What is mastalgia (breast pain)?

From the Guidelines

Mastalgia, or breast pain, is a common condition that can be managed with both non-pharmacological and pharmacological approaches, with the most recent and highest quality study suggesting that reassurance and symptomatic management are often sufficient for mild to moderate cases 1. For mild to moderate mastalgia, start with lifestyle modifications including:

• Wearing a well-fitted supportive bra
• Reducing caffeine and salt intake
• Applying warm or cold compresses to the affected area Evening primrose oil (1000mg three times daily) may help some women, though evidence is limited 1. For moderate to severe pain, over-the-counter pain relievers like ibuprofen (400mg three times daily) or acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) can provide relief 1. If pain persists, prescription options include topical diclofenac gel applied to painful areas, or oral medications like danazol (100-200mg twice daily) or tamoxifen (10mg daily), though these have more significant side effects and should be used under medical supervision 1. Mastalgia often occurs cyclically with menstruation due to hormonal fluctuations affecting breast tissue sensitivity, but can also be non-cyclical due to inflammation, cysts, or other breast conditions 1. Most cases resolve with conservative management, but persistent or severe pain should be evaluated by a healthcare provider to rule out underlying conditions, with imaging recommendations varying by age and clinical significance of pain 1. Key considerations in evaluating breast pain include:
• Comprehensive history
• Type of pain
• Relationship to menses
• Duration
• Location
• Impact on activities of daily living
• Factors that aggravate or alleviate pain
• Any other medical problems and comorbidities
• A thorough clinical breast exam (CBE) 1.

From the Research

Definition and Prevalence of Mastalgia

• Mastalgia is the commonest breast symptom presenting to general practitioners and breast surgeons alike 2
• It affects up to two-thirds of women at some time during their reproductive lives 3
• Breast pain is a common symptom in most women during their lifetime, and many times is self-limited 4

Causes and Classification of Mastalgia

• Mastalgia can be associated with premenstrual syndrome, fibrocystic breast disease, psychologic disturbance and, rarely, breast cancer 3
• It is categorized into 3 main groups: cyclic, noncyclic and extramammary 4
• Contributing factors for physiologic causes of mastalgia include diet, medications, stress, hormonal fluctuations, and an ill-fitting bra 4

Diagnosis and Assessment of Mastalgia

• A thorough clinical evaluation is required to assess the cause of mastalgia 3
• A good history, examination and targeted imaging can help to delineate the underlying cause of mastalgia and therefore guide treatment options 4
• Diary cards are often helpful in assessing the cause of mastalgia 2

Treatment Options for Mastalgia

• Reassurance, support, dietary changes, nonsteroidal anti-inflammatory drugs and occasionally hormonal medications are options to help with improving breast pain 4
• Mechanical breast support, a low-fat, high-carbohydrate diet, and topical nonsteroidal antiinflammatory agents are reasonable first-line treatments 3
• Hormonal agents, such as bromocriptine, tamoxifen and danazol, have all demonstrated efficacy in the treatment of mastalgia, but side effects limit their extensive use 3
• Centchroman and tamoxifen were found to be of similar effectiveness in providing pain relief in mastalgia, but centchroman had a higher frequency of side effects 5

Treatment Outcomes and Recurrence

• Approximately 15% of women require pain-relieving therapy for mastalgia 3
• Sixty percent of cyclic mastalgia recurs after treatment 3
• Noncyclic mastalgia responds poorly to treatment but resolves spontaneously in up to 50% of cases 3
• Patients with severe recurrent or refractory mastalgia may require treatment with tamoxifen, goserelin or testosterone, but the short and long term adverse effects of these drugs preclude their use as first-line agents 6