Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction?

Clinical management of idiopathic mastalgia: a systematic review

ABSTRACT INTRODUCTIONIdiopathic mastalgia (benign breast pain of unknown origin) is often poorly managed because of its subjective nature and unclear aetiology. Mastalgia is a reason for up to 50% of breast outpatient referrals. Existing systematic reviews discuss dated treatment options that provide limited symptomatic relief. METHODSA systematic review was conducted for aetiology and treatment of idiopathic mastalgia in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Databases such as PubMed, MEDLINE, Cochrane Database and the Clinical Trial Registry were searched (February 2016). RESULTSReassurance plus bra-fitting advice provides relief for most women. If symptoms persist, addition of topical non-steroidal anti-inflammatory drugs (NSAIDs) provides relief in 70–92% of women. There is some benefit in reducing dietary coffee and fat intake. Medical treatments have serious side-effects (often androgenic or menopausal) and should be considered only in cases resistant to simpler measures. Dopamine agonists are useful, but less effective than endocrine treatments such as Danazol or Tamoxifen. Of the Selective Oestrogen Receptor Modulator drugs, Ormeloxifene appears most effective, but is not licenced in the United Kingdom. Relaxation therapy, acupuncture and kinesiology may be useful but currently lack good evidence of effectiveness. DISCUSSIONFirst-line management of breast pain should be explanation, reassurance and a bra-fitting advice. Subsequent drug therapy should be balanced against its side-effects; topical NSAIDs and Ormeloxifene show greatest benefit with least side-effects. Newer agents (Ormeloxifene) currently being used for mastalgia in India could be considered in the developed world.

Cyclic and non-cyclic breast-pain: A systematic review on pain reduction, side effects, and quality of life for various treatments

CYCLIC AND NON-CYCLIC BREAST-PAIN

A systematic review on pain reduction, side effects, and quality of life for various treatments.

BACKGROUND

No clear systematic-review on all the various treatment regimen for (Non-) cyclical-breast-pain currently exists.

OBJECTIVES

The aim of this study was to assess the various forms of therapy for treatment of breast-pain and the evidence for their effectiveness.

SEARCH STRATEGY

Search-terms included 'mastalgia' and 'therapy' or 'hormones' or 'nsaid' or 'psychotherapy' or 'analgesia' or 'surgery', and synonyms.

SELECTION CRITERIA

The review was conducted according to the Preferred Reporting Items for Systematic-reviews and Meta-Analysis guidelines. RCT's and pro-/retrospective studies reporting on treatment of breast-pain were considered eligible. Minimal follow-up and sample-size criteria were 6 months and 10 patients respectively.

DATA COLLECTION AND ANALYSIS

Data was extracted using standardized tables and encompassed number of subjects, type of breast-pain and treatment, efficacy of treatment and clinical complications/side-effects. No pooling of data could be achieved due to heterogeneity amongst studies.

MAIN RESULTS

Twenty-three studies were included, that reported on 2100 patients in total. Topical-Diclofenac was found to reduce pain by 58.7 and 63.3 on a Visual-Analogue-Scale (VAS) in cyclical and non-cyclical-breast-pain respectively. Persistent cyclical-breast-pain can be treated with short courses (2-6 months) of either Bromocryptine (VAS↓=25.4) or Danazol (VAS↓=33.6) as long as benefits outweigh the side-effects. Last-resort options for unresponsive and severe debilitating breast-pain include surgery in the form of bilateral mastectomy with reconstruction.

CONCLUSIONS

Pain reduction in patients with breast-pain can be achieved with analgesics, hormonal-regimen and possibly surgery as a last resort. Additional studies are needed with well-described patient-characteristics, robust study set-up, and longer follow-up times.

Factors Effecting Mastalgia

BACKGROUND

Breast pain is one of the leading complaints that ends up with referral to breast surgery clinics. The purpose of the present study was to investigate the factors that cause mastalgia, and its relation with benign or malignant breast disease.

METHODS

The study was performed in 700 patients. Data obtained from surveys, and imaging findings were prospectively recorded, and analyzed.

RESULTS

The mean age was 45.20 ± 10.78 years. The mastalgia group included 500 cases; the asymptomatic group comprised 200 individuals. Stressful lifestyle, caffeine consumption, and smoking were associated with mastalgia (p < 0.05). Rates of women who had breast fed 3 times or more were higher in the mastalgia group (p < 0.05). Increased breast density, and breast imaging-reporting and data system (BI-RADS) 2 mammography findings were related with mastalgia (p < 0.05). Cysts and fibroadenomas were more common in the mastalgia group (p < 0.05). The incidence of a past history of malignant breast disease was significantly higher in the mastalgia group (p < 0.05).

CONCLUSIONS

Stress, caffeine, smoking, lactation frequency, and benign disorders were factors detected to be related with mastalgia. Although a significant relation between mastalgia and malignant breast disease was detected in our study, more controlled studies are still required to investigate this issue further.

Common breast concerns

Breast concerns commonly occur in the outpatient setting and predominantly consist of breast pain, nipple discharge, and breast masses. Many of these concerns can be treated with reassurance and reevaluation, but not if the patient has risk factors for an underlying pathology. This article reviews the diagnosis and treatment of the three most common breast concerns encountered in primary care practices.

Comparison of naproxen with placebo for the management of noncyclical breast pain: a randomized, double-blind, controlled trial

BACKGROUND

Breast pain is a common symptom in patients attending breast clinics. Although most patients experience mastalgia of mild to moderate severity, approximately 15% of patients suffer from severe pain that causes significant distress and some disturbance in their daily life that lead them to seek treatment. Despite a considerable number of drugs suggested for decreasing the severity of mastalgia, there is no standard treatment for the complaint. In this study, we investigated the effect of naproxen on reducing the complaint of breast pain compared with placebo.

METHODS

Eighty-one women suffering from noncyclic breast pain were recruited to a randomized, double-blind, clinical trial between January 2002 and September 2004. All patients were suffering from this complaint for at least 3 months before the study. Patients were randomly assigned to two groups. Patients in the case group received naproxen 250 mg BD. Patients in the placebo group took placebo in a similar manner. The intensity of mastalgia was assessed before and twice after intervention by using a Visual Analogue Scale.

RESULTS

Forty-two of 81 patients were recruited randomly as cases and the remaining 39 were assigned placebo. Of these 24 and 22 patients fulfilled the study protocol respectively. The mean age of patients was 35 (SD = 7.5; range, 19-55) years. The mean pain severity at the beginning of the study was 5.8 and 6.1 in naproxen and placebo groups, respectively. The severity of pain was decreased significantly at the end of the study in both groups (3.9 in patients and 3.7 in controls (P = 0.005 and 0.0001)). Although the decrease in pain severity in each individual group was statistically significant, it was not significant compared with one another (P = 0.64).

CONCLUSIONS

Breast pain is a complex symptom that can be relieved significantly with reassurance. According to the result of this study, naproxen has no superiority over placebo in reducing noncyclic breast pain.