Breast pain (Mastalgia)

 Introduction:

It is a very common problem among women of age group 30-50 year (peak age 35-45 years). It usually presents as a heaviness or discomfort in the breast or as a pricking or stabbing sensation which may remain confined or radiate to adjacent areas. It may be cyclical or non-cyclical.

Causes May be: 

• Hormonal (Cyclical mastalgia)
• Pregnancy (common during the first trimester) 
• After childbirth (breasts may become swollen with milk and painful) 
• Breastfeeding (accidental chewing by baby)
• Infection (e.g., inflammation of the breast, known as mastitis/ abscess)
• Breast lumps
• Certain drugs
• Weight gain
• Poorly fitting bras

☝If the pain occurs with following features:

• Age group is ~ 35
• Discomfort and sometimes pain (diffuse) present
• Usually bilateral but one breast may dominate
• Mainly occurs in later half of menstrual cycle (premenstrual days)
• Breasts may be diffusely nodular or lumpy
• Variable relationship to the pill
• Rare after the menopause

                        👇

It is Cyclical Mastalgia (It has a hormonal basis & is not harmful)

                        👇

🚗Visit your physician for exclusion of a diagnosis of carcinoma &  

💊Management done according to the severity by Progressive step wise therapy

 Step 1: Reassurance

• Proper brassiere support
• Regular review & breast self examination
• Stop smoking (if applicable)
• Diet—exclude or minimize caffeine
• Weight reduction
• Analgesics like Paracetamol 
• Adjustment of oral contraceptives (if applicable)

Step 2: Addition of vitamins

• Vitamin B1 100 mg daily
• Vitamin B6 100 mg daily

Step 3: Substitute

• Evening primrose oil 1000 mg/day (Only taken after consultation with the doctor)

Step 4: Addition of

• Danazol 200 mg/d or Norethisterone 5 mg/d (Only taken after consultation with the doctor)

☝If the pain occurs with following features:

• Breast pain that does vary with menstrual cycle  
• May be unilateral/bilateral & diffuse
• Continuous or intermittent
• No obvious physiological or pathological basis

                  👇

It is Non-cyclical Mastalgia (Less responsive than cyclical mastalgia & difficult to treat but worth a therapeutic trial)

                            👇

🚗Visit your physician for exclusion of a diagnosis of carcinoma & it is managed as 

💊First-line treatment is:

• Proper brassiere support
• Regular review & breast self examination
• Stop smoking (if applicable)
• Diet—exclude or minimize caffeine
• Weight reduction
• Analgesics like paracetamol if pain present
• Adjustment of oral contraceptives (if applicable)
• Exclude caffeine from diet
• Vitamin B1 100 mg daily
• Vitamin B6 100 mg daily

💊Second-line treatment is:

• Norethisterone 5 mg/d (taken only after consultation with the doctor)

☝If the pain occurs with following features:

• Pain is acute, intermittent or chronic
• The breast is normal to palpation
• Palpable swelling ~ 4 cm from sternal edge due to enlargement of costo-chondral cartilage
• X-rays normal
• Aggravated by deep breathing and coughing
• Self-limiting, but may take several months to subside

                               👇

It may be Costochondritis (Tietze’s syndrome)

                              👇

🚕Visit your physician for exclusion of a diagnosis of carcinoma & 

💊Management is done as

• Analgesics like NSAIDs or Paracetamol given for pain
• Infiltration with LA and corticosteroid (with care & only taken after consultation of doctor)

☝If the pain occurs with following features:

• A lump and then soreness (at first)
• A red tender area
• (possibly) fever, tiredness, muscle aches and pains

                 👇

It may be Mastitis (inflammation of breast)

🚕Visit your physician for exclusion of a diagnosis of carcinoma &

💊Management is done as:

Treatment  of systemic symptoms:

• Antibiotics: resolution without progression to an abscess will usu. be prevented by antibiotics 
• Di(flu)cloxacillin 500 mg per oral four times a day for 10 days (IV if severe) or Cephalaxin 500 mg per oral four times a day for 10 days
•  Aspirin or Paracetamol for pain
• Therapeutic ultrasound done
• For candida infections Fluconazole 200-400 mg per oral daily for 4 weeks, second line Nystatin 500000 U oral TDS given

Instructions to patients:

• Keep the affected breast well drained.
• Continue breastfeeding: do frequently and start with the sore side.
• Heat the sore breast before feeding (e.g. with hot shower or hot face washer).
• Cool the breast after feeding: use a cold face washer from the freezer.
• Empty the breast well: hand express if necessary.

☝If a condition develops quickly with following features:

• Florid redness, swelling, dimpling and breast heaviness. 
• Not as painful as it appears—confused with mastitis but unresponsive to antibiotics. 

                              

                                          👇

🚕Visit immediately to Breast surgeon for exclusion of a diagnosis of carcinoma 

                                            👇

because it may be Inflammatory breast cancer (mastitis carcinomatosa)

☝If a pain develops with following features:

• If tenderness and redness persist beyond 48 h and 
• An area of tense induration develops, 
• Then a breast abscess has formed. 

                                      👇

🚕Visit immediately to Breast surgeon for exclusion of a diagnosis of carcinoma and treatment  

                                 👇

Because it may be Breast abscess & 

• It requires surgical drainage under general anaesthesia or 
• Preferably aspiration with a large bore needle under LA every second day until resolution
• Antibiotics (e.g. dicloxacillin 500 mg per oral four times a day for 10 days) 
• Rest and complete emptying of the breast
• Continue breastfeeding from the affected side or express milk if this is not possible.

Reference:

1. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
2. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
3. https://cmijournal.files.wordpress.com/2016/08/23-26-mastalgia.pdf photo credit
4. https://plasticsurgerykey.com/breast-pain/ photo credit
5. https://www.drthindhomeopathy.com/disease/costochondritis/ photo credit
6. https://step2.medbullets.com/gynecology/121861/mastitis photo credit
7. https://www.memorangapp.com/flashcards/32575/Inflammatory+Breast+Cancer/ photo credit
8. https://www.bmj.com/content/353/bmj.i2646 photo credit