QuestionSBA
QuestionChoice
Mastalgia can be caused by hormonal changes, such as those experienced in pregnancy or menstruation. The initial step in management should be a pregnancy test to investigate this.
10017311
a
Urine beta-HCG
QuestionChoice
Mammography is less useful in younger women, as they have dense breast tissue. If imaging is required (e.g. due to a palpable mass on examination), ultrasound would be a better modality of imaging.
10017313
c
Mammography
QuestionChoice
The COCP is not indicated in the management of cyclical mastalgia.
10017315
e
Combined oral contraceptive pill
QuestionChoice
Danazol is used in mastalgia refractory to breast pain not responding to simple analgesia for at least 3 months. As this patient does not fit these criteria, danazol should not be prescribed.
10017314
d
Danazol
QuestionChoice
This may be indicated if a lump is felt, or other investigations do not yield a cause of the pain.
10017312
b
Ultrasound breast
Concept
Chapter
# Summary
 

Cyclical mastalgia, or cyclic breast pain, is a condition characterised by breast tenderness that fluctuates in intensity with the menstrual cycle. It is often associated with premenstrual syndrome and may begin a few days before the onset of menstruation, subsiding by the end of the period. This condition is thought to be linked to hormonal changes during the menstrual cycle and may also be associated with fibrocystic changes in the breast or duct ectasia. Cyclical mastalgia is more prevalent in peri- and premenopausal women. Key investigations include physical examination, mammography, and ultrasound, and the primary management strategies involve lifestyle modifications and pharmacological therapy.
 

# Definition
 

Cyclical mastalgia is a clinical condition that involves breast tenderness, which fluctuates in relation to the monthly menstrual cycle.
 

# Epidemiology
 

Cyclical mastalgia is predominantly experienced by peri- and premenopausal women, with a notable decrease in incidence among postmenopausal women.
 

# Aetiology
 

The aetiology of cyclical mastalgia is believed to be linked to variations in hormone levels during the menstrual cycle, particularly oestrogen and progesterone. It may also be associated with fibrocystic changes in the breast, presenting as breast "lumpiness", or with duct ectasia.
 

# Signs and Symptoms
 

-  Breast tenderness
-  Pain usually beginning a few days before the onset of menstruation and subsiding by the end of the period
-  Possible breast "lumpiness" associated with fibrocystic changes
-  Potential presentation of duct ectasia
 

# Differential Diagnosis
 

-  **Fibrocystic breast changes**: These can present with breast pain, lumpiness, and sometimes nipple discharge.
-  **Breast abscess**: Characterised by localised pain, redness, swelling, and warmth of the affected area, often accompanied by fever.
-  **Mastitis**: Similar to a breast abscess, mastitis presents with breast pain, redness, swelling, and warmth but is usually associated with breastfeeding.
-  **Breast cancer**: Though pain is not a common symptom, breast cancer can present with a painless lump, skin dimpling, nipple inversion, or nipple discharge.
 

# Investigations
 

-  Clinical breast examination: to assess for any palpable masses, skin changes, or nipple discharge
-  Mammography or ultrasound: especially for women over 40, or those with significant risk factors
-  Hormone profile: for suspected hormonal imbalances
 

# Management
 

-  **Lifestyle modifications**: Including regular exercise, a healthy diet, and limiting caffeine and salt intake
-  **Pharmacological therapy**: Non-prescription pain relief such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs); hormone-modulating medications like oral contraceptives or danazol may be used in severe cases
-  **Follow-up and surveillance**: Regular follow-ups to monitor symptoms and evaluate the effectiveness of management strategies
 

# NICE Guidelines
 

[Click here for NICE CKS on breast pain - cyclical](https://cks.nice.org.uk/topics/breast-pain-cyclical/#:~:text=pain%20%2D%20cyclical%3A%20Summary-,Cyclical%20breast%20pain%20is%20related%20to%20the%20menstrual%20cycle%20and,moderate%2Dto%2Dsevere%20pain.)
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Cyclical mastalgia
Topic
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Breast Disease
16006
Mastalgia, which can be caused by hormonal changes like those in pregnancy or menstruation, should initially be evaluated with a pregnancy test.
A 31-year-old patient visits her GP as she is experiencing bilateral breast pain. Her mother had a mastectomy for breast cancer at the age of 58, and she is anxious that she may have breast cancer.

What is the most appropriate initial management step?
a