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| '''For patient information page on this topic, Click [[Mastalgia (patient information)|here]].''' | | '''For the patient information page on this topic, click [[Mastalgia (patient information)|here]].''' |
| {{Mastalgia}} | | {{Mastalgia}} |
| {{CMG}} | | {{CMG}} |
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| {{SK}} Mastodynia; mammalgia; breast pain; pain in the breast | | {{SK}} Mastodynia; mammalgia; breast pain; pain in the breast |
| ==Diagnosis==
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| === Echocardiography or Ultrasound === | | ==[[Mastalgia overview|Overview]]== |
| * Women < 35 years old
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| *:* No imaging indicated if normal physical exam
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| * Women 35 years old and older
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| *:* If focal pain, can start with ultrasound – rule out focal cystic or solid lesion
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| === Other Imaging Findings === | | ==[[Mastalgia historical perspective|Historical Perspective]]== |
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| ==== Mammogram ==== | | ==[[Mastalgia classification|Classification]]== |
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| * Women 35 years old and older
| | ==[[Mastalgia pathophysiology|Pathophysiology]]== |
| *:* If global unilateral or bilateral pain, start with bilateral mammogram
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| *:* If ultrasound unrevealing, proceed to mammogram
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| ==Differential Diagnosis== | | ==[[Mastalgia causes|Causes]]== |
| === Causes Related to the Breast===
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| * '''Fibrocystic Changes'''
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| *:* Increased number of cysts or fibrous tissue in otherwise normal breasts
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| *:* Can be associated with pain or nipple discharge – “fibrocystic disease”
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| *:* If fibrocystic changes are cause of pain- found in 50-90% asymptomatic women
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| *:* Hormonal etiology – pain often cyclic; most severe during luteal phase
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| *:* Tissue edema/water retention with dilated/blocked ducts – not proven
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| * '''Mastitis or Breast Abscess'''
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| *:* Acute onset, usually due to Staphylococcus aureus (S. aureus) or streptococci
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| *:* Erythema, local tenderness induration
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| *:* Most common in lactating women
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| * '''Pendulous Breasts'''
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| *:* Pain due to stretching of Cooper’s ligaments
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| * '''Hidradenitis Suppurativa'''
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| *:* Can involve the breast
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| *:* Presents with painful breast nodules<br>
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| === Causes Unrelated to the Breast === | | ==[[Mastalgia differential diagnosis|Differentiating Mastalgia from other Conditions]]== |
| * '''Trauma to Chest Wall'''
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| * '''Fat Necrosis'''
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| *:* Usually induced by trauma
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| *:* Tender, firm mass, +/- calcification on mammogram
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| * '''Costochondritis'''
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| * '''Intercostal Neuralgia'''
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| *:* Usually due to a respiratory infection
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| * '''Pleuritic Pain from Underlying Pulmonary/Pleural Disease'''
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| * '''Thoracic Spine Arthritis'''
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| * '''Referred Chest Pain'''
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| *:* Gallbladder disease
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| *:* Ischemic heart disease
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| == Risk Stratification and Prognosis== | | ==[[Mastalgia epidemiology and demographics|Epidemiology and Demographics]]== |
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| * Referral
| | ==[[Mastalgia risk factors|Risk Factors]]== |
| *:* Abnormal findings on exam, mammogram or ultrasound
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| *:* Persistent pain unresponsive to symptomatic treatment
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| == Treatment == | | ==[[Mastalgia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * Reassurance
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| *:* Pain resolves spontaneously in 60-80% and will not require further therapy in 90% of patients
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| *:* Pain, fibrocystic changes, and simple fibroadenomas pose no increase in breast cancer risk
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| *:* Pendulous breasts: soft bra with adequate support
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| === Acute Pharmacotherapies === | | ==Diagnosis== |
| * Symptomatic Treatment
| | [[Mastalgia history and symptoms|History and Symptoms]] | [[Mastalgia physical examination|Physical Examination]] | [[Mastalgia laboratory findings|Laboratory Findings]] | [[Mastalgia chest x ray|Chest X Ray]] | [[Mastalgia CT|CT]] | [[Mastalgia MRI|MRI]] | [[Mastalgia echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Mastalgia other imaging findings|Other Imaging Findings]] | [[Mastalgia other diagnostic studies|Other Diagnostic Studies]] |
| *:* Indicated for severe pain or pain lasting > a few days each month
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| *:* Analgesia: acetaminophen or NSAIDs (nonsteriodal anti-inflammatory drugs)
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| *:* Premenstrual engorgement: thiazide diuretic for several days during premenstrual symptoms
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| *:* Other potentially beneficial treatments
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| *:*:* Avoidance of caffeine: no efficacy in randomized controlled trials (RCTs), but some patients report relief
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| *:*:* Vitamin E: 400 IU bid beneficial in some studies but not others (2 negative RCTs)
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| *:*:* Primrose oil (linoleic acid): 1.5-3 g qd effective in 40-60%; may take 3 months for results
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| *:*:* Danazol
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| *:*:*:* Only FDA approved therapy for breast pain
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| *:*:*:* Inhibits luteinizing hormone/follicle stimulating hormone (LH/FSH) secretion (decreased exocrine secretion); blocks exocrine effects on breast
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| *:*:*:* 100-200 mg qd reduces pain and nodularity in patients with fibrocystic disease
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| *:*:*:* Response rate 50-75% for both cyclic and noncyclic breast pain
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| *:*:*:* Significant side effects in 20% (weight gain, acne, irregular menses, hirsutism)
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| *:*:* Tamoxifen: 10 mg bid reduces pain in ~70% via antiestrogen effect
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| *:*:* Bromocriptine: 1.25-5 mg qd may reduce pain via inhibition of prolactin secretion; +/- data
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| *:*:* Oral contraceptive pills (OCPs): can reduce fibrocystic changes via progestin component; efficacy for pain uncertain
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| *:*:* Reduction in hormone replacement therapy (HRT) dose: for postmenopausal women, lower E dose may reduce pain
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| ===Treatments for cyclical breast pain===
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| Specific treatment for cyclical breast pain will be determined by your physician(s) based on:<ref>http://www.childrenshospital.org/az/Site1274/mainpageS1274P0.html Children's Hospital Boston: My Child Has</ref>
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| * your overall health and medical history
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| * extent of the condition
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| * your tolerance for specific medications, procedures, or therapies
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| * expectations for the course of the condition
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| Treatments vary significantly and may include the following:<ref>http://www.childrenshospital.org/az/Site1274/mainpageS1274P0.html Children's Hospital Boston: My Child Has</ref>
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| * caffeine avoidance
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| * a low-fat diet
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| * evening primrose oil
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| * vitamin E
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| * any [[over-the-counter drug|over-the-counter]] pain-reliever
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| In some cases, various supplemental hormones and hormone blockers are also prescribed. These may include:
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| * birth control pills
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| * Bromocriptin (which blocks prolactin in the hypothalamus)
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| * Danazol, a male hormone
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| * thyroid hormones
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| * Tamoxifen, an estrogen blocker
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| Supplemental hormones and hormone blockers may have side effects. In addition, the risks and benefits of such treatment should be carefully discussed with your physician.
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| ===Treatments for non-cyclical breast pain=== | | ==Treatment== |
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| Determining the appropriate treatment for noncyclical breast pain is more difficult, not only because it is hard to pinpoint where the pain is coming from, but also because the pain is not hormonal. Specific treatment for noncyclical breast pain will be determined by your physician(s) based on:
| | [[Mastalgia medical therapy|Medical Therapy]] | [[Mastalgia surgery|Surgery]] | [[Mastalgia prevention|Prevention]] | [[Mastalgia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Mastalgia future or investigational therapies|Future or Investigational Therapies]] |
| * your overall health and medical history
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| * extent of the condition
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| * your tolerance for specific medications, procedures, or therapies
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| * expectations for the course of the condition
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| Generally, physicians will perform a physical examination and may order a mammogram. In some cases, a biopsy of the area is also necessary. If it is determined that the pain is caused by a cyst, the cyst will be aspirated. Depending on where the pain originates, treatment may include analgesics, anti-inflammatory drugs, and compresses.
| | ==Case Studies== |
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| == References ==
| | [[Mastalgia case study one|Case #1]] |
| {{reflist|2}}
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| {{Diseases of the breast}} | | {{Diseases of the breast}} |
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| [[Category:Primary care]] | | [[Category:Primary care]] |
| [[Category:Pain]] | | [[Category:Pain]] |
| | [[Category:Symptoms]] |
| [[Category:Signs and symptoms]] | | [[Category:Signs and symptoms]] |
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