Can mastalgia be another somatic symptom in fibromyalgia syndrome?

Is it mastalgia or myofascial pain? A clinical confusion

Objectives

This study aims to investigate the frequency of myofascial pain syndrome (MPS) and its characteristics in mastalgia patients.

Patients and methods

The localization of pain, age, education, menopausal status, hormone replacement and employment status, and existence of comorbid diseases were reviewed on consecutive 131 female mastalgia patients (mean age 43.3±9.4 years; range, 18 to 75 years) in this prospective study conducted between June and December 2019. A total breast pain index (IBP) was obtained and mastalgia was classified according to these scores as mild, moderate, and severe. Patients were divided into four diagnostic groups of MPS, cyclic mastalgia, fibrocystic breast disease, and mastitis.

Results

The total IBP was significantly higher in MPS group (129.2±49.5) than in cyclic mastalgia group (98.3±11.9) (p<0.05). However, it was significantly higher in mastitis group (230.7±17.6) compared to MPS group (p<0.05). The fibrocystic disease group was similar to MPS group in terms of total IBP (p>0.05). Considering the localization of pain according to the quadrants where the pain was felt, 57.1% of the patients who felt pain in the upper quadrants were from MPS group (p=0.001) and 45.3% of the patients who felt pain in the lower quadrants were from cyclic mastalgia group (p=0.001). Myofascial pain was observed particularly in upper quadrants and almost all was unilateral; however, cyclic mastalgia was observed bilaterally in the majority, particularly in lower quadrants.

Conclusion

Myofascial pain syndrome should be kept in mind as an extramammary disorder in the differential diagnosis of particularly unilateral upper quadrant mastalgia. It may be for the benefit of patients complaining of mastalgia with no primary breast disorder to be consulted with a physiatrist.

Clinical Factors Affecting the Therapeutic Efficacy of Evening Primrose Oil on Mastalgia

BACKGROUND

Saturated fatty acid esters may cause mastalgia via hypersensitivity of breast epithelium to circulating hormones. Evening primrose oil (EPO) may restore the saturated/unsaturated fatty acid balance and decrease sensitivity to steroidal hormones or prolactin. Conflicting results exist regarding EPO treatment for mastalgia. The aim of this study was to determine the effectiveness of EPO and factors affecting its efficacy in treatment of mastalgia.

METHODS

The study included 1015 patients, ages 14-82 (mean age 42.21 ± 10.8), admitted to Acibadem Breast Clinic between January 2015 and March 2018. The patients were divided into group I (n = 581) treated with EPO (1300 mg, twice a day) and group II (n = 434) treated with paracetamol (500 mg, twice a day). The visual analog scale was used to assess EPO's therapeutic efficacy, compared with paracetamol, measured at admittance, 2 weeks, and 6 weeks. Clinical factors affecting the efficacy of EPO were analyzed.

RESULTS

The therapeutic efficacy of EPO on mastalgia was significantly higher than with paracetamol (p < 0.001). Factors significantly affecting the efficacy of EPO treatment were hormone replacement therapy (HRT), IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis (p < 0.01). Replacement of iron or thyroid hormone efficiently treated mastalgia in patients that did not respond to EPO treatment. Side effects (allergy, anxiety, blurred vision, constipation, and nausea) were rare and not statistically significant (p = 0.88).

CONCLUSION

EPO can be used in the treatment of mastalgia without significant side effects. HRT, IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis significantly affect the efficacy of EPO on mastalgia.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

ACR Appropriateness Criteria® Breast Pain

Breast pain is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.