Download The Management of Mastalgia

Dr. Leung Lap Chi
The Management of Mastalgia
Mastalgia(breast pain) is one of the common breast symptoms that one would
encounter in everyday clinical practice. Because of increasing awareness of breast
cancer and the possibility that mastalgia may indicate disease, more women now seek
advice for breast pain. Mastalgia can be broadly divided into 2 groups – cyclic and
noncyclic. Cyclic means the severity of pain fluctuates with the menstrual cycle and
usually the most severe pain would be experienced in the premenstrual period and the
pain dissipates with the onset of menses. It presents mostly in the third decade of life.
Spontaneous resolution occurs in about 22% of patients. Non-cyclic mastalgia usually
presents a decade later and about 50% of patients may have spontaneous resolution.
Overall, about 2/3 of mastalgia are cyclic, 1/4 non-cyclic and the rest are due to
non-mammary causes of which the commonest is costochondritis. Cyclic mastalgia is
more amenable to treatment as compared to non-cyclic mastalgia. Overall, about 90%
of patients with cyclic mastalgia and 2/3 of patients with noncyclic mastalgia can
expect a clinically useful response after adequate medical treatment.
Aetiology of mastalgia
Dietary factors – methylxanthines and saturated fat have been suggested to be the
cause of mastalgia.
Hormonal imbalance – oestrogen excess, progesterone deficiency, changes in
progestin/oestrogen ratio, differences in receptor sensitivity, disparate secretion of
follicle-stimulating hormone (FSH) and luteinizing hormone (LH), low androgen
levels, and high prolactin levels have all been implicated as the cause for mastalgia.
However evidence to confirm the causal relationship between mastalgia and various
hormonal imbalance is lacking.
Management of mastalgia
All patients presented with mastalgia warrant a detailed breast examination. Some
patients with breast cancer do present with mastalgia. Basically, there are 3 types of
breast examination findings:
1. Essentially normal breast
2. Lumpy breast with no dominant mass
3. One or more dominant masses
Essentially normal breast
If the patient is younger than 35, no further investigation is needed because the breast
is dense and mammogram is not very sensitive in picking up any suspicious lesion
and using ultrasound to screen both breast will be very time consuming and not
effective. If the patient is older than 35, one may consider doing screening
mammogram and breast ultrasound.
Lumpy breast with no dominant mass
If the patient is younger than 35, consider breast target ultrasound (focusing on the
suspicious site only). If the patient is older than 35, consider mammogram and breast
ultrasound.
If one or more dominant masses are found
Fine needle aspiration cytology (FNAC) of the palpable mass or masses is required,
together with mammogram and breast ultrasound if the patient is older than 35.
With clinical examination, mammogram and breast ultrasound, and FNAC one of the
following conditions may be identified:
Physiological response to female hormone stimulation
Fibrocystic disease
Breast cancer
Cyst
Fibroadenoma
Duct ectasia
Extramammary causes of which costochondritis is the commonest
Treatment of mastalgia
If specific diagnosis can be identified, appropriate treatment should be delivered
accordingly. The majority of patients who seek treatment for mastalgia suffered from
the worry of the prospect of having breast cancer rather than the pain itself. About
80 to 90% of patients do not need any treatment other than adequate explanation and
reassurance. If the pain is severe enough to justify treatment, it is useful to ask the
patient to record the severity of pain with a pain chart. As for drug treatment, one can
have the following options:
Abstention from medications
Nutritional Treatment
NSAID
Oil of evening primrose
Danazol
Bromocryptin
Tamoxifen
LHRH agonist
Abstention from medications
Recent start of any medication, especially hormones or phenothiazines, coinciding
with the onset of breast pain should be suspected. Withdrawal of oestrogenic drive by
means of oestrogen medication often can produce dramatic relief.
Nutritional Treatment –
Restriction of methylxanthines and dietary fat has doubtful value.
Iodine and Vitamins B1, B6 and E have no proven value.
NSAID
When the pain is not very severe, occasionally a choice of any commonly used
NSAID may be enough to alleviate the patient’s symptom. However prospective
randomized trial using oral analgesic is not available.
Oil of evening primrose
This is in fact gamma-linolenic acid. Given 3 g/day it is only effective in 44% and
27% of cyclic and noncyclic mastalgia, respectively.
Danazol
This attenuated androgen is the 2,3-isoxazol derivative of 17-a-ethynyl testosterone
(ethisterone). At doses of 100mg/day, it inhibits the mid-cycle surge of LH. LH and
FSH remain normal during treatment. It also competitively inhibits oestrogen and
progesterone receptors in breast, hypothalamus, and pituitary, as well as ovarian
steroidogenesis. It can be given up to 400 mg per day in 2 divided doses. It is
effective in 70% of cyclic and 30% noncyclic cases. Side effects include water
retention, GI upset, and headache. One can start and maintain therapy at 100 mg twice
daily for 2 months while maintaining a record of breast pain. If an incomplete
response or no response is obtained, the dose is increased to 200 mg twice daily. If
still no response occurs, another drug should be tried. Therapy should not be
continued for longer than 6 months and should be tapered.
Bromocryptin
This is an ergot alkaloid that acts as a dopaminergic agonist on the
hypothalamic-pituitary axis resulting in suppression of prolactin secretion. Usually
given in doses of 25 mg/day, it is effective in 47% and 20% of cyclic and noncyclic
cases respectively. Side effects include generalised weakness, feeling of cold and
nausea and vomiting. There are reports of serious side effects including seizures,
strokes and fatalities.
Tamoxifen
This is a non-steroidal triphenylethylene derivative that is an estrogen
agonist-antagonist that competitively inhibits the action of oestradiol on the mammary
gland. It is usually given in doses of 20mg/day. It is effective in 85% of cases.
However, it has the potential danger of causing uterine cancer. It is seldom used as the
first line drug.
Luteinizing Hormone-Releasing Hormone Agonist (LHRH)
The mechanism of action is incompletely understood. The potent antigonadotropic
action of LHRH agonist induces complete ovarian inhibition, resulting in low blood
levels of oestradiol, progesterone, ovarian androgens, and prolactin. It may be
effective in up to 80% of severe refractory cases. Side effects can include hot flushes,
myasthenia, depression, vaginal atrophy, decreased libido, visual disorders, and
hypertension, but they usually do not require therapy cessation. LHRH agonist
induces significant loss of trabecular bone, however. For this reason, LHRH
analogues should be reserved for severe refractory cases of mastalgia and are not used
routinely or for longer than 3 months.
Conclusion
Mastalgia can be caused by a variety of causes. It can be cyclic or non-cyclic.
Generally speaking, cyclic mastalgia is more amenable to treatment as compared to
non-cyclic mastalgia. Patients are generally more troubled by the worry of breast
cancer than the actual pain itself. Adequate explanation and reassurance would be able
to alleviate the patient’s worry and no further treatment is needed in the majority of
cases. In case the patient’s symptom is severe enough to warrant drug treatment, a
variety of drugs may be used.