Breast: Pain (Mastodynia, Mastalgia)

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Chapter 155 Breast: Pain (Mastodynia, Mastalgia)

INTRODUCTION

Description: Mastalgia is the nonspecific term used for breast pain of any etiology.
Prevalence: Most women experience breast pain at some point in their lives (may be transient).
Predominant Age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Fibrocystic change. Rapid hormonal change (especially a change that involves an increase in estrogen levels, such as starting birth control pills or hormone replacement or during early pregnancy). In the absence of obvious pathologic changes, mastalgia has been attributed to caffeine consumption and high-fat diets, but hard data are lacking. Nongynecologic causes—dorsal radiculitis or inflammatory changes in the costochondral junction (Tietze’s syndrome), sclerosing adenosis, chest wall muscle spasms, costochondritis, neuritis, fibromyalgia, and referred pain.
Risk Factors: Pregnancy, hormone therapy. Caffeine consumption and high-fat diets have been suggested but remain unconfirmed causes.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Diffuse breast pain, often with radiation to the shoulders or upper arms, which may or may not be related to the menstrual cycle. Unilateral or localized pain suggests a pathologic process.

DIAGNOSTIC APPROACH

Differential Diagnosis

• Fibrocystic change (most commonly presents as cyclic, diffuse, bilateral pain and engorgement, with the worst symptoms occurring just before menses)
• Mastitis or breast abscess
• Trauma
• Chest wall abnormalities (herpes zoster, costochondritis, radicular pain)
• Breast cancer (breast pain is a presenting complaint in less than 10% of patients with breast cancer)
• Mondor’s disease

Associated Conditions: Fibrocystic change, fibroadenoma, and mastitis.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: Mammography may be indicated for other reasons but seldom directly assists in the evaluation of mastalgia.
Special Tests: None indicated.
Diagnostic Procedures: History and physical examination. The presence of scattered bilateral nodularity suggests fibrocystic change.

Pathologic Findings

Based on pathophysiologic changes present.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Analgesics, mechanical support (a well-fitting brassiere worn day and night), local heat, reassurance.
Specific Measures: Caffeine restriction, medical treatment of underlying pathophysiologic changes (e.g., fibrocystic change).
Diet: A reduction in methylxanthine intake is often beneficial. Premenstrual restriction of salt or fluids is recommended for selected patients. The role of vitamins A and E is unknown.
Activity: No restriction. To reduce discomfort, good mechanical breast support is recommended during vigorous activity.
Patient Education: Instruction on monthly breast self-examination; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP145 (Breast Self-Examination), AP026 (Detecting and Treating Breast Problems), AP076 (Mammography).

Drug(s) of Choice

Combination oral contraceptives (70% to 90% success).
Spironolactone 50 mg PO twice a day given 7 to 10 days before periods.
Danazol sodium 200 mg PO twice a day (therapy should start during menstruation or pregnancy must be ruled out); side effects may be significant and recurrence is likely after therapy is discontinued.
Bromocriptine 2.5 mg PO daily (with food), may be increased after 3 to 7 days if needed.
Contraindications: Spironolactone is contraindicated in the presence of anuria, renal insufficiency, or hyperkalemia. Danazol sodium is contraindicated in pregnancy (category X). It may also worsen epilepsy, migraine headaches, and cardiac or renal function. Bromocriptine is contraindicated in patients with uncontrolled hypertension or in patients known to be sensitive to ergot alkaloids.
Precautions: Diuretics must be used with care to avoid fluid and electrolyte disturbances. Bromocriptine may cause hypotension during the first several days of therapy. Care should also be exercised with patients who have compromised hepatic or renal function.
Interactions: Spironolactone enhances the action of other diuretics and increases digoxin levels. Danazol sodium may prolong prothrombin time in patients receiving warfarin.

Alternative Drugs

Hydrochlorothiazide 25 mg PO at bedtime for 7 to 10 days before menses.

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Gonadotropin-releasing hormone agonists (GnRH; leuprolide acetate [Lupron] 3.75 mg IM monthly for no more than 6 months).
Evening primrose and chastberry have shown efficacy in limited trials, but standardization of both therapy and active ingredients in varying preparations limits the ability to fully evaluate these as therapeutic options.

FOLLOW-UP

Patient Monitoring: Patients with mastalgia but no dominant mass may be safely rechecked at a different portion of the next menstrual cycle.
Prevention/Avoidance: None.
Expected Outcome: Symptomatic relief can generally be achieved with a combination of diet changes, analgesics, and specific medications.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although pregnancy may induce mastalgia.
ICD-9-CM Codes: 611.71.

REFERENCES

Level I

Doberl A, Tobiassen T, Rasmussen T. Treatment of recurrent cyclical mastodynia in patients with fibrocystic breast disease. A double-blind placebo-controlled study—The Hjorring project. Acta Obstet Gynecol Scand Suppl. 1984;123:177.

Gorins A, Perret F, Tournant B, et al. A French double-blind crossover study (danazol versus placebo) in the treatment of severe fibrocystic breast disease. Eur J Gynaecol Oncol. 1984;5:85-.

Ioannidou-Mouzaka L, Niagassas M, Galanos A, Kalovidouris A. Pilot study on the treatment of cyclical mastodynia with Quinagolide. Eur J Gynaecol Oncol. 1999;20:117.

Parlati E, Polinari U, Salvi G, et al. Bromocriptine for treatment of benign breast disease. A double-blind clinical trial versus placebo. Acta Obstet Gynecol Scand. 1987;66:483.

Level II

Andersch B. Bromocriptine and premenstrual symptoms: a survey of double blind trials. Obstet Gynecol Surv. 1983;38:643.

Boyle CA, Berkowitz GS, LiVolsi VA, et al. Caffeine consumption and fibrocystic breast disease: a case control epidemiologic study. J Natl Cancer Inst. 1984;72:1015.

Winkler UH, Schindler AE, Brinkmann US, et al. Cyclic progestin therapy for the management of mastopathy and mastodynia. Gynecol Endocrinol. 2001;15:37.

Level III

American College of Obstetricians and Gynecologists. Use of botanicals for management of menopausal symptoms. ACOG Practice Bulletin 28. Washington, DC: ACOG, 2001.

Anonymous. Mastodynia. Lancet. 1982;2:590.

BeLieu RM. Mastodynia. Obstet Gynecol Clin North Am. 1994;21:461.

Carranza-Lira S, Garduno-Hernandez MP, Caisapanta DA, Aparicio H. Evaluation of mastodynia in postmenopausal women taking hormone therapy. Int J Gynaecol Obstet. 2005;89:158.

Ferguson CM, Powel RW. Breast masses in young women. Arch Surg. 1989;124:1338.

Lurie S, Borenstein R. The premenstrual syndrome. Obstet Gynecol Surv. 1990;45:220.

Seltzer MH, Skiles MS. Disease of the breast in young women. Surg Gynecol Obstet. 1980;150:360.

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