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Mastalgia

- 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].

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 indicationToremifene 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.