose oil
  • Because there are no side effects associated, this may be recommended as 1st treatment step
Fish oil supplements
  • Some women have reported relief with the use of fish oil and the fatty acids
Relaxation therapy
  • Engaging in relaxation and stress reducing techniques has been shown to help reduce pain

Reference

Breast pain, 2005; Onstad M, & Stuckey A, 2013; Amin AL, et al., 2013; Colak T, et al, 2003; Rodden AM, 2009

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