Mastalgia

Mastalgia

Approximately 50–70% of women attending any breast clinic present with mastalgia (synonym: mastodynia or mazodynia). True mastalgia (arising from breast tissue) is classified into cyclical and non-cyclical types. Cyclical mastalgia The pain usually starts around the middle of the cycle on day 14 and gradually increases in severity (measured on a visual analogue scale [V AS] as 0–10) until day 27 or 28. Usually both breasts are involved. The pain is usually relieved with the onset of menses. Severe forms may lead to loss of sleep and impaired sexual and other activities of daily life. The pain may radiate to the upper arm and may be mistaken for angina pectoris. The cause is unclear and considerations of hormone imbalance, high ca ff eine intake, low dietary essential fatty acids, water retention or psychoneurosis are not supported by research. In most patients the basal lev els of oestrogen, pro - in gesterone and prolactin are in the normal range. However, most patients do respond to treatment with antioestrogen - drugs, such as tamoxifen, ormeloxifene, luteinising hormone analogues or danazol, suggesting excessive responsiv eness of breast tissue to circulating oestrogen. Non-cyclical mastalgia The pain presents at any time of the menstrual cycle, at any location of the breast and may occur both before and after menopause. It is often well localised. Some patients may have duct ectasia or periductal mastitis. Breast palpation may reveal a very tender spot confined to a point called the trigger spot or trigger point. Other causes are musculoskeletal, in the form of Tietze’s syndrome: a painful costochondral junction with no radiological anomaly and lateral chest wall pain in the anterior axillary line and over serratus anterior. Trauma, cancer or sclerosing adenosis may also result in breast pain. True breast pain must be distinguished from angina, biliary colic, reflex oesophagitis and cervical spondylosis. In low-/middle-income countries, vitamin D and calcium deficiencies are rampant, - leading to bony aches and pains that may present as non- - cyclical mastalgia. About 5% of breast cancers exhibit pain at presentation, but this is rarely the sole presenting feature. Treatment Treatment begins with assessment, including breast examina - tion and imaging. If normal, reassurance that the symptoms are not due to cancer helps the majority of women. The type of pain, cyclical or non-cyclical, should be identified by record - ing a pain chart for 1 month ( Figure 58.12 ). The principles of trea tment are outlined in Table 58.2 and 58.1 . In patients /uni092E/uni093E/uni0939 /uni092E/uni093E/uni0939 /uni092E/uni093E/uni0939 with non-cyclical pain, musculoskeletal pain and other referred causes should be excluded. Trigger point pain may be relieved by local injection of a long-acting corticosteroid such as triamcinolone in combination with lidocaine at the point of maximum tenderness. This may be repeated at intervals until the pain is controlled.

Patient name: Age: Date: Month of visit: 0/1/2/3/4/5/6: Duration of complaint ( /f_i rst visit only): Right Breast____________ Left Breast___________________ Out of ten what was the maximum breast pain score in the last month? Please encircle the number. (Note: 10 is the maximum pain you ever experienced and 0 is no pain) On monthly period chart, insert the letter M below the date on days you have menses. 0 1 2 3 4 How many days in the last month were painful? Right breast pain score Month 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Left breast pain score Month 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Monthly period 3 4 5 6 7 8 9 10 11 12 13 1 2 Month 1 2 3 4 5 6 7 8 9 10 11 12 13 Note: Please bring this card with you on each visit Figure 58.12 Breast pain chart. All India Institute of Medical Sciences modi /f_i cation of the Cardiff Breast Pain Chart. Reg. number: 5 6 7 8 9 10 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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Exclude cancer Reassure Use a VAS breast pain chart to record severity Adequate support Tight sports brassiere during the day Consider medication Flax seed 30 /uni00A0 g daily or oil Rich sources of omega 3 fatty acids of evening primrose and -linolenic acid, respectively Useful in mild to moderate mastalgia Topical non-steroidal anti-in /f_l ammatory cream (diclofenac or piroxicam) four times a day Consider systemic medication if pain score >3 on a VAS of 0-10 Tamoxifen 10 /uni00A0 mg daily For 3–6 months Danazol 50–300 /uni00A0 mg daily For 3–6 months Ormeloxifene 30 /uni00A0 mg twice For 3–6 months used in both cyclical a week and non-cyclical mastalgia and for treating nodularity Short duration: use for 3 months for LHRH agonist alone recalcitrant pain not relieved by the or with antioestrogen: above medications tamoxifen or ormeloxifene LHRH, luteinising hormone-releasing hormone; VAS, visual analogue scale.