Presentor: Dr. Sudhanshu Goyal,PGY-1, General Surgery,Civil Hospital Aizawl.

Dated: 19th May 2015, Tuesday

MASTALGIA

Epidemiology

• Upto 70% women experience at some point in life• Reported incidence in asian population 5% and Indian

study 13%

• MC presenting symptom• 47 % of all breast related visits• 69 % in premenstrual women

• Impaired function• 48 % sexual activity• 37 % physical activity• 12 % social activity• 8 % school activity

• Rare symptom of breast carcinoma• 2.7 % cases of breast pain have carcinoma• 4.6 % of breast cancer cases present with breast pain

MASTALGIA

Cyclical Noncyclical Non-Mammary Pain

Chest Wall Pain

Non-Chest Wall Pain

Classification

Cyclic Mastalgia• Moderate to severe pain B/L diffuse (can be U/L)• More than 7 days• Related to menstrual cycle,

• in luteal phase• resolving with menses

• Pre-menopausal age group, 3rd & 4th decade• No specific hormonal association has been implicated

so far• PRE-MENSTRUAL BREAST TENDERNESS

• Normal physiologic response• 2-3 days before onset of menses• Mild to moderate B/L swelling and tenderness• Self limiting condition

Non-Cyclic Mastalgia• U/L pain specific quadrant• No relation to menstrual cycle• Post-menopausal female, 4th to 5th decade• 31% of breast pain• Etiology

• Idiopathic• Tender cyst• Periductal mastitis• Stretching of coopers ligament• Trauma• Sclerosing adenosis• Mondors disease• Cancer

Chest wall pain

• Always unilateral, localized, burning or knifelike• Increased by activity and reproduced by local

pressure• Etiology• Teitz syndrome• Radicular pain from cervical arthritis• Lateral chest wall pain

Non chest wall pain

• Respiratory infection may cause intercostal neuralgia• If on right side consider• Gallbladder disease• Esophagitis• Hiatal hernia

• If on left side consider• Cardiac source

Workup

• History: exclude non-breast causes• Drugs implicated for mastalgia: • Diuretics• Digitalis• Methyldopa• Spironolactone• Oymetholone

• Physical examination: exclude mass lesion, define breast tenderness and chest wall tenderness• Pain chart for at least 2 months

Treatment• First Line• Upto 85% women just need reassurance• Physical measures

• Brassier of 70% women doesn’t provide adequate support• Well fitting during day and soft supporting while night provides

relief in 85% (compared to 58% with Danazol)• Evening Primrose oil

• RCT have shown low or no efficacy in cyclic mastalgia with significant improvement after 3 months of therapy and pain returning to baseline after 6 months

• No response in non cyclic mastalgia• Caffeine

• Observational studies show improvement in 85% after 8 weeks or more of restriction

• RCT show no response• Vit. E (400 IU 8 hrly) and Vit. B6 (3000 IU 8 hrly) have no

proven response

• Second line• Tamoxifene

• SERM• Effiectiveness

• 71% with 20mg daily in 3 months• 89% with 10mg daily in 6 months

• Response rate• Cyclic mastalgia 94%• Non-cyclic mastalgia 56%

• Recommendation• Start with 10 mg daily for 3 months f/b 10 mg alternate days for 3 months• If no response try 20 mg daily dose

• Side effects• 10% women experience hot flashes and menstrual irregularities• Weight gain, nausea, vaginal dryness and bloating• No known incidence of serious side effects like thromboembolic events,

endometrial cancer and cataract at this dose

• Tropical NSAIDS• 2% Diclofenac diethylammonium locally 8 hrly for 6 months• Minimal side effects

• Third line• Danazol

• Synthetic steroid ethisterone• Effectiveness

• 65% when compared with tamoxifene (72%) and placebo (38%)• 200 mg daily dose for 4 months, luteal phase to decrease side

effects• Side effects

• 50% experience menstrual irregularities• 30% weight gain• 10% hot flashes, hirsutism and voice changes

• Bromocriptine• Inhibit release of prolactin• 2.5mg twice daily dose• Side effects

• 32% nausea• 12% dizziness• 7% vomiting

• No role of surgical management

Conclusion

First line

• Counselling and well supporting brassier• EPO in cases of cyclic mastlagia

Second line

• Tamoxifene 10 mg daily (upto 20mg daily)• Local 2% Diclofenac diethylammonium

Third

line

• Danazol 200mg daily• Bromocriptine 5mg daily