2. Mastalgia
• The commonest breast symptom in women
• The commonest presenting symptom to General Practitioner (GP)
• Two third or 60-70% of women at the age between 15-40 year olds
• 10-20% of the women suffer from severe pain
• There are two types of mastalgia:
• Cyclical mastalgia
• Non-cyclical Mastalgia
3. Cyclical Mastalgia
• Bilaterally and diffuse with more at the upper outer quadrant of the
breast
• It could be more severe in one breast than the other
• It usually occurs 1-2 weeks before menstruation
• It is resolved after the onset of menstruation
• It is often described as fullness, heaviness with dragging or aching
4. Non-cyclical Mastalgia
• It is common among the women at their 40s
• It is usually unilateral
• The pain is felt more at the inner part of the breast or behind the
nipple
• It is described as throbbing, burning or stabbing pain
• It is more likely associated with some breast pathology like breast
cysts, fibroadenoma or ductal ectasia.
• It could be caused by stretching of the Cooper’s ligament, diabetic
mastopathy, traumatic fat necrosis
5. Non-breast pain
• The pain can mimics mastalgia
• It could be chest wall pain:
• Costochondritis
• Herpes zoster
• Non-chest wall pain:
• Ischemic heart disease
• GERD
• PUD
• Biliary colic
6. Etiology of Mastalgia
• Hormonal Abnormalities
• Increased estrogen
• Deficiency of progesterone
• Hyperprolactinemia
• Water retention
• Study showed mastalgia is not associated with water retention
• It is not related to caffeine intake ( Good news for coffee drinkers)
7. Assessment
• History taking and clinical examination by clinician
• USG breast palpable breast lumps or abnormalities
• MMG Women age > 35
“ Triple Assessment for any Breast Abnormalities”
8. Management
• Daily Breast Pain Chart
• “P” at the day of having pain with the score of 0-10 (VAS score)
• Score > 3 required therapy
9. • Reassurance no abnormalities detected at triple assessment
• Supporting and well-fitting bra (70% women has poorly fitted bra)
• Relaxation therapy
• Evening Primose Oil (EPO)
• Some studies did not show any benefits
• Simple Medication
• Diclonec gel (3x / day for 6 months)
10. Hormonal Therapy
• Danazol
• Only FDA approved medication for mastalgia
• Testosterone deratives
• The dosage is 50mg daily up to twice a day for at least 3 months
• Side effects : hair growth, weight gain, voice changes, hot flush and
menstruation irregularities
• Contraindicated for pregnancy as it has teratogenic effect
• Reserved for patient whom is not responded to tamoxifen
11. Hormonal Therapy
• Tamoxifen
• It is selective estrogen receptor modulator
• It is the first line of treatment for mastalgia
• The dosage is 10mg daily
• Relieve cyclical mastalgia in 70 to 90% of cases and non-cyclical mastalgia in
56% of the cases
• Side Effect : Hot flush, menses irregular
• Goserelin (LHRH analog)
• Effective for recurrent mastalgia or mastalgia not responds to others
hormonal therapy
12. Other Medications
• Bromocriptine
• Dopamine agonist, block the release of prolactin
• 50-80% of patients have long-lasting relieve from breast pain
• It was stopped because severe side effect of nausea, vomiting and dizziness
• Lissuride Maleate
• Dopamine agonist
• Binds to prolactin receptor
• Well tolerated and effective
• Not being used widely as it has been associated with pathological gambling
and hypersexuality
13. Surgical Intervention
• Trigger point
• Pain localised at one tiny point of the breast
• If imaging not reveal any underlying pathological abnormalities
• Lignocaine injection
• Steroid injection
• Mastectomy
15. Fibroadenoma
• It is the most common benign breast lump
• They have peak incidence in age 21-25 year olds
• Fewer than 5% occurs at women age > 50 year olds
• It is associated of usage of OCP before age of 20
• It is a hormonal dependent neoplasm
16. Presentation
• Painless mobile breast lump
• It is usually unilateral, but in some case it could be bilateral or
multiple lesion in one breast
• It is usually solitary lesion measuring 1-3 cm in diameter
• Only 20% of cases are multiple or greater than 4cm
• It is mostly found at the upper outer quadrant of the breast
• 15% regress spontaneously; 5-10% of cases progressing to grow
• Malignant potential is extremely low in fibroadenoma
17. Investigation
• Ultrasound Breast
• Ovoid smooth solid mass
• AP narrower than transverse diameter
• Low internal echoes
• Mammogram
• Well-circumscribed lesion
• Diagnosis
• FNA or Core biopsy
18. Managment
• Conservative management
• Small lesion (<3cm)
• 6 monthly follow-up with imaging till age of 35
• For surgical intervention if the lesion not regress or slow increasing in size by
the age of 35
• Surgical intervention
• Size > 5cm
• Rapidly increasing in size
• Symptomatic lesion
• Cosmetic reason by the patient
19. Surgical Intervention
• Ultrasound-guided Vaccum Assisted Biopsy (VAB)
• Cryo-ablation therapy
• Better cosmetic outcome
• Only for lesion less than 3cm
• Surgical excision of the breast lump
• It is a daycare procedure
• It could be done under general anaesthesia or local anaesthesia
• Encourage to wear the sport bra for less post-operative pain
20. Breast Cyst
• It is part of the fibrocystic disease in women
• It is typically developed in 30-50 year-olds women
• The etiology of the breast is unknown but related to estrogen
• That is why most of the simple cyst disappears after menopause
22. Investigation & Management
• Ultrasound breast
• Round, well-circumscribed, anechoic lesion
• Complex cyst thick wall, intracystic mass or discrete solid component
• Mammogram
• Not much helpful in breast cyst
• Management
• USG-guided aspiration / FNA
• Follow-up in 4-6 weeks
• If it recurs rapidly after aspiration surgical excision is warranted
23. Mastitis
• Inflammation of the breast
• It could happen spontaneously or during lactation
• It more commonly affect women aged 15-45 years, especially during
lactation.
• Mastitis can be worsening into breast abscess
24. Lactational Mastitis
• Mastitis occurs approximately 10% of the breast-feeding mother
• It is most common in first 6 weeks of breast-feeding
• The highest incidence occurs in the second and third weeks
postpartum
• The is approximate 10% of mastitis develops into breast abscess
25. Risk factors for lactational mastitis
• Primiparity
• Previous mastitis
• Cracked nipple
• Local milk stasis
• Age > 30
• Pregnancy > 41 weeks of gestation
26. Clinical Presentation
• Breast pain
• Fever, flu-like symptoms
• Engorgement of the breast
• Redness and warm on touch at the affected breast
• There is an area of fluctuating (abscess formation)
• Mastitis is a clinical diagnosis
• USG breast is important if there is suspicious of breast abscess
27. Management of mastitis
• Simple analgesia
• Ibuprofen is a good option with paracetamol as an alternative
• Tramadol and other opiods are avoided due to CNS depression to the infant
• Breast Support
• Emptying the breast
• Suckling or by manual expression
• Mechanical suction recommended for subaerolar abscess
• Hot pack before feeding and cold pack after feeding
• ? Cabbage leaves
28. Medication for mastitis
• Lactation suppression medication
• Carbergolamine
• Bromocriptine
• Side effect : nausea and vomiting
• Antibiotic for 10 days
29.
30. Management of breast abscess
• USG-guided aspiration with antibiotic
• Incision and drainage
• Prolonged healing time
• Regular dressing
• Difficult in breast feeding
• Risk of milk fistula
