Mastodynia

Mastodynia, mastalgia or mammalgia are names for a medical symptom that means breast pain (from the Greek masto-, breast and algos, pain).

Pain can range from minor discomfort to severely incapacitating pain. Many women are more worried about a possible cancer risk than about the pain.

Breast pain during lactation or after weaning is not included into this definition but usually classified as breast engorgement or mastitis.

Types

It can be classified into 2 main clinical patterns:

• cyclical when the pain intensity is changing during the menstrual cycle.
• non-cyclical when the pain remains essentially unchanged during the menstrual cycle. This type is less frequent.

Causes

Cyclical breast pain (cyclical mastalgia) is very often associated with fibrocystic breast changes or duct ectasia and believed to be caused by aberrations in dynamic hormonal changes mainly involving prolactin response to thyrotropin. ^{[1] [2]} Some degree of cyclical breast tenderness is normal in the menstrual cycle, and is usually associated with menstruation and/or premenstrual syndrome (PMS).^[3]

Noncyclical breast pain has various causes and is harder to diagnose. Noncyclical pain has frequently its root cause outside the breast. Some degree of non-cyclical breast tenderness can normally be present due to hormonal changes in puberty (both in girls and boys), in menopause and during pregnancy.^[3] After pregnancy, breast pain can be caused by breastfeeding.^[3] Other causes of non-cyclical breast pain include alcoholism with liver damage (likely due to abnormal steroid metabolism), mastitis and medications such as digitalis, methyldopa (an antihypertensive), spironolactone, certain diuretics, oxymetholone (an anabolic steroid), and chlorpromazine (a typical antipsychotic).^[3] Also, shingles can cause a painful blistering rash on the skin of the breasts.^[3]

Treatments for cyclical breast pain

While in many cases it would possible to predict which treatment will be most effective with a series of endocrinological investigations involving thyroid and complicated pituitary hormone testing ^[4], this is rarely done in practice.

Treatments which demonstrated some effectiveness:

• Vitex agnus-castus extract: there is convincing evidence that Vitex agnus castus is safe and efficient in the treatment of cyclical mastalgia. It is assumed, that like bromocriptine it works by reducing prolactin secretion from the pituitary gland. ^[5]
• Topical and systemic NSAIDs, analgesics
• Progestin based birth control pills or topical progesterone application. This method is effective only in a minority of women but is often tried because of its well known safety profile. Cyclic progestin on days 14-25 did show promising results.^[6]
• Dopamine agonists, best results with a better side effect profile than bromocriptine can be achieved with Dostinex.^[7]The older bromocriptine has been found very efficient with relatively good safety, is however associated with many unpleasant adverse side effects. ^[8] There is very little although promising data on lisuride^[9] and quinagolide.^[10]
• Iodine: supplementation with supraphysiologic levels of iodine has been shown effective in the treatment of breast pain. Not yet widely recommended until the long term effects of supraphysiologic doses of iodine on thyroid health are better understood. ^{[11] [12]}
• Danazol: low dose danazol treatment has been found very efficient with modest side effects. The lowest dose tested in one trial produced the most favorable long term results and was associated with least adverse effects.^[13]
• Thyroid hormone supplementation, especially when hypothyroidism or subclinical hypothyroidism has been diagnosed. However even levothyroxin supplementation in normal patients has been shown effective. ^[14]
• Tamoxifen has been shown effective but is very rarely used because of serious concerns about safety in premenopausal women.
• Anthocyanins from bilberry.^[15]

Treatments for non-cyclical breast pain

Determining the appropriate treatment for noncyclical breast pain is more difficult, not only because it is hard to pinpoint where the pain is coming from, but also because the pain may not have hormonal causes and very often does not respond to hormonal treatment.

Breast cancer risk

Great majority of breast cancer cases do not present with symptoms of pain.

Some epidemiological investigations suggest that women with symptoms of breast pain may have an increased risk of subsequently developing breast cancer and risk increases with duration of symptoms. ^[16] This is consistent with the observation that a few special subtypes of fibrocystic breast changes exhibit increased breast cancer risk – see breast cancer risk of fibrocystic breast changes.

See also

• Breast engorgement

References

1. ^ Dogliotti, L; Faggiuolo, R; Ferusso, A; Orlandi, F; Sandrucci, S; Tibo, A; Angeli, A (1985). "Prolactin and thyrotropin response to thyrotropin-releasing hormone in premenopausal women with fibrocystic disease of the breast". Hormone research 21 (3): 137–44. doi:10.1159/000180038. PMID 3922866.  edit
2. ^ Dogliotti, L; Orlandi, F; Angeli, A (1989). "The endocrine basis of benign breast disorders". World journal of surgery 13 (6): 674–9. doi:10.1007/BF01658413. PMID 2696218.  edit
3. ^ ^{a b c d e} medlineplus > Breast pain By the U.S. National Library of Medicine, U.S. Department of Health and Human Services, National Institutes of Health. Page last updated: 25 January 2011
4. ^ Rea, N; Bove, F; Gentile, A; Parmeggiani, U (1997). "Prolactin response to thyrotropin-releasing hormone as a guideline for cyclical mastalgia treatment". Minerva medica 88 (11): 479–87. PMID 9433398.  edit
5. ^ Carmichael, A.; Carmichael, (2008). "Can Vitex Agnus Castus be Used for the Treatment of Mastalgia? What is the Current Evidence?". Evidence-based complementary and alternative medicine : eCAM 5 (3): 247–250. doi:10.1093/ecam/nem074. PMC 2529385. PMID 18830450. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2529385.  edit
6. ^ Winkler, U. H.; Schindler, A. E.; Brinkmann, U. S.; Ebert, C.; Oberhoff, C. (2001). "Cyclic progestin therapy for the management of mastopathy and mastodynia". Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology 15 Suppl 6: 37–43. PMID 12227885.  edit
7. ^ Aydin, Y.; Atis, A.; Kaleli, S.; Uludağ, S.; Goker, N. (2010). "Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: a randomised, open-label study". European Journal of Obstetrics & Gynecology and Reproductive Biology 150: 203. doi:10.1016/j.ejogrb.2010.02.024.  edit
8. ^ Mansel, RE; Dogliotti, L (1990). "European multicentre trial of bromocriptine in cyclical mastalgia". Lancet 335 (8683): 190–3. doi:10.1016/0140-6736(90)90278-D. PMID 1967667.  edit
9. ^ Kaleli, S.; Aydin, Y.; Erel, C.; Colgar, U. (2001). "Symptomatic treatment of premenstrual mastalgia in premenopausal women with lisuride maleate: a double-blind placebo-controlled randomized study". Fertility and sterility 75 (4): 718–723. doi:10.1016/S0015-0282(01)01668-5. PMID 11287025.  edit
10. ^ Ioannidou-Mouzaka, L.; Niagassas, M.; Galanos, A.; Kalovidouris, A. (1999). "Pilot study on the treatment of cyclical mastodynia with Quinagolide". European journal of gynaecological oncology 20 (2): 117–121. PMID 10376428.  edit
11. ^ Kessler, J. H. (2004). "The Effect of Supraphysiologic Levels of Iodine on Patients with Cyclic Mastalgia". The Breast Journal 10 (4): 328–336. doi:10.1111/j.1075-122X.2004.21341.x. PMID 15239792.  edit
12. ^ Patrick, L. (2008). "Iodine: deficiency and therapeutic considerations". Alternative medicine review : a journal of clinical therapeutic 13 (2): 116–127. PMID 18590348.  edit
13. ^ Mossa, B; Tocci, B; Roscetti, C; Aleandri, V; Morini, A (1989). "Use of low-dose danazol in adenosis of the breast". Minerva ginecologica 41 (9): 455–9. PMID 2622587.  edit
14. ^ Estes, N. C. (1981). "Mastodynia due to fibrocystic disease of the breast controlled with thyroid hormone". American journal of surgery 142 (6): 764–766. doi:10.1016/0002-9610(81)90330-5. PMID 7316045.  edit
15. ^ Leonardi, M. (1993). "Treatment of fibrocystic disease of the breast with myrtillus anthocyanins. Our experience". Minerva ginecologica 45 (12): 617–621. PMID 8139788.  edit
16. ^ Plu-Bureau, G. èV.; Lê, M. G.; Sitruk-Ware, R.; Thalabard, J. -C. (2006). "Cyclical Mastalgia and Breast Cancer Risk: Results of a French Cohort Study". Cancer Epidemiology Biomarkers & Prevention 15: 1229. doi:10.1158/1055-9965.EPI-05-0745.  edit