Mastalgia (breast pain) is common and can be localized or diffuse and unilateral or bilateral.
Etiology of Mastalgia
Localized breast pain is usually caused by a focal disorder that causes a mass Breast Masses (Breast Lumps) The term breast mass (lump) may be discovered by patients incidentally or during breast self-examination or by the clinician during routine physical examination. Masses may be painless or painful... read more , such as a breast cyst, or an infection (eg, mastitis Mastitis Mastitis is painful inflammation of the breast, usually accompanied by infection. Fever later in the puerperium is frequently due to mastitis. Staphylococcal species are the most common causes... read more , abscess). Most breast cancers Breast Cancer Breast cancers are most often epithelial tumors involving the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis... read more do not cause pain.
Diffuse bilateral pain may be caused by fibrocystic changes Etiology or, uncommonly, diffuse bilateral mastitis. However, diffuse bilateral pain is very common in women without breast abnormalities. The most common causes in these women are
Hormonal changes that cause breast tissue proliferation (eg, during the luteal phase or early pregnancy, in women taking estrogens or progestins)
Large, pendulous breasts that stretch Cooper ligaments
Evaluation of Mastalgia
History of present illness should address the temporal pattern of pain and its nature (focal or diffuse, unilateral or bilateral). The relation between chronic or recurrent pain and menstrual cycle phase should be ascertained.
Review of systems should seek other symptoms suggesting pregnancy (eg, abdominal enlargement, amenorrhea, morning nausea) or fibrocystic changes (eg, presence of many masses).
Past medical history should cover disorders that could cause diffuse pain (eg, fibrocystic changes) and use of estrogens and progestins.
Examination focuses on the breast Evaluation Breast symptoms (eg, masses, nipple discharge, pain) are common, accounting for > 15 million physician visits/year. Although > 90% of symptoms have benign causes, breast cancer is always a concern... read more , looking for abnormalities such as mass, nipple inversion or discharge, skin changes including erythema, rash, eczematous appearance, edema, or dimpling (sometimes termed peau d’orange [orange peel]), and signs of infection, such as redness, warmth, and tenderness.
The following is of particular concern:
Signs of infection
Mass, nipple inversion, or skin changes
Interpretation of findings
Absence of abnormal findings suggests that pain is due to hormonal changes or large, pendulous breasts.
Pregnancy testing should be done if pain is unexplained and has lasted less than several months, particularly if other symptoms or signs are consistent with pregnancy.
Other testing is indicated infrequently—only if breast examination detects abnormal findings.
Treatment of Mastalgia
For menstrual-related mastalgia, acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is usually effective. If pain is severe, a brief course of danazol or tamoxifen may be given. These drugs inhibit estrogen and progesterone. If estrogen or a progestin is being taken, stopping may be necessary.
For pregnancy-related breast pain, wearing a firm, supportive brassiere, taking acetaminophen, or both, can help.
Evening primrose oil may reduce the severity of mastalgia.
Diffuse, bilateral breast pain is usually caused by hormonal changes or large, pendulous breasts.
First-line treatment is acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID).
Severe pain caused by hormonal factors is treated by stopping estrogen or a progestin (if either is being taken) or by giving tamoxifen or danazol.
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