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 = 

1. Diffuse, bilateral cyclical mastalgia: most common , latter half of menstrual cycle, susbsides w onset of menstruation. 
2. Diffuse, bilateral non–cyclical mastalgia
3. Unilateral diffuse non–cyclical mastalgia
4. 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)