Breast pain (mastalgia)
Mastalgia is any pain felt in the breast. A thorough history of the pain
(documenting the site, onset and relationship to the menstrual cycle) should be
taken. Mastalgia may occur premenstrually (cyclical mastalgia) or may be
unrelated to the menstrual cycle. The history should also include any previous
or family history of breast disease including carcinoma. A thorough breast examination
including examination of the regional lymph nodes may reveal a cyst, an abscess
or localised inflammation secondary to mastitis. In non-cyclical mastalgia the
chest wall should also be palpated.
Cyclical mastalgia: Most
premenopausal women get some breast discomfort premenstrually. Symptoms
including heaviness, tenderness and increased nodularity of the breast tend to
gradually increase during the premenstrual period. The symptoms tend to subside
as menstruation starts and generally resolve within a few days. If no other
abnormalities are detected imaging is not normally required for cyclical
Non-cyclical mastalgia may arise
from the breast or from non-mammary causes. True breast pain may be caused by
acute mastitis, a breast abscess, fat necrosis or benign breast disorders.
Focal mastalgia may rarely be a presentation of breast cancer therefore
mammography must be considered for women over the age of 35 years with
noncyclical focal mastalgia.
Non-mammary causes include
Tietze’s disease (chostochondritis) in which patients present with a sharp pain
exacerbated by movement and reproduced by pressure on the costochondral
junctions. It usually resolves with rest and nonsteroidal anti-inflammatory
drugs. Pain arising from the chest wall may require infiltration of local
anaesthetic agents and steroids in severe cases. Breast pain may also be
referred pain from conditions such as angina, pleural inflammation, pneumonia
and oesophageal inflammation.
Once underlying pathology has been excluded the majority of patients can
be effectively managed with reassurance. Lifestyle changes have been suggested
including the use of a well-fitting sports bra, reduction of stress, relaxation
therapy and dietary manipulation. Various drug therapies have been shown to be
effective including danazol (a synthetic testosterone), tamoxifen and
bromocriptine although all have significant side effects limiting their
clinical use. Recent advances include lisuride (a dopamine agonist with fewer
side effects than bromocriptine) for cyclical mastalgia and the use of topical
nonsteroidal anti-inflammatory preparations for all types of mastalgia.