Breast pain (Mastalgia)
– common problem, 50% breast problems in GP, 14% referral to breast clinic
– typical age 30 – 50yrs, peak 35-45yrs
– only 1 in 200 with breast pain have breast Ca, <10% breast Ca present w pain
- Pain often feature in juvenile fibroadenoma (soft, rapidly growing tumour in adolescents) or fibroadenoma of adult women
There are 4 types =
- Diffuse, bilateral cyclical mastalgia: most common , latter half of menstrual cycle, susbsides w onset of menstruation.
- Diffuse, bilateral non–cyclical mastalgia
- Unilateral diffuse non–cyclical mastalgia
- Localised breast pain
Sx
heaviness or discomfort in breast or as a prickling or stabbing sensation. Pain can radiate down inner arm esp if heavy objects carried or using arms constantly (cleaning)
Causes
- Probability = pregnancy, cyclical mastalgia (benign mammary dysplasia)
- Serious disorders = neoplasia, inflammatory breast Ca, infection (mastitis, abscess), MI
- Pitfalls = pregnancy, costochondritis, referred pain, mechanical (bra, wt change, trauma), nerve entrapment
Examination
breast exam + to rule out differentials
Investigations
the following should be considered but as a general rule unless the cause of the pain is very obvious, imaging should be used.
- USS – not in post menopausal (fatty breast) + not for diffuse pain with no masses
- Mammography – not if <40yrs
- Excision biopsy – if localized pain & possible mass
- CXR + ECG
CYCLICAL MASTALGIA
= peak 35yr, premenstrual pain, diffusely nodular or lumpy breasts, variable relationship to OCP. Unknown cause but may be due to overproduction of prolactin or oestrgoen or underproduction of progesterone.
– Mx: exclude cancer + aspirate palpable cysts if present THEN
- Mild pain: reassure, regular breast exam, diet with optimal BMI, supportive bra, adjust OCP or HRT, paracetamol + ibuprofen for pain relief
- Moderate pain: as above PLUS one or a combination of mefenamic acid (ponstan) 500mg TDS; vitamin B1 (thiamine) 100mg daily; vitamin B6 (pyridoxine) 100mg daily. Consider ceasing the OCP
- If no response: noresthisterone (Primolut) 5mg daily for second half of cycle or danazol 200mg daily (steroid hormone that inhibits ovulation & suppresses menstruation but sig SE of virilisation). Nb: if get to this point probably best to refer to a breast specialist
Nb: some will use evening primrose oil but RCT show no more effective than placebo but if trial = 1g TDS for trial of 3 months, if effective continue for 6 months.
NON-CYCLICAL MASTALGIA
= peak early 40s, bilat + diffuse pain w no obvious physical cause or pathological basis
– Mx: very difficult to treat but worth a therapeutic trial of –
- First line: exclude caffeine, wt reduction if needed, vitamin B1/B6 100mg daily
- Second line: norethisterone 5mg daily + paracetamol + ibuprofen
CHEST WALL PAIN
= one of the most common causes of ‘mastalgia’ & common in women in desk jobs. Easiest way to distinguish this is examine breast by asking women to roll on side so breast tissue off chest wall & palpate chest wall if painful 🡪 chest wall pain.
Mx: reassurance + tight fitting bra + analgesics + local NSAIDs to chest wall + exercise/stretching (swimming)