Breast pain

Mastalgia or Mastodynia

Introduction

Breast pain, or mastalgia, affects up to 70% of women at some point in life. It can be:

Cyclical: Related to the menstrual cycle (hormonal, premenstrual).
Non-cyclical: Constant or intermittent, unrelated to cycle (trauma, infection, cysts, medications).
Extramammary (referred): Pain felt in breast area but originating from chest wall, muscles, heart, or lungs.

While mastalgia is a frequent concern, breast cancer rarely presents with pain alone (less than 5% of cases).

Pathophysiology

Cyclical mastalgia: Estrogen and progesterone fluctuations → water retention, ductal and stromal changes → breast swelling and tenderness.
Non-cyclical mastalgia: Localized pathology (cysts, infection, trauma) or systemic (medications, costochondritis).
Referred pain: From chest wall (musculoskeletal), cervical spine, cardiac or pulmonary disease.

Causes of Breast Pain

1. Cyclical Mastalgia (Hormonal)

Premenstrual breast tenderness.
Hormonal contraceptives (oral contraceptive pills).
Hormone replacement therapy (HRT).
Puberty, pregnancy, perimenopause.

2. Non-Cyclical Breast Pain

Fibrocystic breast changes.
Breast cysts.
Fibroadenomas.
Mastitis / breast abscess: Common in lactating women.
Post-surgical pain (scar, nerve injury).
Trauma.

3. Medications

Antidepressants (SSRIs: Fluoxetine, Sertraline).
Spironolactone.
Digitalis (Digoxin).
Methyldopa.

4. Extramammary Causes (Referred Pain)

Musculoskeletal: Costochondritis, muscle strain.
Cardiac: Angina, myocardial infarction (especially in women, may present atypically).
Pulmonary: Pleurisy, pulmonary embolism.
Gastrointestinal: GERD, gallbladder disease.

5. Rare Causes

Male breast pain (gynecomastia, steroid use).
Breast cancer (rarely presents with isolated pain, but must be excluded).

Clinical Features

Cyclical mastalgia:
- Bilateral, diffuse, worse in upper outer quadrants.
- Associated with menstrual cycle, improves after menstruation.
Non-cyclical mastalgia:
- Unilateral, localized, sharp or burning.
- May be associated with lump, infection, trauma.
Extramammary pain:
- Often reproducible with chest wall palpation or movement.
- Not related to breast tissue itself.

Associated features:

Nipple discharge.
Breast lump or skin changes (dimpling, redness, ulceration).
Systemic symptoms: fever (infection), weight loss (cancer).

Diagnostic Approach

1. History

Pain pattern: cyclical vs non-cyclical.
Duration, severity, location.
Relation to menstrual cycle, pregnancy, lactation.
Medications, caffeine, smoking, alcohol use.
Family history of breast cancer.

2. Examination

Inspect: symmetry, skin changes, nipple retraction/discharge.
Palpate: tenderness, lumps, nodularity.
Axillary lymph nodes.
Chest wall, musculoskeletal exam.

3. Investigations

Mammography: Women >40, suspicious findings.
Breast ultrasound: Younger women (<35), cyst vs solid lesion.
MRI breast: Complex or indeterminate cases.
Biopsy (FNAC/core): If suspicious lump or abnormal imaging.
Blood tests: Hormones, prolactin if endocrine disorder suspected.
ECG, chest X-ray, endoscopy: If extramammary pain suspected.

Management and Treatment

Treatment depends on whether pain is cyclical, non-cyclical, or extramammary.

A. General Measures

Reassurance (breast cancer is rare cause of pain).
Supportive bra (reduces pain).
Warm compresses, gentle massage.
Reduce caffeine and high-fat diet.
Smoking cessation.
Regular exercise, stress management.

B. Pharmacological Treatment

1. Simple Analgesics

Paracetamol 500–1000 mg orally every 6–8 h (max 4 g/day).
NSAIDs:
- Ibuprofen 400 mg orally every 8 h.
- Diclofenac gel 1% applied topically 3–4 times/day.

2. Hormonal Therapy (for severe refractory cyclical mastalgia)

Tamoxifen (selective estrogen receptor modulator):
- 10 mg orally once daily × 3–6 months.
- Effective in reducing pain but carries risks (thromboembolism, endometrial hyperplasia).
Danazol (androgen derivative):
- 200–400 mg orally daily in divided doses.
- Effective but side effects (weight gain, acne, voice change).
Bromocriptine (dopamine agonist, reduces prolactin):
- 2.5 mg orally twice daily.

3. Antibiotics (if infection / mastitis)

Flucloxacillin 500 mg orally every 6 h for 7–10 days.
Clindamycin 300 mg orally every 6 h (if penicillin allergy).

4. Hormone-Related Pain

Consider adjusting oral contraceptives or HRT dose.

C. Interventional / Surgical Treatment

Aspiration of breast cysts if symptomatic.
Drainage of abscess if mastitis not resolving.
Excision of fibroadenoma / suspicious lump.
Surgery for refractory mastalgia is rarely indicated.

Complications

Anxiety, depression, reduced quality of life.
Sleep disturbance.
Misdiagnosis and missed underlying serious pathology (e.g., breast cancer).

Prognosis

Cyclical mastalgia: Usually improves after menopause or with lifestyle/hormonal therapy.
Non-cyclical mastalgia: Depends on underlying cause (infection, cysts, musculoskeletal).
Extramammary pain: Resolves with treatment of primary disease.

Patient Education

Most breast pain is benign and treatable.
Keep a pain diary (relation to cycle, triggers, severity).
Wear supportive bra.
Reduce caffeine and alcohol.
Complete prescribed antibiotics if infection.
Always seek medical advice if pain is persistent, associated with lump, nipple changes, discharge, or systemic symptoms.

Saidala 24

الصفحات

بحث هذه المدونة