Mastalgia, or breast pain, is a common complaint affecting up to 70% of women at some point in their lives. It can be cyclic, related to the menstrual cycle, or non-cyclic. First-line treatment involves reassurance, proper bra support, and supplements like evening primrose oil. If symptoms persist, tamoxifen is effective for both cyclic and non-cyclic mastalgia. Danazol and bromocriptine may be tried as third-line options if tamoxifen provides no relief. Proper diagnosis is important to rule out potential underlying causes of breast pain.

1. Presentor: Dr. Sudhanshu Goyal,
PGY-1, General Surgery,
Civil Hospital Aizawl.
Dated: 19th May 2015, Tuesday
MASTALGIA

2. Epidemiology
• Upto 70% women experience at some point in life
• Reported incidence in asian population 5% and Indian
study 13%
• MC presenting symptom
• 47 % of all breast related visits
• 69 % in premenstrual women
• Impaired function
• 48 % sexual activity
• 37 % physical activity
• 12 % social activity
• 8 % school activity
• Rare symptom of breast carcinoma
• 2.7 % cases of breast pain have carcinoma
• 4.6 % of breast cancer cases present with breast pain

3. MASTALGIA
Cyclical Noncyclical Non-Mammary Pain
Chest Wall Pain Non-Chest Wall Pain
Classification

4. Cyclic Mastalgia
• Moderate to severe pain B/L diffuse (can be U/L)
• More than 7 days
• Related to menstrual cycle,
• in luteal phase
• resolving with menses
• Pre-menopausal age group, 3rd & 4th decade
• No specific hormonal association has been implicated
so far
• PRE-MENSTRUAL BREAST TENDERNESS
• Normal physiologic response
• 2-3 days before onset of menses
• Mild to moderate B/L swelling and tenderness
• Self limiting condition

5. Non-Cyclic Mastalgia
• U/L pain specific quadrant
• No relation to menstrual cycle
• Post-menopausal female, 4th to 5th decade
• 31% of breast pain
• Etiology
• Idiopathic
• Tender cyst
• Periductal mastitis
• Stretching of coopers ligament
• Trauma
• Sclerosing adenosis
• Mondors disease
• Cancer

6. Chest wall pain
• Always unilateral, localized, burning or knifelike
• Increased by activity and reproduced by local
pressure
• Etiology
• Teitz syndrome
• Radicular pain from cervical arthritis
• Lateral chest wall pain

7. Non chest wall pain
• Respiratory infection may cause intercostal
neuralgia
• If on right side consider
• Gallbladder disease
• Esophagitis
• Hiatal hernia
• If on left side consider
• Cardiac source

8. Workup
• History: exclude non-breast causes
• Drugs implicated for mastalgia:
• Diuretics
• Digitalis
• Methyldopa
• Spironolactone
• Oymetholone
• Physical examination: exclude mass lesion, define
breast tenderness and chest wall tenderness
• Pain chart for at least 2 months

10. Treatment
• First Line
• Upto 85% women just need reassurance
• Physical measures
• Brassier of 70% women doesn’t provide adequate support
• Well fitting during day and soft supporting while night provides
relief in 85% (compared to 58% with Danazol)
• Evening Primrose oil
• RCT have shown low or no efficacy in cyclic mastalgia with
significant improvement after 3 months of therapy and pain
returning to baseline after 6 months
• No response in non cyclic mastalgia
• Caffeine
• Observational studies show improvement in 85% after 8 weeks
or more of restriction
• RCT show no response
• Vit. E (400 IU 8 hrly) and Vit. B6 (3000 IU 8 hrly) have no
proven response

11. • Second line
• Tamoxifene
• SERM
• Effiectiveness
• 71% with 20mg daily in 3 months
• 89% with 10mg daily in 6 months
• Response rate
• Cyclic mastalgia 94%
• Non-cyclic mastalgia 56%
• Recommendation
• Start with 10 mg daily for 3 months
f/b 10 mg alternate days for 3 months
• If no response try 20 mg daily dose
• Side effects
• 10% women experience hot flashes and menstrual irregularities
• Weight gain, nausea, vaginal dryness and bloating
• No known incidence of serious side effects like thromboembolic events,
endometrial cancer and cataract at this dose
• Tropical NSAIDS
• 2% Diclofenac diethylammonium locally 8 hrly for 6 months
• Minimal side effects

12. • Third line
• Danazol
• Synthetic steroid ethisterone
• Effectiveness
• 65% when compared with tamoxifene (72%) and placebo (38%)
• 200 mg daily dose for 4 months, luteal phase to decrease side
effects
• Side effects
• 50% experience menstrual irregularities
• 30% weight gain
• 10% hot flashes, hirsutism and voice changes
• Bromocriptine
• Inhibit release of prolactin
• 2.5mg twice daily dose
• Side effects
• 32% nausea
• 12% dizziness
• 7% vomiting
• No role of surgical management

13. Conclusion
First line
• Counselling and well supporting brassier
• EPO in cases of cyclic mastlagia
Second line
• Tamoxifene 10 mg daily (upto 20mg daily)
• Local 2% Diclofenac diethylammonium
Third line
• Danazol 200mg daily
• Bromocriptine 5mg daily