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Dr. Leung Lap Chi The Management of Mastalgia Mastalgia(breast pain) is one of the common breast symptoms that one would encounter in everyday clinical practice. Because of increasing awareness of breast cancer and the possibility that mastalgia may indicate disease, more women now seek advice for breast pain. Mastalgia can be broadly divided into 2 groups – cyclic and noncyclic. Cyclic means the severity of pain fluctuates with the menstrual cycle and usually the most severe pain would be experienced in the premenstrual period and the pain dissipates with the onset of menses. It presents mostly in the third decade of life. Spontaneous resolution occurs in about 22% of patients. Non-cyclic mastalgia usually presents a decade later and about 50% of patients may have spontaneous resolution. Overall, about 2/3 of mastalgia are cyclic, 1/4 non-cyclic and the rest are due to non-mammary causes of which the commonest is costochondritis. Cyclic mastalgia is more amenable to treatment as compared to non-cyclic mastalgia. Overall, about 90% of patients with cyclic mastalgia and 2/3 of patients with noncyclic mastalgia can expect a clinically useful response after adequate medical treatment. Aetiology of mastalgia Dietary factors – methylxanthines and saturated fat have been suggested to be the cause of mastalgia. Hormonal imbalance – oestrogen excess, progesterone deficiency, changes in progestin/oestrogen ratio, differences in receptor sensitivity, disparate secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), low androgen levels, and high prolactin levels have all been implicated as the cause for mastalgia. However evidence to confirm the causal relationship between mastalgia and various hormonal imbalance is lacking. Management of mastalgia All patients presented with mastalgia warrant a detailed breast examination. Some patients with breast cancer do present with mastalgia. Basically, there are 3 types of breast examination findings: 1. Essentially normal breast 2. Lumpy breast with no dominant mass 3. One or more dominant masses

Handout of Dr Leung Lap Chi (Dec 2003)

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Page 1: Handout of Dr Leung Lap Chi (Dec 2003)

Dr. Leung Lap Chi The Management of Mastalgia Mastalgia(breast pain) is one of the common breast symptoms that one would encounter in everyday clinical practice. Because of increasing awareness of breast cancer and the possibility that mastalgia may indicate disease, more women now seek advice for breast pain. Mastalgia can be broadly divided into 2 groups – cyclic and noncyclic. Cyclic means the severity of pain fluctuates with the menstrual cycle and usually the most severe pain would be experienced in the premenstrual period and the pain dissipates with the onset of menses. It presents mostly in the third decade of life. Spontaneous resolution occurs in about 22% of patients. Non-cyclic mastalgia usually presents a decade later and about 50% of patients may have spontaneous resolution. Overall, about 2/3 of mastalgia are cyclic, 1/4 non-cyclic and the rest are due to non-mammary causes of which the commonest is costochondritis. Cyclic mastalgia is more amenable to treatment as compared to non-cyclic mastalgia. Overall, about 90% of patients with cyclic mastalgia and 2/3 of patients with noncyclic mastalgia can expect a clinically useful response after adequate medical treatment. Aetiology of mastalgia Dietary factors – methylxanthines and saturated fat have been suggested to be the cause of mastalgia. Hormonal imbalance – oestrogen excess, progesterone deficiency, changes in progestin/oestrogen ratio, differences in receptor sensitivity, disparate secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), low androgen levels, and high prolactin levels have all been implicated as the cause for mastalgia. However evidence to confirm the causal relationship between mastalgia and various hormonal imbalance is lacking. Management of mastalgia All patients presented with mastalgia warrant a detailed breast examination. Some patients with breast cancer do present with mastalgia. Basically, there are 3 types of breast examination findings: 1. Essentially normal breast 2. Lumpy breast with no dominant mass 3. One or more dominant masses

Page 2: Handout of Dr Leung Lap Chi (Dec 2003)

Essentially normal breast If the patient is younger than 35, no further investigation is needed because the breast is dense and mammogram is not very sensitive in picking up any suspicious lesion and using ultrasound to screen both breast will be very time consuming and not effective. If the patient is older than 35, one may consider doing screening mammogram and breast ultrasound. Lumpy breast with no dominant mass If the patient is younger than 35, consider breast target ultrasound (focusing on the suspicious site only). If the patient is older than 35, consider mammogram and breast ultrasound. If one or more dominant masses are found Fine needle aspiration cytology (FNAC) of the palpable mass or masses is required, together with mammogram and breast ultrasound if the patient is older than 35. With clinical examination, mammogram and breast ultrasound, and FNAC one of the following conditions may be identified: Physiological response to female hormone stimulation Fibrocystic disease Breast cancer Cyst Fibroadenoma Duct ectasia Extramammary causes of which costochondritis is the commonest Treatment of mastalgia If specific diagnosis can be identified, appropriate treatment should be delivered accordingly. The majority of patients who seek treatment for mastalgia suffered from the worry of the prospect of having breast cancer rather than the pain itself. About 80 to 90% of patients do not need any treatment other than adequate explanation and reassurance. If the pain is severe enough to justify treatment, it is useful to ask the patient to record the severity of pain with a pain chart. As for drug treatment, one can have the following options: Abstention from medications Nutritional Treatment NSAID Oil of evening primrose

Page 3: Handout of Dr Leung Lap Chi (Dec 2003)

Danazol Bromocryptin Tamoxifen LHRH agonist Abstention from medications Recent start of any medication, especially hormones or phenothiazines, coinciding with the onset of breast pain should be suspected. Withdrawal of oestrogenic drive by means of oestrogen medication often can produce dramatic relief. Nutritional Treatment – Restriction of methylxanthines and dietary fat has doubtful value. Iodine and Vitamins B1, B6 and E have no proven value. NSAID When the pain is not very severe, occasionally a choice of any commonly used NSAID may be enough to alleviate the patient’s symptom. However prospective randomized trial using oral analgesic is not available. Oil of evening primrose This is in fact gamma-linolenic acid. Given 3 g/day it is only effective in 44% and 27% of cyclic and noncyclic mastalgia, respectively. Danazol This attenuated androgen is the 2,3-isoxazol derivative of 17-a-ethynyl testosterone (ethisterone). At doses of 100mg/day, it inhibits the mid-cycle surge of LH. LH and FSH remain normal during treatment. It also competitively inhibits oestrogen and progesterone receptors in breast, hypothalamus, and pituitary, as well as ovarian steroidogenesis. It can be given up to 400 mg per day in 2 divided doses. It is effective in 70% of cyclic and 30% noncyclic cases. Side effects include water retention, GI upset, and headache. One can start and maintain therapy at 100 mg twice daily for 2 months while maintaining a record of breast pain. If an incomplete response or no response is obtained, the dose is increased to 200 mg twice daily. If still no response occurs, another drug should be tried. Therapy should not be continued for longer than 6 months and should be tapered.

Page 4: Handout of Dr Leung Lap Chi (Dec 2003)

Bromocryptin This is an ergot alkaloid that acts as a dopaminergic agonist on the hypothalamic-pituitary axis resulting in suppression of prolactin secretion. Usually given in doses of 25 mg/day, it is effective in 47% and 20% of cyclic and noncyclic cases respectively. Side effects include generalised weakness, feeling of cold and nausea and vomiting. There are reports of serious side effects including seizures, strokes and fatalities. Tamoxifen This is a non-steroidal triphenylethylene derivative that is an estrogen agonist-antagonist that competitively inhibits the action of oestradiol on the mammary gland. It is usually given in doses of 20mg/day. It is effective in 85% of cases. However, it has the potential danger of causing uterine cancer. It is seldom used as the first line drug. Luteinizing Hormone-Releasing Hormone Agonist (LHRH) The mechanism of action is incompletely understood. The potent antigonadotropic action of LHRH agonist induces complete ovarian inhibition, resulting in low blood levels of oestradiol, progesterone, ovarian androgens, and prolactin. It may be effective in up to 80% of severe refractory cases. Side effects can include hot flushes, myasthenia, depression, vaginal atrophy, decreased libido, visual disorders, and hypertension, but they usually do not require therapy cessation. LHRH agonist induces significant loss of trabecular bone, however. For this reason, LHRH analogues should be reserved for severe refractory cases of mastalgia and are not used routinely or for longer than 3 months. Conclusion Mastalgia can be caused by a variety of causes. It can be cyclic or non-cyclic. Generally speaking, cyclic mastalgia is more amenable to treatment as compared to non-cyclic mastalgia. Patients are generally more troubled by the worry of breast cancer than the actual pain itself. Adequate explanation and reassurance would be able to alleviate the patient’s worry and no further treatment is needed in the majority of cases. In case the patient’s symptom is severe enough to warrant drug treatment, a variety of drugs may be used.