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Breast Pain (Mastalgia)

INTRODUCTION

Key facts and checkpoints

  • Typical age span for mastalgia is 30–50 yrs

  • Peak incidence is 35–45 yrs

  • There are four common clinical presentations:

    1. diffuse, bilateral cyclical mastalgia (commonest)

    2. diffuse, bilateral non-cyclical mastalgia

    3. unilateral diffuse non-cyclical mastalgia

    4. localised breast pain

Figure B5

Pain patterns for cyclical and non-cyclical mastalgia

A graph represents the pain patterns for cyclical and non-cyclical mastalgia. The horizontal axis represents one menstrual cycle with menses at the start and end. The vertical axis represents pain. The graph shows two curves. The curve representing non-cyclical mastalgia has few highs and lows, but the pain almost remains the same with few deviations. The curve representing cyclical mastalgia begins with moderate pain. The pain decreases gradually and reaches the lowest point and maintains for a while. The pain again surges to a peak value and it falls back drastically to the lowest point.
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CYCLICAL MASTALGIA

Features

  • Typical age is ~35

  • Discomfort and sometimes pain are present

  • Usu. bilateral but one breast can dominate

  • Mainly premenstrual

  • Breasts diffusely nodular or lumpy

  • Variable relationship to the pill

  • Rare after the menopause

Management After excluding a diagnosis of carcinoma and aspirating palpable cysts, various treatments are possible and can be given according to severity (see Table B4). Regular follow-up screening is advisable.

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Table B4 Management plan for mastalgia

Progressive stepwise therapy

Step 1

Reassurance—explain high remission rate

Proper brassiere support—expert fitting

Optimal diet; weight reduction; no smoking

Analgesics, e.g. paracetamol

Step 2

Adjust oral contraception or HRT (if applicable)

Consider trial

Evening primrose oil 1 g tds for 3 mths (unconvincing evidence)

Step 3

Refer to breast specialist to consider prescribing danazol or tamoxifen or other strategy

NON-CYCLICAL MASTALGIA

Pain, which is continuous or intermittent, does not vary within the menstrual cycle. Typical age is early 40s.

Management Non-cyclical mastalgia is very difficult to treat, being less responsive than cyclical mastalgia. It is worth a therapeutic trial.

COSTOCHONDRITIS (TIETZE SYNDROME)

Features

  • Palpable swelling ~4 cm from sternal edge due to enlargement of costochondral cartilage

  • Aggravated by deep breathing and coughing

  • Self-limiting, but may take several mths to subside

Treatment

  • Infiltration with LA and corticosteroid (with care)

MASTITIS

Clinical features

  • A lump and then soreness (at first)

  • A red tender area

  • (Possibly) fever, tiredness, muscle aches and pains

Treatment (systemic symptoms)

  • Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics

    di(flu)cloxacillin 500 mg (o) qid for at least 5 d, and up to 10 d (IV if severe)

    or if hypersensitive to penicillin cephalexin 500 mg (o) qid for at least 5 d

  • Therapeutic US (2 W/cm2 for 6 mins) daily for 2–3 d

  • Ibuprofen or paracetamol for pain

Instructions to patients

  • Keep the affected breast well drained

  • Continue breastfeeding: do frequently and start with the sore side

  • Heat the sore breast before feeding (e.g. with hot shower or hot facewasher)

  • Cool the breast after feeding: use a cold facewasher from the freezer

  • Empty the breast well: hand express if nec.

    ...

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