Mastalgia

Excerpt

Mastalgia, or breast pain, affects up to 70% of women at some point in their lives and is a common concern in primary care. Also known as mastodynia, mastalgia prompts many women to seek clinical evaluation due to a fear that the pain is a breast cancer symptom. However, despite its frequent occurrence, mastalgia is rarely linked to breast cancer, associated with only 2% to 7% of women with breast pain. Diagnostic studies may be indicated in some patients, but clinicians may be unsure when clinical assessment is sufficient or if further evaluation is necessary, resulting in a substantial number of referrals to secondary care breast units.

Mastalgia is typically characterized as 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. This breast pain is often located in the upper outer quadrant of the breast and can sometimes radiate to an ipsilateral arm. Mastalgia 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.

Based on the pattern of breast pain, associated factors, and location, mastalgia is classified into 3 categories: cyclic, noncyclic, and extramammary pain. Cyclic breast pain, the most common type, is experienced by about two-thirds of affected women. Breast pain is linked to hormonal fluctuations during the menstrual cycle, with symptoms intensifying during the luteal phase and subsiding with menstruation. Factors such as hormonal medications, caffeine, and dietary fat intake may exacerbate symptoms, though their influence remains inconclusive. Noncyclic breast pain, accounting for one-third of cases, is unrelated to the menstrual cycle and is often caused by factors such as large breasts, cysts, pregnancy, trauma, prior breast surgery, or inflammatory conditions like mastitis and abscesses. Extramammary breast pain arises from sources outside the breast, including musculoskeletal issues like costochondritis, cervical arthritis, or systemic conditions, including gallbladder disease, pleuritis, or cardiac disorders.

Assessment of mastalgia begins with a detailed history to understand the nature of the pain, associated symptoms, and contributing factors like medication use or family history of breast disease. The clinical examination focuses on identifying indications for further diagnostic evaluation, differentiating between mastalgia that may be addressed with reassurance and breast pain with suspicious features. Management typically involves supportive measures eg, patient education to alleviate anxiety, proper bra fitting to reduce symptoms, and dietary adjustments, though evidence for the effectiveness of these changes is limited. Topical NSAIDs, such as diclofenac, are recommended as a first-line treatment. Hormonal treatments, including tamoxifen and bromocriptine, may be considered for severe cases but carry significant adverse effects. Natural remedies like evening primrose oil and vitamin E are widely used but lack strong evidence of efficacy.

Referral to specialists is not typically urgent unless other concerning symptoms, eg, a lump, are present. However, long-standing cyclic pain that affects quality of life may warrant further evaluation to explore advanced treatments or provide imaging for reassurance. Cyclic mastalgia often resolves spontaneously but can recur, while noncyclic pain is more resistant to treatment but frequently subsides over time. Extramammary pain requires accurate identification of its source for effective management. A stepwise approach to treatment, beginning with noninvasive methods and progressing to specialist care for severe or persistent symptoms, ensures that mastalgia is managed effectively while minimizing unnecessary interventions and patient distress.