Mastalgia

Section: Breast Curriculum: Curriculum, page 9

Definition

• Excessive breast pain in the absence of a palpable lump

Incidence

• 70-80% if women will get breast pain in their lifetime
• Only 0.5% of women will have cancer
• Only 3% of women with breast cancer present with pain as their primary symptom

Classification

• True breast pain
  • Cyclical 60%
  • Non-Cyclical 40%
    • Pregnancy, cyst, sclerosing adenosis, cancer
  • Referred pain
• Mechanism
  • True breast pain
    • Hormonal change:
      • ? Too much oestrogen – no sig evidence
      • ? Too much prolactin – women with mastalgia produce more prolactin for longer after stimulation
    • Tissue oedema in ?follicular phase – not proven and use of diuretics not supported
    • Upper outer quadrant affected most (bulk of breast tissue)

Clinical

True breast pain

• Cyclical
  • Usually starts in 20s, 50% < 30 years old
  • Tends to be 1-2 wks before each period - pre-menstrual crescendo
  • Frequently bilateral; UOQ & associated with increased nodularity (± radiates to inner arm)
  • “Tender” / “heavy”
  • Mean duration ≈ 7yrs (longer if onset < 20yrs)
• Non-cyclical
  • Most common in 30s; 12% post-menopausal
  • No relation to menses
  • Frequently unilateral and long duration
  • Can be associated with trigger points
  • “Burning” pain

Referred pain

• Features
  • Unilateral, worse with movement, can be reproduced with pressure on the chest wall
• Tietze’s syndrome
  • Not = Costochondritis
  • Swelling at costal cartilages, aetiology unknown
  • Rx: Steroid injection or anti-inflammatories
• Rib injury
  • Cervical root syndromes
• Angina
• Mondor disease

Principles of Management:

• Exclude malignancy – clinical exam, Mamm if > 40 yrs, USS if localised breast pain
• Assess cause – treat if possible
• Reassurance

Chest wall pain

• Reassurance +/- NSAIDS
• Lifestyle modification
• Single injection of prednisone/local anaesthetic if localised to costal margin

Chronic pain following surgery

• Up to 50% women
• Rule out underlying recurrence
• Gabapentin/amitriptyline

True mastalgia

• Reassurance is the only treatment necessary in up to 85% of pts
• Supportive well fitted bra (± Wear night & day)
• Simple pain relief – e.g. Panadol + anti-inflammatory creams – Voltaren Emugel
• Lifestyle - Healthy weight, ↓ caffeine intake (overstimulates breast cells), ↓ fat intake
• Try stopping COC or HRT …or take HRT on alternate days or change to higher progesterone pill

Medical Rx for Refractory Pain:

• Failed above measures / mastalgia > 6/12 / major life disruption
• Pain chart
• NSAIDs (for short periods in the cycle)
• No evidence for evening primrose oil
• Tamoxifen (10 mg daily) for 3 – 6 months
  • During luteal phase
  • If refractory then every day

Appropriate Use of Imaging

• Up to 7% of operable cancer presents with pain as only symptom
• Image if
  • Screening mammography is not up to date
  • Palpable abnormality
  • Non-cyclical / unilateral / other clinical suspicion
  • If no evidence of disease:
    • Simple measures to relieve breast pain ± re-assess after 3 months with a pain diary (including relation to menstrual cycle)

Mastalgia – Chronic Pain Principles

• General Principles of Pain Assessment
  • Starts with adequate assessment of the pain
  • Absence of appropriate assessment is the leading reason for poor pain management
  • A comprehensive pain assessment addresses the pain’s:
    • Nature
    • Cause
    • Personal context:
      • Psychological
      • Social
      • Spiritual
      • Practical issues
      • Underlying pathophysiology
• General Principles of Pain Management
  • Use of appropriate interventions
    • Pharmacologic
    • Non-pharmacologic
    • Education of the patient, family, and all caregivers about the plan
    • Ongoing assessment of treatment outcomes
    • Regular review of the plan of care
  • Use of other members of the interdisciplinary team, including:
    • Nurses
    • Social workers
    • Pharmacists
    • Chaplains
    • Physiotherapists
    • Occupational therapists
    • Child life specialists
  • Flexibility is essential—successful plans are tailored to the individual patient and family
  • Willingness to ask for help from colleagues with more expertise when the plan is not effective at controlling the patient’s pain

Northshore Guidline

In the absence of clinical asymmetry, a palpable lump or other risk factors:

• Bilateral or Cyclical
• Imaging and treatment on clinical grounds:
  • Mammography age > 35 years.
  • Ultra Sound age < 35 years.

In the absence of clinical evidence of disease

• Provide Mastalgia Pamphlet
• For severe pain and in the absence of clinical evidence of disease, discuss with consultant the prescribing of Tamoxifen (10 mg daily) for 3 – 6 months.
  • The risk of endometrial cancer must be discussed with patient.