para>ltrasound is the imaging test of choice for children and adolescents. A mammogram is not useful.
Diagnostic Procedures/Other
- Cysts may need to be aspirated to relieve symptoms or verify diagnosis.
- Biopsies may be indicated based on the results of examination, ultrasound, or mammography.
Pediatric Considerations
In children and adolescents, do not perform biopsies unless there is a suspicion for cancer. Refer to a specialist in pediatric breast disease.
Test Interpretation
- 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
TREATMENT
GENERAL MEASURES
- Stop or modify the current hormonal therapy.
- A repeat examination may help to establish any cyclic nodularity pattern.
- Wear a properly fitted support bra (may be fitted by a professional).
- Reassurance (sufficient for most patients)
- Weight loss for obese patients
- Smoking cessation
- Relaxation training
MEDICATION
First Line
Acetaminophen or NSAIDs, either oral or topical (e.g., diclofenac sodium or piroxicam) (4)[B]
Second Line
- Oral contraceptives may help some patients prevent fibrocystic disease but may worsen pain in some sensitive patients.
- If the patient is on an oral contraceptive, switch to the one that has a lower estrogen component.
- In some patients with mastalgia only during their menses, menstrual suppression with continuous oral contraceptives may be of benefit.
- Oral progesterone: 10 mg PO daily
- Other possibilities for patients with refractory symptoms, used infrequently because of potential side effects, include the following:
- Danazol 100 mg BID (possibly lower doses) may be the most effective; major adverse effects include menstrual irregularities, weight gain, acne, hirsutism, and voice change; may be used during luteal phase only; approved by the FDA for this indication
- Toremifene 30 mg PO daily (5)[B]
- Bromocriptine 5 mg PO daily and cabergoline 0.5 mg PO weekly, both during the 2nd half of the menstrual cycle are equally effective, but cabergoline has fewer side effects (6)[B].
- Tamoxifen or Centchroman: Selective estrogen receptor modulators (SERM) may be used with a dose of 10 mg or 30 mg daily respectively (7)[A].
ADDITIONAL THERAPIES
If the patient is breastfeeding, correct any breastfeeding difficulties; treat underlying mastitis or breast abscess.
Pediatric Considerations
Children and adolescents may require referrals to a specialist.
SURGERY/OTHER PROCEDURES
Some patients may need surgical breast reduction.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Vitamin E and evening primrose oil have not been found to be of benefit for chronic mastalgia (2)[A].
- Flaxseed oil is not effective for the treatment of mastalgia (2)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
As needed
Patient Monitoring
- As needed for patients not receiving pharmacotherapy
- Time of follow-up will vary by type of pharmacotherapy and patient 's particular problems.
DIET
- Decrease fat intake to 20% of total calories.
- No evidence suggests that reduction in caffeine intake may help to decrease the severity or incidence of the disease (3)[A].
PATIENT EDUCATION
Avoid or adjust risk factors.
PROGNOSIS
- Premenstrual mastalgia increases with age and then generally stops at menopause unless the patient is receiving hormone therapy (HT).
- Most patients can control symptoms without receiving HT.
- Several months of HT may provide several more months of relief, but mastalgia may recur.
- Cyclic mastalgia responds better than noncyclic mastalgia to treatment.
- Effects of long-term HT are unknown.
REFERENCES
11 Scurr J, Hedger W, Morris P, et al. The prevalence, severity, and impact of breast pain in the general population. Breast J. 2014;20(5):508 " 513.22 Chase C, Wells J, Eley S. Caffeine and breast pain: revisiting the connection. Nurs Womens Health. 2011;15(4):286 " 294.33 Genc V, Genc A, Ustuner E, et al. Is there an association between mastalgia and fibromyalgia? Comparing prevalence and symptom severity. Breast. 2011;20(4):314 " 318.44 Ahmadinejad M, Delfan B, Haghdani S, et al. Comparing the effect of diclofenac gel and piroxicam gel on mastalgia. Breast J. 2010;16(2):213 " 214.55 Gong C, Song E, Jia W, et al. A double-blind randomized controlled trial of toremifen therapy for mastalgia. Arch Surg. 2006;141(1):43 " 47.66 Aydin Y, Atis A, Kaleli S, et al. Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: a randomised, open-label study. Eur J Obstet Gynecol Reprod Biol. 2010;150(2):203 " 206.77 Jain BK, Bansal A, Choudhary D, et al. Centchroman vs tamoxifen for regression of mastalgia: a randomized controlled trial. Int J Surg. 2015;15:11 " 16.
ADDITIONAL READING
- Ader DN, Shriver CD. Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg. 1997;185(5):466 " 470.
- Blommers J, de Lange-De Klerk ES, Kuik DJ, et al. Evening primrose oil and fish oil for severe chronic mastalgia: a randomized, double-blind, controlled trial. Am J Obstet Gynecol. 2002;187(5):1389 " 1394.
- Brennan M, Houssami N, French J. Management of benign breast conditions. Part 1 " painful breasts. Aust Fam Physician. 2005;34(3):143 " 144.
- Colak T, Ipek T, Kanik A, et al. Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment. J Am Coll Surg. 2003;196(4):525 " 530.
- Miltenburg DM, Speights VOJr. Benign breast disease. Obstet Gynecol Clin North Am. 2008;35(2):285 " 300.
- Olawaiye A, Withiam-Leitch M, Danakas G, et al. Mastalgia: a review of management. J Reprod Med. 2005;50(12):933 " 939.
- Rosolowich V, Saettler E, Szuck B. SOGC Clinical Practice Guideline: Mastalgia. Ottawa, Canada: Society of Obstetricians and Gynaecologists of Canada; 2006. http://sogc.org/guidelines/mastalgia/
- Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clinic Proc. 2004;79(3):353 " 372.
SEE ALSO
- Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)
- Algorithms: Breast Discharge; Breast Pain
CODES
ICD10
N64.4 Mastodynia
ICD9
611.71 Mastodynia
SNOMED
- 53430007 Pain of breast (finding)
- 237453001 Cyclical mastalgia
- 237454007 Non-cyclical mastalgia
- 315250005 Persistent mastalgia (finding)
- 135876005 Mastalgia of puberty (finding)
CLINICAL PEARLS
- When evaluating a patient with breast pain, always rule out cancer first.
- In the adolescent population, do not biopsy; instead, refer to a pediatric specialist.
- Premenstrual mastalgia increases with age and then generally stops at menopause unless the patient is receiving HT.