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Breast pain

Breast pain ( mastodynia , mastalgia ) is a common symptom – occurs in 70 to 80 % of women some time in their lives 2nd commonest reason ( 1st is a lump ) for which a woman seeks help -for breast related issues ( even in older age group ) Breast pain is rarely associated with breast cancer
○ number quoted varies from 1 % to 0.5 % ( Normal breast examination and with only breast pain )
○ causes significant anxiety and fear in women who relate to and are convinced they have breast cancer Severe pain can affect QOL- particularly
○ sleep patterns
○ sexual activity
○ physical activity
○ work , school and social activity A study has shown that breast pain is
○ typically reported by older women
○ those with large breast cup sizes
○ those who self reported lower activity and fitness Accounts for upto 50 %-referrals to breast OP clinics Usually self limiting Most women would be managed by reassurance and simple drugs

large breasts age 30-50 yrs ill fitting bras medications ( see below ) other possible risk factors include
older age , stress , caffeine , smoking , incd frequency of lactation and h/o Ca breast

Approach-Take a detailed history and examine to help distinguish if the pain is cyclical , non-cyclical or extramammary
 In history ask about
◘ family h/o Ca breast
◘ relation to menstrual cycle
◘ has the patient felt a lump
◘ discharge
◘ breast feeding – recent or current
◘ pain severity over time
◘ location of pain , quality , duration , radiation
◘ h/o breast surgery or trauma
◘ relationship to physical activity
◘ impact on daily living
◘ other risk factors for breast cancer 
 Drug history -medications which can cause breast pain include
◘ Hormonal medications eg
estrogens ,progestogens ,OCP , HRT , Clomiphine , cyproterone
◘ Antidepressant , antipsychotic and anxiolytic medications e.g
sertraline and other SSRIs , venlafaxine , mirtazepine , amitriptyline
◘ Antihypertensive and cardiac medications e.g spironolactone , methyldopa , digoxin
◘ Antimicrobial agents e.g metronidazole
◘ Miscellaneous others e.g methadone , domperidone
 Examination Breast examination is essential
○ breast pain can arise from chest wall or the breast itself
○ examination of cervical and thoracic spine , chest wall , shoulders ,upper extremities , heart , lungs and abdomen may also be useful

Cylical mastalgia-in pre-menopausal women
related to periods 
usually 1-2 weeks before period More common variant Seen more in 20-45 age group pain is diffuse in upper outer quadrant with radiation to axilla and ipsilateral arm -often described as “dull ” , ” heavy ” or ” aching ” Can be uni or bilateral but a study has shown that
○ in 38 % – pain was unilateral ( in the breast with ↑ parenchyma )
○ and in 61 % of those with b/l pain had pain in one breast more than the other Often accompanied by a swelling that waxes and wanes with the menstrual cycle Pain is more in luteal phase – due to ↑ ed water content in the breast stroma caused by increasing hormone levels Pain normally disappears after the period and women would be pain free for up to 2 weeks – then the pain recommences but in some women pain may be present in the entire cycle with with pre-menstrual intensification of symptoms Cause is not clear- various theories have been implicated e.g
○ histological ( fribrocystic histology )
○ hormonal
○ fluid and electrolyte balance and nutritional association
○ psychological

Reassurance – pain not due to cancer Bra support Dietary interventions – e.g low fat diet ( no evidence of effectiveness ) Evening primrose oil – lack of evidence and NICE does not support its use now Oral or topical NSAIDs or paracetamol Lifestyle measures as exercise , smoking cessation Address stress , anxiety , PMS if required Resolves spontaneously within 3 months of onset in 20-30% of women but tends to relapse and remit and up to 60 % of women develop recurrent symptoms 2 yrs after treatment

Non-cyclical –Unrelated to menstrual cycle Less common than cyclical mastalgia Usually in women in their 40s or 50s Tends to be unilateral and localized to a particular quadrant of the breast Constant or intermittent Causes include
○ pregnancy
○ cysts
○ periductal mastitis
○ stretching of Cooper’s ligament
○ traumatic fat necrosis
○ Mondor’s disease ( rare cause because of thrombophlebitis of the superficial veins of the breast and anterior chest wall ) from Mondor’s disease- a rare cause of chest pain : a case report J Med Case Rep
○ diabetic mastopathy
○ neoplasia
○ non-mammary pain
○ trauma

Responds poorly to treatment Spontaneous resolution in about 50% patients NSAIDS advocated widely Treat referred pain appropriately

extra-mammary-Broad range of causes Musculoskeletal e.g
costochondritis / Tietze’s
chest wall pain
chest wall trauma / rib fracture
cervical , thoracic neurological or muscular conditions Gallstones Pleural irritation Pneumonia Shingles Oesophageal spasm CV – CAD / angina PE GORD Fibromyalgia

Pre-menopausal women Normal breast examination Try and distinguish cyclical or non cyclical Pain chart – for e.g daily up to 3 months to establish severity

Serious underlying cause suspected Refer if symptoms persist
○ duration not clear
○ NCCP document recommends a review at 3 months and referral if pain intractable with a completed pain chart
CKS also recommends referral to breast clinic for cyclical breast pain which does not respond to 1st line treatment after 3 months Pain interferes with quality of life Anxious patient who are not reassured by their GP Unilateral persistent pain in post-menopausal women Extramammary cause of breast pain

Danazol – evidence of benefit 3 rd line
only FDA approved medication for mastalgia
also licensed in UK – it is the only drug which has license for mastalgia Tamoxifen – evidence of benefit but associated with sig and common SEs LHRH agonists – specialist use concerns about menopausal SEs Surgery- insufficient evidence LA and steroid injections

References

  1. Breast pain Amit Goyal BMJ Clin Evid. 2014 : 2014 : 0818
  2. Irish Cancer Society General Information Breast Pain Evaluation and Management of Breast Pain Robin L Smith et al Mayo Clin Proc . 2004 ; 79 :353-372
  3. ACR Appropriateness Criteria® Breast Pain Expert Panel on Breast Imaging : Peter M Jokich et al J Am Coll Radiol 2017 ; 14 : S25-S33
  4. A systematic review of Current Understanding and Management of Mastalgia Kamal Kataria et al Indian J Surg . 2014 Jun ; 76 (3) : 217-222
  5. Evaluation of common breast complaints in Primary Care by Mary Alison Smania The Nurse Practitioner October 2017
  6. Management of Breast pain ( mastalgia ) in Primary care – National cancer control Programme
  7. Breast pain- cyclical CKS NHS
  8. DynaMed mastalgia
  9. Clinical management of idiopathic mastalgia : a systemic review Shazia P Hafiz et al CSIRO Publishing Journal Compilation Royal New Zealand College of General Practitioners 2018

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