Mastalgia or breast pain is a distressing condition seen in women. The nagging pain in the breasts affects the quality of life adversely. Usually symptoms involve both breasts though many women may have pain in one breast only. Breast pain is broadly divided into two types; cyclic and non-cyclic. Cyclic pain is related to menstrual cycles whereas the non-cyclic pain occurs irrespective of menses. In 75% of affected women, the pain is cyclic that is usually associated with hormonal changes of breast or chest wall.
Mastalgia predominantly affects women though men may rarely be involved. It occurs during the reproductive life between adolescence and menopause. In women with mastalgia, the frequency of breast cancer is 1.2 – 6.7%.
What are the risk factors for mastalgia?
There are many lifestyle related factors that are associated with occurrence of mastalgia. These include diet rich in saturated fats, tobacco smoking, obesity, pregnancy, breast hypertrophy or excessive enlargement and hormone therapy. Familial tendency has also been reported.
What are the causes of mastalgia?
Many disorders can result in breast pain and include fibrocystic disease, breast trauma, breast engorgement, mastitis, breast abscess, lump in the breast, breast cancer, hidradenitis, costochondritis, post radiation therapy and referred pain from other areas like gall bladder disease.
How is the diagnosis of cause of breast pain done?
The diagnosis of cyclic mastalgia is done by its relation with menses as well as by excluding other causes listed above. A detailed history and clinical examination of both breasts and chest wall are performed. It is important to assess location, duration, frequency, severity, associated symptoms and aggravating and relieving factors. Any family history of breast cancer is recorded.
The physician examines breast in both sitting and lying down positions. Presence of area of tenderness, lump, breast asymmetry, dimpling, bruises, nipple discharge and enlargement of lymph nodes in the axilla are recorded.
What are the investigations performed in mastalgia?
Imaging is performed if a lump is detected or if cancer is suspected. The imaging modalities are x-ray and ultrasonography. X-ray is preferred in women above 35 and ultrasonography in younger women. Image guided needle aspiration is done. It has both diagnostic value and is also therapeutic in breast cysts.
Trucut or wide bore needle biopsy is also done. The biopsy provides tissue diagnosis of benign conditions like fibrocystic changes, duct ectasia, solitary papillomas and simple fibroadenomas. A small increase in risk of breast cancer occurs in conditions like ductal hyperplasia without atypia, sclerosingadenosis, diffuse papillomatosis and complex fibroadenomas. Moderate increase in risk of breast cancer occurs in atypical ductal hyperplasia and atypical lobular hyperplasia.
How is mastalgia managed?
The management of mastalgia is done by multimodal approach. The general measures include modification or stoppage of hormone replacement therapy, frequent clinical examination and follow-up and reassurance. Wearing properly fitting bra for breast support is essential. Other measures include weight reduction in obese people, cessation of smoking and use of relaxation techniques like yoga or meditation.
Drug therapy includes use of acetaminophen or NSAIDs for pain relief. Danazol is most effective in the management of mastalgia. Other useful drugs include toremifene, bromocriptine and cabergoline.
Vitamin E has anti-oxidant properties and Evening primrose oil contains essential fatty acids; both are effective in the management of breast pain due to fibrocystic disease. Flax seed oil may also be used, though it is not as effective as Evening primrose oil.
Dr. Uday Singh Dadhwal
(Specialist General Surgery)
Bahrain Specialist Hospital
Email: uday.dadhwal@bsh.com