What is mastalgia

Mastalgia or breast pain is a common complaint among women that can include breast tenderness, sharp burning pain or tightness in your breast tissue. The pain may be constant or it may occur only occasionally. If you have mastalgia, talk to a health professional about it, especially if it is severe or interfering with your daily life.

Mastalgia can range from mild to severe. It may occur:

• Just a few days a month, in the two to three days leading up to your period. This normal, mild-to-moderate pain affects both breasts.
• A week or longer each month, starting before your period and sometimes continuing through your menstrual cycle. The pain may be moderate or severe, and affects both breasts.
• Throughout the month, not related to your menstrual cycle.

Postmenopausal women sometimes have mastalgia, but breast pain is more common in younger women who haven’t completed menopause.

Most times, mastalgia signals a noncancerous (benign) breast condition and rarely indicates breast cancer. Still, unexplained mastalgia that doesn’t go away after one or two menstrual cycles or that persists after menopause needs to be evaluated by your doctor.

There are two main types of mastalgia – cyclical (relating to the menstrual cycle) and non-cyclical. Each type of mastalgia has distinct characteristics.

Mastalgia management tips

• Wearing a supportive bra, such as a sports bra, will help reduce pain, which is especially important for women with large breasts or those who take part in sports. It’s worth noting that bras lose their elasticity with time and may need to be replaced regularly.
• Acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs) should reduce cyclical pain. If the pain is severe, a brief course of danizol or tamoxifen can be considered, but the side effects of these drugs are a concern.
• Supplements such as vitamins B6, B1, E or evening primrose oil are used by some clinicians, but there is no scientific evidence to support this. High caffeine intake has been linked to mastalgia, but the research is not conclusive.

Cyclical mastalgia

Cyclical mastalgia is linked your menstrual cycle and changing hormone levels. It usually goes away during pregnancy and menopause. For many women, it is normal for breasts to become tender or painful just before their period. About two thirds of women with mastalgia have this type of pain.

• Clearly related to your menstrual cycle
• Described as dull, heavy or aching
• Often accompanied by breast swelling or lumpiness
• Usually affects both breasts but may be more severe in one breast, particularly the upper, outer portions, and can radiate to the underarm
• Usually starts in the second half of the menstrual cycle, increases until the period begins, then settles during the period
• Can be more severe and prolonged for 1 to 2 weeks before a period for some women
• Intensifies during the two weeks leading up to the start of your period, then eases up afterward
• More likely to affect women in their 20s and 30s before menopause as well as women in their 40s who are transitioning to menopause

Non-cyclical mastalgia

Non-cyclical mastalgia is not related to the menstrual cycle.

There are a number of causes including infection and benign (non-cancerous) breast lumps. Sometimes the pain comes from the breast tissue in one or both breasts without any physical cause. About one third of women with mastalgia have this type of pain.

• Unrelated to your menstrual cycle
• Described as tight, burning, drawing, achy or sore
• Constant or intermittent (can come and go)
• Usually affects one breast, in a localized area, but may spread more diffusely across the breast
• Most likely to affect women after menopause, usually affects women in their 40s-50s

Non-cyclical mastalgia cause could be injury, trauma, musculoskeletal issues such as costochondritis, cervical vertebra issues or strain of the Coopers ligaments, especially in women with large or pendulous breasts.

A range of medications can cause non-cyclical mastalgia, including oral contraceptives, hormonal treatments, antidepressants (SSRIs) and some car-diac drugs such as digoxin (Lanoxin,Sig-maxin) and spironolactone (Aldactone, Spiractin).

Other causes include fibrocystic breast changes, breast cysts, mastitis, breast surgery and a poorly fitted or unsupportive bra. Breast cancer can also be a cause but this is rare; some forms of inflammatory breast cancer cause pain. Strain in the pectoralis major muscle can also mimic breast pain.

Are there other types of pain that can be mistaken for mastalgia?

The term “extramammary” means “outside the breast.” Extramammary breast pain feels like it starts in the breast tissue, but its source is actually somewhere else. Pulling a muscle in your chest, for example, can cause pain in your chest wall or rib cage that spreads (radiates) to your breast.

Pain in the breast area can be referred from other parts of the body including:

• joints – spine and ribs
• nerves – compression or irritation
• muscles – chest & upper back

or may be from other illnesses such as:

• shingles
• pneumonia
• gall stones

Referred pain in the breast area tends to be:

• on one side of the body only
• brought on by activity
• experienced at the extremities of the breast
• felt when pressure is applied on a specific area of the chest wall

Your doctor will need to do a thorough physical examination to determine the cause of any referred breast pain.

Mastalgia causes

Sometimes, it’s not possible to identify the exact cause of mastalgia. Contributing factors may include one or more of the following:

• Reproductive hormones. Cyclic mastalgia appears to have a strong link to hormones and your menstrual cycle. Cyclic mastalgia often decreases or disappears with pregnancy or menopause.
• Breast structure. Noncyclic mastalgia often results from changes that occur in the milk ducts or milk glands. This can result in the development of breast cysts. Breast trauma, prior breast surgery or other factors localized to the breast can lead to mastalgia. Breast pain may also start outside the breast — in the chest wall, muscles, joints or heart, for example — and radiate to the breast.
• Fatty acid imbalance. An imbalance of fatty acids within the cells may affect the sensitivity of breast tissue to circulating hormones.
• Medication use. Certain hormonal medications, including some infertility treatments and oral birth control pills, may be associated with mastalgia. Also, breast tenderness is a possible side effect of estrogen and progesterone hormone therapies that are used after menopause. Breast pain may be associated with certain antidepressants, including selective serotonin reuptake inhibitor (SSRI) antidepressants.
• Certain medicines may also cause breast pain, including:
  • Oxymetholone
  • Chlorpromazine
  • Water pills (diuretics)
  • Digitalis preparations
  • Methyldopa
  • Spironolactone
• Breast size. Women with large breasts may have noncyclic mastalgia related to the size of their breasts. Neck, shoulder and back pain may accompany mastalgia due to large breasts.
• Breast surgery. Breast pain associated with breast surgery and scar formation can sometimes linger after incisions have healed.

Some breast tenderness is normal. The discomfort may be caused by hormone changes from:

Menopause (unless a woman is taking hormone replacement therapy)
Menstruation and premenstrual syndrome (PMS)
Pregnancy — breast tenderness tends to be more common during the first trimester
Puberty in both girls and boys

Soon after having a baby, a woman’s breasts may become swollen with milk. This can be very painful. If you also have an area of redness, call your health care provider, as this may be a sign of an infection or other more serious breast problem.

Breastfeeding itself may also cause breast pain.

Fibrocystic breast changes are a common cause of breast pain. Fibrocystic breast tissue contains lumps or cysts that tend to be more tender just before your menstrual period.

Some breast tenderness is normal. The discomfort may be caused by hormone changes from:

• Menopause (unless a woman is taking hormone replacement therapy)
• Menstruation and premenstrual syndrome (PMS)
• Pregnancy — breast tenderness tends to be more common during the first trimester
• Puberty in both girls and boys

Soon after having a baby, a woman’s breasts may become swollen with milk. This can be very painful. If you also have an area of redness, call your health care provider, as this may be a sign of an infection or other more serious breast problem.

Breastfeeding itself may also cause breast pain.

Fibrocystic breast changes are a common cause of breast pain. Fibrocystic breast tissue contains lumps or cysts that tend to be more tender just before your menstrual period.

Mastalgia symptoms

There are two main types of mastalgia – cyclical and non-cyclical. Each type of mastalgia has distinct characteristics.

Cyclical mastalgia

Cyclical mastalgia is linked your menstrual cycle and changing hormone levels. It usually goes away during pregnancy and menopause. For many women, it is normal for breasts to become tender or painful just before their period. About two thirds of women with mastalgia have this type of pain.

• Clearly related to your menstrual cycle
• Described as dull, heavy or aching
• Often accompanied by breast swelling or lumpiness
• Usually affects both breasts but may be more severe in one breast, particularly the upper, outer portions, and can radiate to the underarm
• Usually starts in the second half of the menstrual cycle, increases until the period begins, then settles during the period
• Can be more severe and prolonged for 1 to 2 weeks before a period for some women
• Intensifies during the two weeks leading up to the start of your period, then eases up afterward
• More likely to affect women in their 20s and 30s before menopause as well as women in their 40s who are transitioning to menopause

Non-cyclical mastalgia

Non-cyclical mastalgia is not related to the menstrual cycle.

There are a number of causes including infection and benign (non-cancerous) breast lumps. Sometimes the pain comes from the breast tissue in one or both breasts without any physical cause. About one third of women with mastalgia have this type of pain.

• Unrelated to your menstrual cycle
• Described as tight, burning, drawing, achy or sore
• Constant or intermittent (can come and go)
• Usually affects one breast, in a localized area, but may spread more diffusely across the breast
• Most likely to affect women after menopause, usually affects women in their 40s-50s

Mastalgia diagnosis

Tests to evaluate your condition may include:

• Clinical breast exam. Your doctor checks for changes in your breasts, examining your breasts and the lymph nodes in your lower neck and underarm. Your doctor will likely listen to your heart and lungs and check your chest and abdomen to determine whether the pain could be related to another condition. If your medical history and the breast and physical exam reveal nothing unusual, you may not need additional tests.
• Mammogram. If your doctor feels a breast lump or unusual thickening, or detects a focused area of pain in your breast tissue, you’ll need an X-ray exam of your breast that evaluates the area of concern found during the breast exam (diagnostic mammogram).
• Ultrasound. An ultrasound exam uses sound waves to produce images of your breasts, and it’s often done along with a mammogram. You might need an ultrasound to evaluate a focused area of pain even if the mammogram appears normal.
• Breast biopsy. Suspicious breast lumps, areas of thickening or unusual areas seen during imaging exams may require a biopsy before your doctor can make a diagnosis. During a biopsy, your doctor obtains a small sample of breast tissue from the area in question and sends it for lab analysis.

Mastalgia treatment

For many women, mastalgia resolves on its own over time. You may not need any treatment.

If you do require treatment, your doctor might recommend that you:

• Eliminate an underlying cause or aggravating factor. This may involve a simple adjustment, such as wearing a bra with extra support.
• Use a topical nonsteroidal anti-inflammatory (NSAID) medication. You may need to use NSAIDs when your pain is intense. Your doctor may recommend you apply an NSAID cream directly to the area where you feel pain.
• Adjust birth control pills. If you take birth control pills, skipping the pill-free week or switching birth control methods may help mastalgia symptoms. But don’t try this without your doctor’s advice.
• Reduce the dose of menopausal hormone therapy. You might consider lowering the dose of menopausal hormone therapy or stopping it entirely.
• Take a prescription medication. Danazol is the only prescription medication approved by the Food and Drug Administration for treating mastalgia and tenderness. However, danazol carries the risk of potentially severe side effects, such as acne, weight gain and voice changes, which limit its use. Tamoxifen, a prescription medication for breast cancer treatment and prevention, may be recommended for some women, but this drug also carries the potential for side effects that may be more bothersome than the mastalgia itself.

There is no evidence that stopping or changing the combined oral contraceptive pill affects mastalgia. In fact, mastalgia usually goes away after a few months when you first start oral contraceptives. There are no studies about the effect of menopausal hormone replacement therapy on mastalgia – your doctor might recommend stopping menopausal hormone replacement therapy or trying a low dose and increasing it slowly.

Home remedies

Even though there is little research to show the effectiveness of these self-care remedies, some may be worth a try:

• Use hot or cold compresses on your breasts.
• Wear a firm support bra, fitted by a professional if possible.
• Wear a sports bra during exercise, especially when your breasts may be more sensitive.
• Experiment with relaxation therapy, which can help control the high levels of anxiety associated with severe mastalgia.
• Limit or eliminate caffeine, a dietary change some women find helpful, although medical studies of caffeine’s effect on mastalgia and other premenstrual symptoms have been inconclusive.
• Follow a low-fat diet and eat more complex carbohydrates, a strategy that’s helped some women with mastalgia in observational studies.
• Consider using an over-the-counter pain reliever, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) — but ask your doctor how much to take, as long-term use may increase your risk of liver problems and other side effects.
• Keep a journal, noting when you experience mastalgia and other symptoms, to determine if your pain is cyclic or noncyclic.

Alternative medicine

Vitamins and dietary supplements may lessen mastalgia symptoms and severity for some women. Ask your doctor if one of these might help you — and ask about doses and any possible side effects:

• Evening primrose oil. This supplement may change the balance of fatty acids in your cells, which may reduce mastalgia.
• Vitamin E. Early studies showed a possible beneficial effect of vitamin E on mastalgia in premenstrual women who experience mastalgia that fluctuates during the menstrual cycle. In one study, 200 IU of vitamin E taken twice daily for two months improved symptoms in women with cyclic mastalgia. There was no additional benefit after four months.

For adults older than 18 years, pregnant women, and breastfeeding women, the maximum dose of vitamin E is 1,000 milligrams daily (or 1,500 IU).

If you try a supplement for mastalgia, stop taking it if you don’t notice any improvement in your mastalgia after a few months. Try just one supplement at a time so that you can clearly determine which one helps alleviate the pain — or not.