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Breast pain
Breast pain ( mastodynia , mastalgia ) is a common symptom – occurs in 70 to 80 % of women some time in their lives 2nd commonest reason ( 1st is a lump ) for which a woman seeks help -for breast related issues ( even in older age group ) Breast pain is rarely associated with breast cancer ○ number quoted varies from 1 % to 0.5 % ( Normal breast examination and with only breast pain ) ○ causes significant anxiety and fear in women who relate to and are convinced they have breast cancer Severe pain can affect QOL- particularly ○ sleep patterns ○ sexual activity ○ physical activity ○ work , school and social activity A study has shown that breast pain is ○ typically reported by older women ○ those with large breast cup sizes ○ those who self reported lower activity and fitness Accounts for upto 50 %-referrals to breast OP clinics Usually self limiting Most women would be managed by reassurance and simple drugs
large breasts age 30-50 yrs ill fitting bras medications ( see below ) other possible risk factors include older age , stress , caffeine , smoking , incd frequency of lactation and h/o Ca breast
Approach-Take a detailed history and examine to help distinguish if the pain is cyclical , non-cyclical or extramammary In history ask about ◘ family h/o Ca breast ◘ relation to menstrual cycle ◘ has the patient felt a lump ◘ discharge ◘ breast feeding – recent or current ◘ pain severity over time ◘ location of pain , quality , duration , radiation ◘ h/o breast surgery or trauma ◘ relationship to physical activity ◘ impact on daily living ◘ other risk factors for breast cancer Drug history -medications which can cause breast pain include ◘ Hormonal medications eg estrogens ,progestogens ,OCP , HRT , Clomiphine , cyproterone ◘ Antidepressant , antipsychotic and anxiolytic medications e.g sertraline and other SSRIs , venlafaxine , mirtazepine , amitriptyline ◘ Antihypertensive and cardiac medications e.g spironolactone , methyldopa , digoxin ◘ Antimicrobial agents e.g metronidazole ◘ Miscellaneous others e.g methadone , domperidone Examination Breast examination is essential ○ breast pain can arise from chest wall or the breast itself ○ examination of cervical and thoracic spine , chest wall , shoulders ,upper extremities , heart , lungs and abdomen may also be useful
Cylical mastalgia-in pre-menopausal women related to periods usually 1-2 weeks before period More common variant Seen more in 20-45 age group pain is diffuse in upper outer quadrant with radiation to axilla and ipsilateral arm -often described as “dull ” , ” heavy ” or ” aching ” Can be uni or bilateral but a study has shown that ○ in 38 % – pain was unilateral ( in the breast with ↑ parenchyma ) ○ and in 61 % of those with b/l pain had pain in one breast more than the other Often accompanied by a swelling that waxes and wanes with the menstrual cycle Pain is more in luteal phase – due to ↑ ed water content in the breast stroma caused by increasing hormone levels Pain normally disappears after the period and women would be pain free for up to 2 weeks – then the pain recommences but in some women pain may be present in the entire cycle with with pre-menstrual intensification of symptoms Cause is not clear- various theories have been implicated e.g ○ histological ( fribrocystic histology ) ○ hormonal ○ fluid and electrolyte balance and nutritional association ○ psychological
Reassurance – pain not due to cancer Bra support Dietary interventions – e.g low fat diet ( no evidence of effectiveness ) Evening primrose oil – lack of evidence and NICE does not support its use now Oral or topical NSAIDs or paracetamol Lifestyle measures as exercise , smoking cessation Address stress , anxiety , PMS if required Resolves spontaneously within 3 months of onset in 20-30% of women but tends to relapse and remit and up to 60 % of women develop recurrent symptoms 2 yrs after treatment
Non-cyclical –Unrelated to menstrual cycle Less common than cyclical mastalgia Usually in women in their 40s or 50s Tends to be unilateral and localized to a particular quadrant of the breast Constant or intermittent Causes include ○ pregnancy ○ cysts ○ periductal mastitis ○ stretching of Cooper’s ligament ○ traumatic fat necrosis ○ Mondor’s disease ( rare cause because of thrombophlebitis of the superficial veins of the breast and anterior chest wall ) from Mondor’s disease- a rare cause of chest pain : a case report J Med Case Rep ○ diabetic mastopathy ○ neoplasia ○ non-mammary pain ○ trauma
Responds poorly to treatment Spontaneous resolution in about 50% patients NSAIDS advocated widely Treat referred pain appropriately
extra-mammary-Broad range of causes Musculoskeletal e.g costochondritis / Tietze’s chest wall pain chest wall trauma / rib fracture cervical , thoracic neurological or muscular conditions Gallstones Pleural irritation Pneumonia Shingles Oesophageal spasm CV – CAD / angina PE GORD Fibromyalgia
Pre-menopausal women Normal breast examination Try and distinguish cyclical or non cyclical Pain chart – for e.g daily up to 3 months to establish severity
Serious underlying cause suspected Refer if symptoms persist ○ duration not clear ○ NCCP document recommends a review at 3 months and referral if pain intractable with a completed pain chart CKS also recommends referral to breast clinic for cyclical breast pain which does not respond to 1st line treatment after 3 months Pain interferes with quality of life Anxious patient who are not reassured by their GP Unilateral persistent pain in post-menopausal women Extramammary cause of breast pain
Danazol – evidence of benefit 3 rd line only FDA approved medication for mastalgia also licensed in UK – it is the only drug which has license for mastalgia Tamoxifen – evidence of benefit but associated with sig and common SEs LHRH agonists – specialist use concerns about menopausal SEs Surgery- insufficient evidence LA and steroid injections
References Breast pain Amit Goyal BMJ Clin Evid. 2014 : 2014 : 0818 Irish Cancer Society General Information Breast Pain Evaluation and Management of Breast Pain Robin L Smith et al Mayo Clin Proc . 2004 ; 79 :353-372 ACR Appropriateness Criteria® Breast Pain Expert Panel on Breast Imaging : Peter M Jokich et al J Am Coll Radiol 2017 ; 14 : S25-S33 A systematic review of Current Understanding and Management of Mastalgia Kamal Kataria et al Indian J Surg . 2014 Jun ; 76 (3) : 217-222 Evaluation of common breast complaints in Primary Care by Mary Alison Smania The Nurse Practitioner October 2017 Management of Breast pain ( mastalgia ) in Primary care – National cancer control Programme Breast pain- cyclical CKS NHS DynaMed mastalgia Clinical management of idiopathic mastalgia : a systemic review Shazia P Hafiz et al CSIRO Publishing Journal Compilation Royal New Zealand College of General Practitioners 2018
