How best to address breast pain in nonbreastfeeding women

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Applied Evidence

How best to address breast pain in nonbreastfeeding women

J Fam Pract. 2019 September;68(7):379-382,384-388

By

Jennifer Lochner, MD

Maggie Larson, DO

Emily Torell, MD, MPH

Sarina Schrager, MD, MS

This guide—with accompanying algorithms—will help you to streamline your approach to breast pain in a patient who isn’t breastfeeding.

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PRACTICE RECOMMENDATIONS

› Instruct patients to maintain a pain diary, which, along with a careful history and physical examination, helps to determine the cause of breast pain and the type of evaluation needed. C

› Treat cyclic, bilateral breast pain with chasteberry and flaxseed. B

› Consider short-term treatment with danazol or tamoxifen for women with severe pain. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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2. Chetlen AL, Kapoor MM, Watts MR. Mastalgia: imaging work-up appropriateness. Acad Radiol. 2017;24:345-349.

3. Expert Panel on Breast Imaging: Jokich PM, Bailey L, D’Orsi C, et al. ACR Appropriateness Criteria Breast Pain. J Am Coll Radiol. 2017;14:S25-S33.

4. Arslan M, Küçükerdem HS, Can H, et al. Retrospective analysis of women with only mastalgia. J Breast Health. 2016;12:151-154.

5. Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clin Proc. 2004;79:353-372.

6. Mansel RE. ABC of breast diseases. Breast pain. BMJ. 1994;309:866-868.

7. Ader DN, South-Paul J, Adera T, et al. Cyclical mastalgia: prevalence and associated health and behavioral factors. J Psychosom Obstet Gynaecol. 2001;22:71-76.

8. Iddon J, Dixon JM. Mastalgia. BMJ. 2013;347:f3288.

9. Eren T, Aslan A, Ozemir IA, et al. Factors effecting mastalgia. Breast Care (Basel). 2016;11:188-193.

10. Pearlman MD, Griffin JL. Benign breast disease. Obstet Gynecol. 2010;116:747-758.

11. Gateley CA, Mansel RE. The Cardiff Breast Score. Br J Hosp Med. 1991;45:16.

12. Michigan Medicine. University of Michigan. Common breast problems: guidelines for clinical care. https://www.med.umich.edu/1info/FHP/practiceguides/breast/breast.pdf. Updated June 2013. Accessed September 3, 2019.

13. Millet AV, Dirbas FM. Clinical management of breast pain: a review. Obstet Gynecol Surv. 2002;57:451-461.

14. American College of Radiology. ACR Appropriateness Criteria: Breast Pain. https://acsearch.acr.org/docs/3091546/Narrative/. Revised 2018. Accessed July 2, 2019.

15. American College of Radiology. ACR Appropriateness Criteria: Palpable Breast Masses. https://acsearch.acr.org/docs/69495/Narrative/. Revised 2016. Accessed September 3, 2019.

16. Loving VA, DeMartini WB, Eby PR, et al. Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 2010;195:1472-1477.

17. Molckovsky A, Fitzgerald B, Freedman O, et al. Approach to inflammatory breast cancer. Can Fam Physician. 2009;55:25-31.

18. Ammari FF, Yaghan RJ, Omari AK. Periductal mastitis: clinical characteristics and outcome. Saudi Med J. 2002;23:819-822.

19. Lannin DR. Twenty-two year experience with recurring subareolar abscess and lactiferous duct fistula treated by a single breast surgeon. Am J Surg. 2004;188:407-410.

20. Wilson JP, Massoll N, Marshall J, et al. Idiopathic granulomatous mastitis: in search of a therapeutic paradigm. Am Surg. 2007;73:798-802.

21. Bouton ME, Jayaram L, O’Neill PJ, et al. Management of idiopathic granulomatous mastitis with observation. Am J Surg. 2015;210:258-262.

22. Olawaiye A, Withiam-Leitch M, Danakas G, et al. Mastalgia: a review of management. J Reprod Med. 2005;50:933-939.

23. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Gynecology. Practice Bulletin No. 164: Diagnosis and management of benign breast disorders. Obstet Gynecol. 2016;127:e141-e156.

24. Mirghafourvand M, Mohammad-Alizadeh-Charandabi S, Ahmadpour P, et al. Effects of Vitex agnus and flaxseed on cyclic mastalgia: a randomized controlled trial. Complement Ther Med. 2016;24:90-95.

25. Vaziri F, Zamani Lari M, Sansami Dehaghani A, et al. Comparing the effects of dietary flaxseed and omega-3 fatty acids supplement on cyclical mastalgia in Iranian women: a randomized clinical trial. Int J Fam Med. 2014;2014:174532.

26. Sohrabi N, Kashanian M, Ghafoori SS, et al. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: “a pilot trial”. Complement Ther Med. 2013;21:141-146.

27. McFayden IJ, Chetty U, Setchell KD, et al. A randomized double blind-cross over trial of soya protein for the treatment of cyclical breast pain. Breast. 2000;9:271-276.

28. Pruthi S, Wahner-Roedler DL, Torkelson CJ, et al. Vitamin E and evening primrose oil for management of cyclical mastalgia: a randomized pilot study. Altern Med Rev. 2010;15:59-67.

29. Halaska M, Raus K, Beles P, et al. Treatment of cyclical mastodynia using an extract of Vitex agnus castus: results of a double-blind comparison with a placebo. Ceska Gynekol. 1998;63:388-392.

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34. Kontostolis E, Stefanidis K, Navrozoglou I, et al. Comparison of tamoxifen with danazol for treatment of cyclical mastalgia. Gynecol Endocrinol. 1997;11:393-397.

35. Marjoribanks J, Brown J, O’Brien PM, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013;(6):CD001396. doi: 10.1002/14651858.CD001396.pub3.

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CASE 1

Robin S is a 40-year-old woman who has never had children or been pregnant. She is in a relationship with a woman so does not use contraception. She has no family history of cancer. She presents with worsening bilateral breast pain that starts 10 days before the onset of her period. The pain has been present for about 4 years, but it has worsened over the last 6 months such that she is unable to wear a bra during these 10 days, finds lying in bed on her side too painful for sleep, and is unable to exercise. She has tried to eliminate caffeine from her diet and takes ibuprofen, but neither of these interventions has controlled her pain. Her breast exam is normal except for diffuse tenderness over both breasts.

CASE 2

Meg R is a 50-year-old healthy woman. She is a G2P2 who breastfed each of her children for 1 year. She does not smoke. She has no family history of breast cancer or other malignancies. She presents with 2 months of deep, left-sided breast pain. She describes the pain as constant, progressive, dull, and achy. She points to a spot in the upper outer quadrant of her left breast and describes the pain as being close to her ribs. She had a screening mammogram 3 weeks earlier that was normal, with findings of dense breasts. She did not tell the technician that she was having pain. Clinical breast examination of both breasts reveals tenderness to deep palpation of the left breast. She has dense breasts but a focal mass is not palpated.

Mastalgia, or breast pain, is one of the most common breast symptoms seen in primary care and a common reason for referrals to breast surgeons. Up to 70% of women will experience breast pain during their lifetime—most in their premenopausal years.^1,2

The most common type of breast pain is cyclic (ie, relating to the menstrual cycle); it accounts for up to 70% of all cases of breast pain in women.^1,3 The other 2 types of breast pain are noncyclic and extramammary. The cause of cyclic breast pain is unclear, but it is likely hormonally mediated and multifactorial. In the vast majority of women with breast pain, no distinct etiology is found, and there is a very low incidence of breast cancer.^2,4

Up to 70% of women will experience breast pain during their lifetime, most in their premenopausal years.

In this review, we describe how to proceed when a woman who is not breastfeeding presents with cyclic or noncyclic breast pain.

Evaluation: Focus on the pain, medications, and history

Evaluation of breast pain should begin with the patient describing the pain, including its quality, location, radiation, and relationship to the menstrual cycle. It’s important to inquire about recent trauma or aggravating activities and to order a pregnancy test for women of childbearing age.¹

Cyclic mastalgia is typically described as diffuse, either unilateral or bilateral, with an aching or heavy quality. The pain is often felt in the upper outer quadrant of the breast with radiation to the axilla. It most commonly occurs during the luteal phase of the menstrual cycle, improves with the onset of menses, and is thought to be related to the increased water content in breast stroma caused by increasing hormone levels during the luteal phase.^5-7

Continue to: Noncyclic mastalgia