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A summary of the diagnostic strategy model for mastalgia is presented in TABLE 100.1.
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Probability diagnosis
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In the non-pregnant patient, generalised pain, which may be cyclical or non-cyclical, is commonest. Typical patterns are illustrated in FIGURE 100.1.
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Cyclical mastalgia is the commonest diffuse breast pain. It occurs in the latter half of the menstrual cycle, especially in the premenstrual days, and subsides with the onset of menstruation. It obviously has a hormonal basis, which may be an abnormality in prolactin secretion. The main underlying disorder is benign mammary dysplasia, also referred to as fibroadenosis, chronic mastitis, cystic hyperplasia or fibrocystic breast disease.
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Non-cyclical mastalgia, which is pain that does not vary within the menstrual cycle, is also quite common and the cause is poorly understood. It may be associated with mammary duct ectasia (see CHAPTER 101).
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Serious disorders not to be missed
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The three important serious disorders not to be missed with any painful chest condition—neoplasia, infection and myocardial ischaemia—are applicable for breast pain.
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We must avoid the trap of considering that breast pain is not compatible with malignancy. Mastalgia can be a presenting symptom (although uncommon) of breast cancer. ‘Mastitis carcinomatosa’, which is a rare florid form of breast cancer found in young women, often during lactation, is red and hot but not invariably painful or tender.2 Pain may also be a symptom in juvenile fibroadenoma, a soft rapidly growing tumour in adolescents, and in the fibroadenoma of adult women.
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Mastitis is common among nursing mothers. It should be regarded as a serious and urgent problem because a breast abscess can develop quickly. Apart from bacterial infection, infection with Candida albicans may occur following the use of antibiotics. Candida infection usually causes severe breast or nipple pain, producing a feeling like ‘hot cords’, especially during and after feeding.
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A constricting pain under the left breast should be regarded as myocardial ischaemia until proved otherwise.
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These include various causes of apparent mastalgia, such as several musculoskeletal chest wall conditions and referred pain from organs such as the heart, oesophagus, lungs and gall bladder and, in particular, from the upper thoracic spine.
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Musculoskeletal conditions include costochondritis, pectoralis muscle strains or spasm, and entrapment of the lateral cutaneous branch of the third intercostal nerve. Ankylosing spondylitis can affect the chest wall under the breasts. Mastalgia may be the first symptom of pregnancy. Pregnancy should be excluded before commencing drug treatment.
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Seven masquerades checklist
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Of these, depression, drugs and spinal dysfunction are probable causes. Drugs that can cause breast discomfort include oral contraceptives, HRT and methylxanthine derivatives such as theophylline. Drugs that cause tender gynaecomastia (more applicable to men) include digoxin, cimetidine, spironolactone and marijuana.
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Dysfunction of the upper thoracic spine and even the lower cervical spine can refer pain under a breast. If suspected, these areas of the spine should be examined.
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Psychogenic considerations
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The symptoms may be exaggerated as a result of an underlying psychogenic disorder, but with a symptom such as breast pain most women fear malignancy and need reassurance.