Mastalgia

Mastalgia refers to breast pain and is a common presenting complaint among female patients.

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.

Classification

There are multiple causes for breast pain, however a common way to categorise types of breast pain is as cyclical, non-cyclical, or extra mammary.

The most common form of breast pain is cyclical pain, which is defined as pain associated with the menstrual cycle. Typically, cyclical pain affects both breasts, beginning a few days before the beginning of menstruation and subsiding at the end. It is caused by hormonal changes, therefore most cases come in those actively menstruating or using HRT.

Around a third of mastalgia is non-cyclical pain is unrelated to the menstrual cycle. It can be caused by medication, including hormonal contraceptives, anti-depressants (such as sertraline), or antipsychotic drugs (such as haloperidol). Other causes of breast pain can be extramammary pain, such as chest wall pain or shoulder pain.

Clinical Features

Any history should ask specific about any other features that could indicate a pathological cause of mastalgia, such as lumps, skin changes, fevers, or discharge, as well as association with menstrual cycle. Ensure to as about drug history, breast-feeding, pregnancies, previous medical history, and family history.

Investigations

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.

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 guidance 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. 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)

*Many previous suggested treatments, such as the use of OCPs, low-fat diet, or use of vitamin E, are no longer recommended