Mastalgia

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Mastalgia is defined as breast pain or discomfort. It is often caused by physiological changes (e.g., hormonal effects, lactation), but can also result from underlying disease (e.g., benign inflammatory breast conditions). Mastalgia is classified as cyclical (associated with menstrual cycles), noncyclical (not associated with menstrual cycles), or extramammary (originating outside of the breast, such as the chest wall). Imaging is required for all patients with an associated palpable breast mass. In patients without a palpable mass, cyclical mastalgia typically requires no further evaluation while breast imaging may be indicated in women with noncyclical mastalgia. Evaluation of extramammary pain depends on the suspected source of pain (e.g., musculoskeletal, pulmonary). Treatment commonly involves reassurance, analgesics, and management of the underlying etiology. In patients with severe or persistent pain, hormonal therapy (e.g., danazol, tamoxifen) may be considered under specialist guidance.

• Peak age: 30–50 years of age ^[2]
• Approx. 70% of women are affected during their lifetime. ^[2]

Epidemiological data refers to the US, unless otherwise specified.

• Cyclical mastalgia: primary breast pain associated with the menstrual cycle
  • Hormonal fluctuations of the menstrual cycle
  • Postmenopausal hormone therapy
  • Oral contraceptive use
• Noncyclical mastalgia: primary breast pain not associated with the menstrual cycle
  • Inflammatory breast conditions
    • Mastitis
    • Breast abscess
    • Mammary duct ectasia
    • Superficial thrombophlebitis (Mondor disease of the breast)
  • Breast lumps or cysts
  • Pendulous breasts
  • Medications (e.g., hormone replacement therapy, oral contraceptives)
  • Previous breast surgery
  • Breast cancer (uncommon)
• Extramammary pain: secondary breast pain referred from extramammary locations
  • Costochondritis
  • Chest wall trauma
  • Shingles
  • Cardiac, esophageal, or pulmonary causes

• Cyclical mastalgia ^[4]
  • Often bilateral, diffuse breast pain
  • Typically most severe in the upper outer quadrant of the breasts
  • May radiate to the medial aspect of the upper arm
  • Usually worsens the week prior to the onset of menstruation
• Noncyclical mastalgia ^[4]
  • Unilateral or bilateral breast pain, usually located over the costal cartilage
  • Sharp or burning pain and/or soreness
• Extramammary pain: depends on the underlying condition

Clinical assessment ^[3][4]

• Patient history
  • Nature of pain
  • Recent musculoskeletal injury or trauma; see also “Fat necrosis of the breast”
  • Association with menstruation
  • Family history of breast cancer
• Medication review
• Focused physical examination
  • Clinical breast examination (see also “Breast cysts” and “Mastitis”)
  • Musculoskeletal examination of the chest wall

Examine the chest wall in all patients with mastalgia to evaluate for extramammary sources of pain. ^[3]

Imaging ^[4][5][6]

Palpable breast mass

• Imaging is indicated for all patients.
• See “Palpable breast mass” for details.

No palpable breast mass

• Cyclical mastalgia: no imaging necessary (regardless of age)
• Focal noncyclical mastalgia
  • Age < 30 years: breast ultrasound
  • Age ≥ 30 years: breast ultrasound, diagnostic mammography, or digital breast tomosynthesis ^[6]
• Nonfocal or diffuse noncyclical mastalgia
  • Age ≥ 40 years or risk factors for breast cancer: diagnostic mammography
  • Age < 40 years: no imaging necessary

Imaging is indicated for all patients with mastalgia and a palpable breast mass. ^[3]

Initial management ^[3][4]

• Identify and treat the underlying etiology.
• Nonpharmacological measures
  • Reassurance ^[3][4][7]
  • Use of a supportive, well-fitting bra
  • Adjust causative medications, if feasible. ^[3]
• Analgesics
  • First-line : topical NSAIDs ^[4]
  • Alternatives: oral NSAIDs or acetaminophen ^[3]
  • See “Pain management” for details and dosages.

Management of moderate, severe, or refractory symptoms

• Consider gynecology referral for hormonal treatment (e.g., tamoxifen, danazol, or goserelin). ^[3][4]

Cyclical mastalgia ^[8]

• Usually resolves spontaneously within 3 months of onset
• Typically relapses and remits

Noncyclical mastalgia ^[8]

• Resolves spontaneously in approx. 50% of patients
• Usually responds poorly to treatment