Continuing Education Activity

Mastalgia refers to a common breast pain that a female suffers from during her lifetime. Approximately two-thirds of women develop this pain during their reproductive life and seek medical attention either because it adversely affects their daily life or out of the fear of any serious underlying pathology like breast cancer. The breast pain ranges from mild to severe, could be intermittent or constant; but requires adequate evaluation and proper treatment. This activity reviews the evaluation and treatment of mastalgia and highlights the role of the health care team in managing patients with this condition.

Objectives:

• Identify the etiology of mastalgia.
• Describe the evaluation of mastalgia.
• Summarize the management options available for mastalgia.

Introduction

Mastalgia is a  medical term used for breast pain, one of the most common complaints among women of 15 to 40 years of age (child-bearing age). Approximately two-thirds of women during their reproductive lives suffer from this condition and seek medical help. It is a dull, aching pain while some women may describe it as heaviness, tightness, discomfort, or burning sensation in the breast tissue, which may be unilateral or bilateral. Most often, it is located in the upper outer quadrant of the breast and can sometimes radiate to an ipsilateral arm. It is most common in premenopausal and perimenopausal women, but postmenopausal women can also rarely develop such pain. The breast pain ranges from mild to severe, could be intermittent or constant throughout the day, and may interfere with the female's quality of life.[1][2][3]

Many a time, it is not possible to determine the exact cause of such breast pain. However, it is generally believed that in the majority of cases, such breast pain is not a sign of cancer. Still, professionals recommend a detailed medical review with proper history and physical exam done by a primary caregiver to rule out any such possibility.

Classification[4][3][2]

Cyclic Mastalgia

Breast pain that is associated with the menstrual cycle due to hormonal variation often associated with breast swelling, tenderness, and lumpiness and generally bilateral in nature. Pain intensifies a couple of weeks before the start of periods, decreasing on the day when bleeding starts and subsides over the next few days. Most commonly seen in premenopausal women in the third or fourth decades of life.

Non-Cyclic Mastalgia

Breast pain that is not associated with the menstrual cycle and does not vary with hormonal changes in the body. Instead, they are often related to internal anatomical changes, injuries, surgery, infections, or sometimes associated with other breast pathology, i.e., breast cysts or fibroadenoma. These are generally described as a localized sharp, burning breast pain. They are unilateral, constant, or intermittent, affecting one breast with a pinpoint localized area of involvement. Most likely affect women in their 30s and 50s.

Extramammary Mastalgia

It refers to the breast pain that is originating from a location outside the breast, such as the heart, lung, chest wall, or the esophagus. Extramammary breast pain feels as if it starts in the breast tissue, but in fact, it is a referred pain having its origin somewhere else. For example, pain originating from the chest wall (costochondritis), epigastric pain in GERD, or pain of gallbladder and stomach disease can be referred to give a false impression of breast pain.

Etiology

The exact etiology of mastalgia remains undefined.[2] However,  increased sensitivity of breast tissue towards the hormonal variation during the menstrual cycle plays a vital role in the development of cyclic mastalgia. Moreover, this cyclic pain often abates with pregnancy or menopause, which further strengthens the etiologic role of hormonal fluctuations.

Non-Cyclic breast pain results from changes in the anatomical structure like the development of breast cyst, prior breast trauma or surgery, injury to the chest wall, muscle, or joint, intercostal neuralgia, Tietze syndrome, and other spinal and paraspinal disorders which can cause referred breast pain.[5]

The use of certain medications has also been implicated with breast pain which includes, OCPs (oral contraceptive pills), estrogen, and progesterone hormonal therapies, certain antidepressants like SSRI (selective serotonin reuptake inhibitors), and antihistamines.

Some studies claim that anxiety, stress, and depression are contributing factors, while a few others mention that caffeinated drinks, fatty diet, and smoking also play a major role in its development.[6]

Epidemiology

Mastalgia is considered to be the most common breast complaint with which a female presents in her reproductive age. About 70 percent of women in the US suffer from this condition during their lifetime, out of whom only 30 percent seek medical help. The peak age of incidence for cyclic mastalgia is 20 to 40 years of life. The incidence decreases with increasing age and early pregnancy and is less commonly found in postmenopausal women.

Many females having breast pain reported a negative impact on their life, especially interference with sexual activity (40% females), physical activity (30% females), negative impact on work, and social activities (10% females).[7]

The prevalence of breast pain also varies depending on ethnicity. Women of Asian ethnicity report breast pain in 5% population while studies conducted in the UK showed a 60% incidence in British women.

Pathophysiology

Cyclic breast pain, which is related to hormonal changes, is predominantly associated with the luteal phase of the menstrual cycle and improves with the onset of menses. The periodic discomfort is because of the increase in estrogen level that stimulates the ductal elements of the breast, while simultaneously, there is a decrease in progesterone stimulation of stroma. A concurrent increase in prolactin, causing increased ductal secretion, also contributes towards pain and swelling during this phase. Association of cyclic mastalgia with the use of hormonal therapy such as oral contraceptives and hormone replacement therapy, with its resolution during pregnancy/lactation and menopause also justifies its hormonal etiology.[8]

Non-Cyclic breast pain is not hormone-related and may be inflammatory, vascular, muscular, or neoplastic in origin. It has an unusual pattern with intermittent or constant pain, a variable location, and most likely unilateral. A few of the common causes include breast cyst, fat necrosis due to trauma, mastitis or breast abscess, duct ectasia [because of duct dilation with periductal inflammation], and costochondritis or chest pain due to angina.[5]

Some other causes like the consumption of high-fat content diet, smoking, drinking caffeinated beverages, and use of certain medications (antidepressants, antibiotics, antihistamine) have also been linked with mastalgia, but their exact pathophysiology is unknown.[9]

History and Physical

A detailed history and physical exam is the first and foremost step that delineates the course of investigation and plan of treatment. History regarding the nature of pain, its location, severity, onset, and the use of a pain diary to chart out its cyclic or noncyclic pattern can provide valuable information leading towards an accurate diagnosis. 

The physical examination further helps to identify any alarming feature that needs special attention. Emphasis should be made to explore the chest wall along with breast examination to differentiate extramammary pain from true mastalgia. The breast should be adequately explored with the review of all four quadrants. Supraclavicular, infraclavicular, and axillary regional lymph nodes should be palpated, and the breast should be examined for any lump, skin changes, nipple retraction, color change, ulceration, swelling, or edema, inflammation, scars, or abnormal nipple discharge. The examination should also involve elevation of breast tissue with one hand and palpating the underlying chest wall with the other hand to look for any chest wall deformity.[10][11]

Any abnormal finding identified is carefully documented, and the patient should be referred to a specialist for further evaluation.

Evaluation

Imaging modalities most commonly used to evaluate any abnormal physical exam findings include mammography and breast ultrasound. The primary aim of such testing is to rule out any serious pathology (breast cancer) underlying a suspicious finding. Young females with cyclic mastalgia, which are bilateral and non-focal, having no family history of breast cancer, and a normal previous breast screen does not require further investigation with imaging. While a female with non-cyclic focal mastalgia and a strong suspicion of underlying grave pathology is a positive candidate for further investigation with an imaging modality.[11]

Breast Ultrasound[12][13]

Ultrasound uses sound waves to produce an image of the breast area being examined. Ultrasonography is being used in patients age less than 35 years because of dense breast tissue. However, if any suspicious finding is observed on USG, a mammogram is recommended for further evaluation.

Mammogram[14][15]

It is an imaging modality that uses high amperage, low voltage X-rays. Female more than 35-year of age should undergo mammography if a physical exam detects a focal area of pain with an unusual thickening or a breast lump. 

Breast Biopsy

If imaging modalities show any abnormal finding regarding a breast lump or a focal thickening with underlying breast pain in that region, further investigation is then carried out with the help of biopsy. During a biopsy[preferably core needle biopsy], a sample of breast tissue is taken from the area under question and send for further histopathologic evaluation. 

Sometimes breast imaging is done to alleviate patient's anxiety, and once they are reassured with a negative imaging result, they stop seeking further medical assistance.

Treatment / Management

In the majority of cases, general reassurance that these pain episodes are not associated with breast cancer or any other grave pathology helps alleviate patient symptoms, and they no longer seek medical assistance. However, a few, about 15% to 20%, still require treatment because of either the negative impact this disease has on their life or increased intensity and frequency of pain episodes after the first visit.[2]

The initial step in the management of such a patient is to search for the exact etiology of mastalgia and focusing on alleviating their pain with conservative treatment. 

Conservative Management

Using well-fitting sports bra:[11][16]

This helps to contain and provide support to the heavy, pendulous painful breasts during strenuous physical activities of the day. 60% to 70% of women report pain relief with the use of adequately fitted breast garments.

Use hot and cold compresses:

This might provide relief when applied, especially during the night before sleep.

Relaxation therapy:

It helps to relieve high levels of anxiety and depression associated with mastalgia.

Dietary modification:[17]

Reducing the intake of tea, coffee, chocolate, and carbonated soft drink while using a low-fat diet high in vitamin and fiber has shown beneficial effects. Inculcation of exercise regime within the routine also provides pain relief as physical activity decreases estrogen release and increases its breakdown, thus proving beneficial.

Using over the counter pain medications:

Oral or topical administration of ibuprofen or the use of acetaminophen and NSAIDs have shown promising results. However, these are temporary acute pain managing agents,  and there should be monitored and tailored to prevent the development of serious side effects with their use in toxic amounts.

Pharmacological Management

Generally, breast pain resolves on its own in 3 to 6 months. If it doesn't, then pharmacological treatment provides promising results in the majority of cases.

Topical or Oral NSAID use:[18]

Symptomatic treatment with adequate analgesia is achieved with the use of NSAID when the pain is intense. Oral NSAID, acetaminophen, or ibuprofen and topical (diclofenac in patch or gel form) are the best available modalities in this regard.

Evening Primrose Oil and vitamin E:[19][20]

Literature has shown promising results with the use of these supplements. The use of primrose oil is documented to maintain a favorable balance of fatty acid in our cells, while the use of vitamin E as an antioxidant also plays a vital role in alleviating breast pain. Using 200 IU of vitamin E twice daily with evening primrose oil for three months showed progressive improvement in symptoms of premenopausal women with cyclic breast pain. However, it is recommended to stop its use if no improvement is observed after 4 to 6 months period.

Prescription Medication use

Tamoxifen:[21]

In cases of severe refractory mastalgia, tamoxifen is considered the first-line treatment, a prescription medication for breast cancer. It is administered during the luteal phase of the menstrual cycle in a low dose to avoid side effects. Treatment should be stopped after a period of 3 to 4 months if no favorable results are obtained.  Close monitoring is required as this drug is associated with side effects like headache, nausea, vaginal dryness, hot flashes, and joint pain. 

Danazol:[22]

The only FDA approved drug for the treatment of mastalgia. This is also not free from side effects, which include acne, voice changes, weight gain, hot flashes, and menstrual irregularities. The majority of the patients tend to lose adherence because of such an intolerable side effect profile.

A thorough discussion should be conducted with the patient regarding the benefit and risk profile before the start of these medications.

Differential Diagnosis

The major primary concern of female presenting with mastalgia is breast cancer. However, breast pain is one of the least associated symptoms of breast cancer, present only in 0.5% to 2% patient later diagnosed with cancer. Other differentials for breast pain include pain from a previous surgical scar, chest wall pain from previous trauma, breastfeeding associated mastitis, costochondritis, rib fracture, shingles, referred shoulder pain, or sometimes it may be a clue to other serious diseases like coronary artery disease, pleurisy or pericarditis.

Prognosis

It is complicated to predict prognosis as mastalgia presents many underlying pathological and psychological causes. However, if no underlying pathology is present, it has high rates of spontaneous remission within three months to 3 years. Factors that are affecting the prognosis include the age of onset and the underlying etiology.

For cyclic breast pain, 60% of patients will show a successful response to therapy, but recurrence is generally seen within two years, while 20% to 30% will show complete resolution.

In non-cyclic pain, there is an inadequate response to therapy unless and until the exact underlying etiology is known and adequately treated. Still, 50% of women will show spontaneous resolution.[23]

Complications

In the majority of cases, the complications seen are related to the medication used for the treatment of mastalgia. 

Side effects such as nausea, bloating, headache, vaginal dryness, hot flashes, leg cramps, weight gain, and menstrual irregularities are most commonly associated with pharmacological treatment modalities, likely with the use of danazol and tamoxifen. Generally, it is preferred to question the patient regarding the history of such symptoms before starting these drugs.[24]

Deterrence and Patient Education

Breast pain is a major symptom for which a patient seeks medical attention either out of the fear of having underlying breast cancer or due to its adverse effects on the daily activities of life. However, only 30% of females having breast pain present themselves for medical review. Thus it is important to advise females with breast pain to seek medical assistance so that a thorough history and physical examination is being done and if needed imaging modalities are also being institutionalized in order to make a correct and accurate diagnosis on a timely basis. This will not only help to reduce undue anxiety and pain episodes in patients but will also improve the quality of life and will further provide an opportunity for the patient to get herself educated about her own body.[25]

The strengthening of the patient-physician relationship with open communication will even provide an opportunity for the health caregiver to make females understand the nature of their disease, and consideration of the conservative approach of management with the use of social support, acetaminophen, and NSAID along with the discussion of risks and benefits with the use of pharmacological therapy.

Patients should be educated about the alarm signs and self-breast examination techniques should be taught so that a meticulous watch is kept by the patient and any suspicious finding should immediately be reported and accessed.

Enhancing Healthcare Team Outcomes

Treatment of mastalgia varies over a wide spectrum which requires good clinical judgment and adequate patient education to optimize the outcome. Prognosis depends on making correct diagnosis which not only includes history and examination but also inculcates imaging modalities and expertise from radiologists. The role of nurse practitioners and nutritionists is crucial in instructions regarding the self-breast examination and charting out a specific nutritional diet, low in fat while enriched in vitamins and fiber to optimize pharmacological treatment. The expertise of an endocrinologist might come in handy while dealing with dose adjustments and initiation of second-line hormonal replacement therapies. Moreover, as it is seen that mastalgia also has a psychological aspect associated with it, and hence, specialists in holistic medicine and a good psychologist team should be kept on board for adequate management of this disease.[25] 

Interprofessional teamwork is required to adequately treat this disease, providing an integrated approach from making its accurate diagnosis utilizing clinical knowledge and imaging, managing patient stress and anxiety, educating them regarding dietary and lifestyle modifications, and simultaneously ruling out any dangerous underlying pathology and dealing with ongoing recurrences. 

Case-control and Cohort studies have shown that patient-physician interpersonal communication and adequate reassurance from a primary care provider is what marks the best treatment outcome in up to 70% of cases. An improved outcome is seen with the use of a combination of psychological and pharmacological treatment modalities in the majority of resistant cases of mastalgia.