Mastalgia

Definition

• Mastalgia is breast pain that affects up to 77% of women at some point in their lives

• It may be accompanied by tenderness, lumpiness, fullness, heaviness or an increase in breast size

• It is typically benign and not indicative of breast cancer, although it can cause significant discomfort and anxiety

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Differential Diagnoses

• Cyclical mastalgia, usually bilateral, worsening premenstrually and most common in premenopausal women in their 30s

• Non-cyclical mastalgia, which may be unilateral or bilateral, with burning, stabbing or throbbing pain, more common in women in their 40s

• Pregnancy-related breast changes

• Breast cancer

• Effects of hormonal contraceptive use

• Mastitis or breast abscess

• Chest wall pain from costochondritis or thoracic back pain

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Investigation

• Obtain a thorough history and encourage completion of a pain chart to characterise the pattern of pain

• Conduct a detailed physical examination of the breasts, including palpation for masses or asymmetry

• Arrange breast imaging with ultrasound and/or mammography based on clinical findings and patient age

• Consider triple assessment (clinical examination, imaging and non-surgical biopsy) for any significant findings such as asymmetrical thickening or a discrete palpable mass

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Management

• Reassure the patient that mastalgia is typically benign and not caused by breast cancer

• Promote breast awareness and ensure appropriate breast screening is in place

• Advise the use of a well-fitting supportive bra, for example a sports bra

• Recommend analgesia with paracetamol 1 g QID as needed

• Use topical NSAIDs for localised pain relief

• Suggest evening primrose oil at a dose of 1000 mg 2–3 times daily for 2–3 months

• Encourage lifestyle modifications such as smoking cessation and achieving an ideal body weight

• For severe cases affecting quality of life, consider hormonal treatments such as danazol or tamoxifen with referral for specialist review

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Notes

• Cyclical mastalgia typically improves with the onset of menstruation, whereas non-cyclical mastalgia does not vary with the menstrual cycle and may warrant further evaluation

• Chest wall pain should be considered when breast imaging is normal and the pain may originate from muscles, ribs or ligaments

• A combination of reassurance, conservative measures and tailored pharmacological therapy often yields the best outcomes

• Ongoing patient education and follow-up are crucial, as most cases of mastalgia tend to improve over time regardless of treatment