Breast pain (mastalgia) Flashcards
Probability diagnosis
Pregnancy
Cracked or inflamed nipple
Cyclical mastalgia:
benign mammary dysplasia
Serious disorders not to be missed
Vascular:
- acute coronary insufficiency
- thrombophlebitis (Mondor disease)
Infection:
- mastitis
- breast abscess
Cancer:
- breast (uncommon presentation)
- mastitis carcinomatosa
Pitfalls (often missed)
- Pregnancy
- Chest wall pain (e.g. costochondritis)
- Pectoralis muscle spasm
- Referred pain, esp. thoracic spine
- Bornholm disease (epidemic pleurodynia)
- Herpes zoster
- Mechanical:
- bra problems
- weight change
- trauma
- Rarities:
- hyperprolactinaemia
- nerve entrapment
- mammary duct ectasia
- sclerosing adenosis
- ankylosing spondylitis
Masquerades checklist
Depression
Drugs (e.g. OCP, HRT, marijuana)
Spinal dysfunction
Is the patient trying to tell me something?
Yes. Fear of malignancy.
Consider psychogenic causes.
Key history
- Relate the pain to the menstrual cycle and determine whether the patient is pregnant or not.
- Key questions:
Could you be pregnant?
Is your period on time or overdue?
Is pain in both breasts or only one?
Do you have pain before your periods (cyclical mastalgia) or all the time during your cycle (non-cyclical mastalgia)?
Do you have pain in your back or where your ribs join your chest bone?
Key examination
Systematic breast palpation to check for;
- soreness or
- lumps including regional lymph nodes
Underlying chest wall and thoracic spine (T3–T6)
Key investigations
Pregnancy test
Mammography (>40 years) and ultrasound
FNA/excision biopsy for lump with localised pain
Consider CXR and ECG
Diagnostic tips
Consider cancer or candida if constant (prickling) breast pain.
Consider a rare florid form of breast cancer, ‘mastitis carcinomatosa’, if red, hot area.
Watch for abscess if a lactating woman has unilateral breast pain and ‘flu’ symptoms.
Key facts and checkpoints
Typical age span for mastalgia is 30–50 yrs
Peak incidence is 35–45 yrs
There are four common clinical presentations:
- diffuse, bilateral cyclical mastalgia (commonest)
- diffuse, bilateral non-cyclical mastalgia
- unilateral diffuse non-cyclical mastalgia
- localised breast pain
Pain patterns for cyclical and non-cyclical mastalgia
Cyclical mastalgia
Features
- Typical age is ~35
- Discomfort and sometimes pain are present
- Usu. bilateral but one breast can dominate
- Mainly premenstrual
- Breasts diffusely nodular or lumpy
- Variable relationship to the pill
- Rare after the menopause
Management
- Exclude carcinoma and aspirate palpable cysts
- various Rx can be given according to severity.
- Regular follow-up screening is advisable.
Management plan for mastalgia
Progressive stepwise therapy
Step 1
- Reassurance—explain high remission rate
- Proper brassiere support—expert fitting
- Optimal diet; weight reduction; no smoking
- Analgesics, e.g. paracetamol
Step 2
- Adjust oral contraception or HRT (if applicable)
- Consider trial
- Evening primrose oil 1 g tds for 3 mo (unconvincing evidence)
Step 3
- Refer to breast specialist to consider;
- prescribing danazol or tamoxifen or other strategy
Non-cyclical mastalgia
Pain, which is continuous or intermittent
- does not vary within the menstrual cycle.
Typical age is early 40s.
Management
- very difficult to treat
- being less responsive than cyclical mastalgia.
- It is worth a therapeutic trial.
