La mastalgia es un síntoma muy frecuente por el que las pacientes consultan. Es fundamental prestar atención a este signo, descartar patología subyacente t tratarlo en caso de que sea necesario.

1. DRA. A. MORENO ELOLA
DRA. A. MORENO ELOLA
HOSPITAL CLINICO SAN CARLOS MADRID
HOSPITAL CLINICO SAN CARLOS MADRID
DESCRIPTION:
oBreast pain that interferes with daily activity of a woman.
oThe commonest symptom in patients attending a breast clinic (70%)
•Cyclic
•Noncyclic
Cardiff Marks and Spencer study

2. MEDICAL HISTORY
• Descriptive terms
• Periodicity
Tenderness/ heaviness/ burning
Tenderness/ heaviness/ burning
Related to cycle
Related to cycle
• Duration
• Distribution in breast
• Radiation
• Aggravating factors
• Relieving factors
Physical contact
Physical contact
Analgesics/drugs/brassiere
Analgesics/drugs/brassiere
• Diurnal pattern
• Disturbance of lifestyle
Cardiff Mastalgia Protocol
Sleep loss/ family problem
Sleep loss/ family problem

3. AETIOLOGY
 In the past: Water retention
Psychoneurosis
 Endocrine abnormalities
DISTURBANCE OF HYPOTHALAMIC CONTROL
DISTURBANCE OF HYPOTHALAMIC CONTROL
Hyperoestrogenism: Increased secretion from the ovary And deficient
Hyperoestrogenism: Increased secretion from the ovary And deficient
progesterone production
progesterone production
Hyperprolactinaemia (PRL)
Hyperprolactinaemia (PRL)
 Caffeine and metilxanthines: Interference with adenosine triphosphate
degradation by metylxanthines
 Prostaglandins and essential fatty acids (EFA): Abnormality in
prostaglandin synthesis due to deficient EFA intake in the diet. Deficient
production of PGE1=amplification of PRL effects.
 Stress: Impact on hypothalamus: PRL
 Others: Vasospasm, ductal ectasia, tubal ligation, lack of breastfeeding,

4. CLASIFICATION
Título del gráfico
40
30
20
10
0
CYCLIC
NONCYCLIC TIETZE
OTHER
TRAUMA
ADENOSIS
CANCER

5. Cyclical mastalgia (CM)
 68% of women*.
 The commonest: 40% of mastalgia.
 Age: the most younger.
 Cause: endocrin. Related to menstrual cycle and particularly with
ovulation. Score chart id useful.
 Bilateral, both superior-outer-q
 Nodularity
 >1 week per cycle or high intensity
of symptoms: obtrusive features in
lifestyle.
Ader et al. (2001)*

6. Noncyclical mastalgia (NCM)
 Frequency: second.
 Not related to cycle: pre and postmenopausal
 Subtypes:
1.TRUE NMC (27% of total)
.
 Loc: Unilateral. specific, trigger Spot
 Age older (median 34)
 Less intense: Linear analogue scale
 Less nodularity
 Duration= continuous: 27-35 m
• Radiological changes: ductal ectasia in 33%
 Rel. to cancer in 7 -12%

7. MNC
2. Musculoskeletal pain (11%)
• Unilateral in 92%. Chronic.
•Treatment: injection of steroid and local anaesthetic.
•SUBTYPES:
•1. Tietze´s Syndrome. (costochondral junction): Pain occurs on
pressure over
the affected cartilage.
•2. Lateral chest wall pain: Anterior axillary line. Relates to the slips of origin of
the serratus anterior muscle.

8. • Trauma: 8 %. Persistent pain due to previous
biopsy scar.
•Sclerosing adenosis: 4,5 %
•Phantom symptoms.
•Mondor syndrome
•Cancer
•Inadequate brasserie

9. •¿ HOW? ¿ WHO ? ¿ WHY ?
•CORRECT CLASIFICATION: 85 % of success.
•REASSURANCE
•Medical treatment is neccessary only in 15%
•Surgical treatment not indicated.

10. TREATMENT
Reassurance and supportive measures
 Reassurance that is not due to cancer
 Well-fitting brassiere:
 Size.
 El 75 % of women do not know the exact
size**.
 DIET:
 Esential fatty-acids
 Metilxanthines (coffe,te)*
 Vitamine E: 41% of improvement**
 Supplement of iodine >50%
*Minton (1979)
**Elisabeth Sanabria, XXIV Reunión de la SESPM, Orense 2005.
*** KHANNA (India 1997)

11. •First line*
•Action: Impeded androgen that acts as antigonadotrophin:
FSH and LH
•Approved by the FDA.
Inhibits Oestrogen and progesteron receptors in hypothalamus and breast.
Prevents ovulation.
Success
MC: 70% y En MNC:40 %.
rate
•Spotting,weight gain, headache, nausea , mood
Side effects:20 %.
changes, depression, acne and hirsutism,.
•Clearly related to dose
DOSE
100 mg/24 h
• If not success: 200 mg/24 h up to 6 months
•If success: manintenance dose of 100 mg/48h.
*Wetzig NR.et al. 1994
Gestrinone:
Gestrinone:
••Androgenic antiestrogenic,
Androgenic antiestrogenic,
antiprog.
antiprog.
••Less side-effects
Less side-effects
••No experience
No experience

12. TREATMENT: DRUGS.Tamoxifen
 Antioestrogen*.
 Only licensed for breast cancer. Second-line drug for mastalgia.
 Acts blocking oestrogen receptors in ovary and breast.

Success rate
78-98% for CM and 56% for NCM
hot flashes(26%), vaginal bleed (16%)and
endometrial cancer.
15 % discontinuance

Side effects

DOSE 10 mg/d for 3-6 months, repeated for relapse if necessary.
 OTHER SERMS (Receptor modulator)**
Toremefine
Toremefine
Ormeloxifine
Ormeloxifine
 Gel afimoxifine: (Tamogel): transcutaneus route. (1/d. for 4 cycles)***
*Faiz and Fentiman,2000, **Dhar A et al, 2007, **Mansel RE et al, 2007

13. TREATMENT: DRUGS.Bromocriptine
 Inhibitor of prolactin. Only in patients w. abnormal levels of PRL.
 Success rate
 Side effects
´
 DOSAGE
CM.: 78%
35%,
nausea, cefalea, headache, dizziness
severe: vascular (due to high dosage)
discontinuance: 29%
Slow introduction in incremental scheme to minimize side-effects*:
1.25 mg/d (1st w.) to 2.5 mg/d (3 months)
Up to 2,5 mg/12h
Cabergoline is as effective as bromocriptine for the treatment of cyclic
mastalgia but has minimal side effects compared to bromocriptine**.
*Deliski et al. Sofia 2000, **Yavuz Aydin et al. 2010

14. OTHER TREATMENTS:
Evening primrose oil (EPO)*
 Fatty acid deficiency hypothesis: supplementary diet w. EFA
 EPO=Unique containing 7% of linolenic acid + 72% linoleic acid.
 First line in mild to moderate CM (58% response rates)*
 No side effects
Vitex Agnus Castus (VAC)**
 Antioestrogen. Inhibits FSH and stimulates LH
 Inhibits PRL secretion.
 Spasmolitic
 First line in mild to moderate CM. Response rates close to 54%
 No side effects
*Louiza Velentzis, J. et al. 2010.
**G. Tamagno, et al.2009, Z. He, et al2009.W. Wuttke, et al 2003, Donna E. Webster et. al.2010.

15. NCM UNRESPONSIVE TO ENDOCRINE
THERAPY:
 Luteinizing hormone-releasing hormone (LHRH) analogue
(subcutaneous
dosage of 3,5 mg/28 d. x 6 months)
 Topical nonsteroidal antiinflammatory agents to be safe, effective (96%),
rapid and acceptable mode of treatment for cyclical and non-cyclical
mastalgia.
 Tietze´s syndrome or chest wall pain: Steroid /local anaesthetic injection:
initial relief: 70%. Continued relief: 33%
 Tricyclic antidepressants
 Surgical excision: Rarely indicated, high incidence of complications.
T. Colak, T.Ipek, A.Zanik et al. 2003.
Semih Kaleli et al. 2001.
S. Qureshi, N. Sultan, et al. 2005.
W.A.Townley, C.A.T.Durrant, D.Gault. 2004

16. PRINCIPLES OF MASTALGIA
TREATMENT
 Reassurance. Exclude cancer.
 Define pattern. History.
 Cyclical (response rate: 92%).
EPO (6/d)
Danazol (100-300mg/d)
Bromocriptine (1,25mg/d to 3,75-5mg/d)
 True noncyclical (overall response 64%)
Danazol
EPO
Bromocriptine
 Musculoeskeletal chest wall pain
Lidocaine/Steroid injection to trigger spot
 Surgery: last resort