What is the management of mastodynia (breast pain) in an elderly male patient?

Management of Mastodynia in Elderly Males

The management of mastodynia (breast pain) in elderly males should focus on identifying the underlying cause, with treatment directed at the specific etiology rather than symptomatic management alone.

Diagnostic Approach

Initial Assessment

• Rule out breast cancer, which is rare but important in elderly males
  • Diagnostic mammography or digital breast tomosynthesis (DBT) is recommended as the initial imaging study for males ≥25 years with breast pain 1
  • Ultrasound should be performed if mammography/DBT shows indeterminate or suspicious findings 1

Common Causes in Elderly Males

1. Gynecomastia - most common cause

   • Defined as actual glandular breast tissue enlargement (vs. pseudogynecomastia which is fatty tissue deposition) 2
   • Often medication-induced in elderly males

2. Medication-induced mastodynia

   • Antipsychotics (especially those causing hyperprolactinemia) 2
   • 5-α reductase inhibitors (finasteride, dutasteride) 2
   • Spironolactone 2
   • Phenytoin 2
   • Hormone replacement therapies 1

3. Chest wall pain (extramammary)

   • Often misdiagnosed as breast pain

Treatment Algorithm

Step 1: Address Medication-Related Causes

• Review and modify medications that may cause gynecomastia/mastodynia:
  • Consider switching from spironolactone to eplerenone (25-50 mg daily initially) 2
  • Consider amiloride (10-40 mg/day) as alternative to spironolactone 2
  • Switch to prolactin-sparing antipsychotics if applicable (aripiprazole, clozapine, quetiapine) 2
  • Consider discontinuation or dose adjustment of 5-α reductase inhibitors 2

Step 2: Pain Management

• For mild to moderate pain:

  • Acetaminophen as first-line analgesic in elderly patients 1
  • NSAIDs if no contraindications (use with caution in elderly due to GI, renal, and cardiovascular risks) 1

• For severe pain:

  • Multimodal analgesia approach to minimize opioid requirements 1
  • Consider local anesthetic injections for chest wall pain 3

Step 3: Management of Gynecomastia

• Reassurance and observation for mild cases 2
• For persistent, troublesome gynecomastia (>12-24 months):
  • Surgical options may be considered:
    • Liposuction for predominantly fatty tissue
    • Direct excision for predominantly glandular tissue
    • Combined approaches for mixed composition 2

Special Considerations for Elderly Patients

• Treatment should be adapted to biological (not chronological) age 1
• Perform geriatric assessment before making treatment decisions 1
• Consider potential drug interactions and comorbidities when selecting medications
• Monitor closely for adverse effects of medications, particularly NSAIDs and opioids 1
• Venous thromboembolism prophylaxis should be considered in high-risk patients with limited mobility 1

Follow-up

• Regular follow-up to assess response to treatment
• Repeat imaging only if clinical findings change or new symptoms develop
• Consider referral to specialist (endocrinology, surgery) for refractory cases or when surgical intervention is being considered

Warning Signs Requiring Urgent Evaluation

• Unilateral, persistent, or worsening pain
• Associated breast mass or skin changes
• Nipple discharge or retraction
• Axillary adenopathy

By following this structured approach to mastodynia in elderly males, clinicians can effectively diagnose and manage this condition while minimizing unnecessary interventions and addressing quality of life concerns.