• 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