Mastalgia

Mastalgia refers to breast pain and is a common presenting complaint among female patients:
- Mastalgia is the most common symptom:
  - In patients undergoing breast imaging
- It affects approximately:
  - 70% of women
- It is usually mild and self-limited but in:
  - Approximately 15% of affected women will require treatment
- One study of almost 1700 women (mean age 34 years) surveyed by online questionnaire:
  - Found that over one-half (51.5%) had experienced breast pain:
    - Pain was more commonly reported among:
      - Older women
      - Those with larger breast sizes
      - Those less fit and / or physically active
  - In addition, of those who reported symptoms:
    - 41% and 35% reported negative impacts from breast pain on their sexual health and sleep, respectively
  - 10% of those symptomatic had reported breast pain as an issue for over half of their lives
- It is classified in three categories:
  - Cyclic:
    - The level of pain can:
      - Vary according to the menstrual cycle:
        Cyclical pain is associated with:
        Hormonal fluctuations of the menstrual cycle
    - Cyclic breast pain:
      - Is the most common type:
        Affecting two-thirds of patients with true mastalgia
    - Is more common in:
      - Premenopausal women in the 30s
    - It is usually:
      - Bilateral
    - It is more often felt:
      - In the upper outer quadrant
    - Its intensity increases just before menstruation and decreases after menstruation
    - It is thought to be caused by hormonal changes:
      - Therefore, most cases come in those actively menstruating or using HRT
    - Minor cyclical breast discomfort is normal:
      - It begins during the late luteal phase and dissipates with the onset of menses
      - This is usually bilateral and diffuse pain
      - Cyclical breast discomfort is caused by normal hormonal changes associated with ovulation:
        That stimulate the proliferation of normal glandular breast tissue and result in pain
        The stimulation of:
        Ductal elements by estrogen
        Stroma by progesterone
        Stimulation of ductal secretion by prolactin:
        All contribute to cyclical pain during the menstrual cycle
      - Cyclical breast pain can also be associated with pharmacologic hormonal agents:
        Postmenopausal hormone therapy
        Oral contraceptive pills

Non-cyclic:
- It is not associated with the menstrual cycle
- Noncyclical pain affects one-third of women with true mastalgia:
  - The pain does not follow the usual menstrual pattern:
    - May be constant or intermittent
    - Is more likely to be unilateral and variable in its location in the breast
- Noncyclical breast pain is more likely to be related to:
  - A breast or chest wall lesion
- Possible etiologies include:
  - Large pendulous breasts:
    - Large pendulous breasts may cause pain due to stretching of Cooper’s ligaments
    - Neck, back, and shoulder pain and headache may be present, as well as a rash under the pendulous breast in the inframammary fold
  - Diet, lifestyle:
    - The role of diet and lifestyle in causing breast pain is uncertain
    - Although a high-fat diet, smoking, and caffeine intake have been associated with breast pain:
      - It is difficult to conduct randomized trials with appropriate blinding that will negate the placebo effect:
      - Hence, there is currently no high-quality evidence to suggest that:
        A low-fat diet, smoking cessation, or caffeine avoidance reduces breast pain
  - Hormone replacement therapy:
    - Up to one-third of menopausal women receiving postmenopausal hormone therapy experience some degree of noncyclical breast pain:
      - Which may spontaneously resolve over time
- Breast cysts:
  - Solitary cysts:
    - Particularly when the presentation is abrupt:
      - Are frequently painful
- Ductal ectasia:
  - Is characterized by distention of subareolar ducts due to inflammation unrelated to infection
  - Ductal ectasia may be associated with fever and acute local pain and tendernesscaused by:
    - Penetration of the duct wall by lipid material, which may resolve to leave a subareolar nodule:
      - In one study, the site and degree of duct dilatation correlated with the intensity of noncyclical breast pain
- Mastitis:
  - Mastitis or breast abscess typically presents as:
    - A painful, swollen, and red breast in a febrile woman
  - Mastitis is more prevalent during lactation but can also occur in nonlactating women:
    - Idiopathic granulomatous mastitis [IGM]) or smokers
- Inflammatory breast cancer:
  - Women with de novo inflammatory breast cancer (primary disease) may present with pain and a rapidly progressing tender, firm, enlarged breast
  - The skin over the breast is warm and thickened, with a “peau d’orange” (orange skin) appearance, but there is often no fever or leukocytosis
- Hidradenitis suppurativa:
  - Although primarily confined to the axilla>
    - Can involve the breast and present as breast nodules and pain
- Other:
- Other etiologies of breast pain include:
  - Pregnancy
  - Thrombophlebitis (Mondor’s disease)
  - Trauma
  - Macrocysts
  - Prior breast surgery
  - Medications, including:
    - Oral contraceptives
    - Anti-depressants:
      - Such as sertraline
    - Antipsychotic drugs:
      - Such as haloperidol
    - Cardiovascular agents
    - Antibiotics
- Is felt as pain related to the chest wall:
  - Rather than the breast itself
- It is not associated with the menstrual cycle
- It may be felt either:
  - Continuously or intermittently
- It is rare as compared to the cyclic type:
  - Around a third of mastalgia is non-cyclical pain not unrelated to the menstrual cycle
- It is found in women who are in their 40s
- It is usually localized to one side and felt at a single area
- Extramammary:
  - Some women who present with breast pain actually have referred pain from sources other than the breasts
  - The breast is innervated by the anterolateral and anteromedial branches of the intercostal nerves (T3 to T5):
    - Irritation of these nerves anywhere along their course can lead to pain that is felt in the breast or nipple
      - Women presenting with breast pain more often have extramammary painrather than true mastalgia
  - Extramammary pain may be from:
    - Musculoskeletal sources such as:
      - The chest wall, spinal or paraspinal disorders, trauma, or scarring from prior biopsy
    - It may also be related to medical problems such as:
      - Biliary, pulmonary, esophageal, or cardiac disease
    - Chest wall pain:
      - Is frequently due to pectoralis major muscle injury, related to repetitive activities such as water skiing, raking, rowing, or shoveling
      - Chest wall pain that presents as bilateral parasternal discomfort can also arise from costochondritis (typically the second through fifth costochondral junctions) or Tietze syndrome (typically the second and third costochondral junctions)
      - Other etiologies of chest wall pain include slipping and clicking ribs and arthritis
    - Spinal and paraspinal disorders:
      - Radicular chest wall pain may be due to cervical arthritis:
        This pain typically occurs in older women in whom vertebral, spinal, and paraspinal problems in the neck and upper thorax accumulate with age
      - Paraspinal muscle spasm and other impingements on the free course of the sensory nerves from the neck and upper thorax can cause a radiculopathy leading to pain or hyperesthesia
      - Burning pain, which is typical of nerve root pressure, is a common feature
      - Imaging studies of the neck may reveal the etiology of the pain
    - Trauma:
      - Breast pain can be caused by local trauma, such as seat belt injury, child or pet kicking, or intimate partner violence, to the breasts or anterior chest wall
    - Pain can also be caused by intercostal neuralgia due to a respiratory infection or underlying pleuritic lesions:
    - Additionally, gallbladder disease or ischemic heart disease may present as intermittent chest pain attributed to the breast
    - Post-thoracotomy syndrome:
      - Is an unusual disorder in which a healing chest wound simulates the effect of a suckling infant
      - It can be associated with an elevated prolactin concentration, breast pain, and milk production
      - A similar effect can be seen with other forms of chest wall irritation, including burns and chafing from clothing overlying the nipple
Pathophysiology of breast pain is not fully elucidated:
- Etiologic factors:
  - High levels of serum fatty acid levels
  - Increase in basal prolactin levels
  - Excessive fatty diet
  - Psychological factors:
    - Are also shown to play a role in the etiology in some studies
A primary concern for patients with mastalgia:
- Is that it is related to breast cancer:
  - However, the incidence of a breast malignancy associated with a presenting complaint of mastalgia is low:
- A thorough assessment is required to determine the cause of the pain:
  - Explore any potential associated symptoms, and hopefully to reassure and manage their symptoms
It is rare for men to experience mastalgia:
- However, it can occur in those who have developed:
  - Gynaecomastia
Clinical Features:
- During the history and physical one should ask about specific features that could indicate a pathological cause of mastalgia, such as:
  - Lumps (breast nodules)
  - Skin changes:
    - Skin erythema
    - Skin dimpling (retraction)
    - Peu de orange
  - Nipple retraction
  - Nipple discharge
  - Fevers
Work-up:
- Breast pain in isolation with no other relevant features on history or examination:
  - Is not an indication for imaging
- All patients within reproductive age should have a pregnancy test
- The American College of Radiology Appropriateness Criteria guidelines recommend the following approach to selecting an imaging modality:
  - Women with cyclical or bilateral non-focal breast pain usually do not require imaging:
    - The yield of finding a specific cause with imaging is low
  - Women with noncyclical, unilateral, or focal breast pain that is not extramammary (eg, chest wall pain), as determined by physical exam:
    - Should undergo breast imaging to elucidate the underlying etiology and exclude breast cancer
    - The choice of imaging modality is based on age:
      - Women under 30 years of age should undergo ultrasound because it is more accurate than mammography for that age group:
        Mammography is added if abnormality is found on the ultrasound and / or if a patient’s history or risk status justifies the radiation exposure (eg, family history of premenopausal breast cancer)
      - Women between 30 and 39 years of age should also undergo ultrasound, and unilateral or bilateral mammography should also be performed because in this age group some small cancers are found on mammography but not ultrasound.
      - Women age 40 and older should undergo both mammography and ultrasound

Management:
- Any underlying cause suspected should be investigated and managed as appropriate
- However, in most cases the mastalgia pain will be idiopathic in nature and therefore reassurance and pain control, is the primary form of management
- NICE guidelines states:
  - The management for cyclical breast pain should include:
    - Wearing a better fitting bra or soft-support bra during the night

The use of oral ibuprofen or paracetamol or topical NSAIDs can help alleviate pain
- Non-cyclical pain does not usually respond well to treatment but in idiopathic cases will often resolve spontaneously
- If first line management options are unsuccessful, a referral to a specialist may be warranted (breast surgeon)
- Second line treatment for breast pain include:
  - The use of Danazol:
  - An anti-gonadotrophin agent:
    - Yet these can be accompanied with unpleasant side-effects:
      - Such as nausea, dizziness, and weight gain
References:
Mansel RE. Clinical Assessment of mastalgia. Br J Clin Pract Suppl 1989; 43: 17-9.
Gateley CA, Holland PA. Drug therapy of mastalgia. What are the options? Drugs 1994; 48: 709-16.
Watt-Boolsen S, Eskildsen PC, Blaehr H. Release of prolactin, thyro- tropin and growth hormone in women with cyclical mastalgia and fibrocystic disease of the breast. Cancer 1985; 56: 500-2.
Seema A. Khan, A. Vania Apkarian. Mastalgia and breast cancer: a protective association? Cancer Detection and Prevention 2002; 26: 192-6.
Fox H, Walker LG, Heys SD, Ah-See AK, Eremin O. Are patients with mastalgia anxious, and does relaxation therapy help? The Breast 1997; 6: 138-42.
Preece PE, Baum M, Mansel RE, Webster DJ, Fortt RW, Gravelle IH, et al. Importance of mastalgia in operable breast cancer. Br Med J (Clin Res Ed) 1982; 284: 1299-300.
Plu-Bureau G, Thalabard JC, Sitruk-Ware R, Asselain B, Mauvais-Jar- vis P. Cyclical mastalgia as a marker of breast cancer susceptibility: results of a case-control study among French women. Br J Cancer 1992; 65: 945-9.
Aksu G, Hocaoğlu Ç. Evaluation of Anxiety, Alexytimia and Depres- sion levels in patients undergoing Radiologic Evaluation for Mas- talgia. Klinik Psikiyatri 2004; 7: 95-102