Mastalgia

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Mastalgia is breast pain. It’s a super common complaint, but one that we don’t spend a lot of time learning about in OB/GYN residency.  But a systematic approach and knowing a little bit of evidence makes this an easier problem to tackle!

There are 3 types of breast pain: cyclical, noncyclical, and extramammary 

Cyclical 

  • Characterizes about ⅔ of patients with mastalgia.

  • Associated with hormonal fluctuations of menstrual cycles, usually starts about a week prior to menses.

  • Usually bilateral, most severe in upper outer quadrants.

  • Caused by stimulation of ductal elements by estrogen.

  • Can also be associated with pharmacologic hormonal agents (ie. OCPs, HRT).

Noncyclical 

  • Represents ⅓ of women with true mastalgia.

  • Does not follow a menstrual pattern.

  • More likely to be unilateral or located in one position on a breast, etc. 

  • Causes are highly variable:

    • Large, pendulous breasts;

    • Diet and lifestyle (high fat diet, smoking, caffeine intake);

    • Breast cysts; ductal ectasia (meaning distention of subareolar ducts due to inflammation unrelated to infection);

    • Mastitis;

    • Inflammatory breast cancer;

    • Hidradenitis suppurativa;

    • Mondor’s disease (thrombophlebitis of the breast);

    • Trauma;

    • Certain medications, such as some SSRIs and antipsychotics, as well as spironolactone.

Extramammary - not a “true mastalgia.” 

  • Basically referred pain from the intercostal nerves, or chest wall pain likely due to muscular injury.

How common is mastalgia, and what are risk factors? 

  • Very common - up to 70% of women in the US will experience some type of mastalgia in their life.

  • Those at higher risk are older women, those with larger breast size, less fit and/or physically active.

How do you approach the evaluation of mastalgia? 

  1. History characterizing questions are super important with mastalgia! They can help to elicit the differences commonly seen between the cyclical and non-cyclical types, as well as find other potential causes of pain that are not true mastalgia.  

    • Where is the pain? Is it bilateral or just on one side? 

    • What does the pain feel like? Aching? Pinching? 

    • When does the pain occur? Does it occur around your period? 

    • Do you take any hormonal medications? 

    • Is it associated with other types of pain, like neck, back or shoulder pain? 

    • Have you had a fevers/chills/systemic symptoms? 

    • Have you had any recent trauma to the chest? 

    • Does the pain affect daily function? 

    • Complete medical, surgical history etc. 

  2. Physical the breast exam can help to rule out any obvious causes, such as infection, mass or malignancy.

    • Examine for evidence of malignancy: mass, skin changes, or bloody nipple discharge.

    • Make sure you examine all 4 quadrants of the breast as well as the chest wall.

    • May have to have the patient lay on their side to be able to examine the chest wall when the breast falls away from the chest wall.

  3. Imaging/Labs Imaging is not always necessary, but can be in the right circumstances:

  • If mass, skin changes, bloody nipple discharge → mammography with or without ultrasound.

  • If no suspicious findings, may not necessarily need imaging, but will depend on presentation as well as if they are due for annual screening anyway.

  • Chance of having breast cancer with no abnormality on physical exam or imaging is about 0.5%. 

How do you treat mastalgia? 

  • Reassurance

    • Many times, women just want to know that their breast pain is normal and that they do not have breast cancer!

    • Studies have demonstrated this will be enough to satisfy 78-85% of women with normal findings.

    • Approximately 15% of women will need some other kind of treatment.

  • First line therapies

    • Physical support - well-fitting bra for support, warm compress or ice packs or gentle massage.

    • Over the counter analgesics - Tylenol, NSAIDs; topical NSAIds may also be useful.

    • Change in or cessation of hormonal medications 

  • Second line - if still having debilitating breast pain after first line treatments:

    • Tamoxifen - 10 or 20 mg daily, but can be associated with vasomotor symptoms of menopause.

    • Danazol - only FDA-approved treatment for mastalgia (fibrocystic breast disease) - usually around 200 mg daily.

      • Can be androgenizing, so avoid if planning pregnancy.

      • Rare hepatotoxicity with large doses (>400mg).

  • Other therapies not proven by randomized trial data:

    • Lifestyle changes (weight loss, stopping caffeine, low fat diet - 15% fat).

    • Evening primrose oil.

    • Vitamin E.

      • Many of these are offered and available over the counter, and have not demonstrated evidence of harm, either! So they may still be useful in your anti-mastalgia arsenal.