Mastalgia, breast pain. Dra Moreno (www.oncocir.com)
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La mastalgia es un síntoma muy frecuente por el que las pacientes consultan. Es fundamental prestar atención a este signo, descartar patología subyacente t tratarlo en caso de que sea necesario.
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Mastalgia, breast pain. Dra Moreno (www.oncocir.com)
- 1. DRA. A. MORENO ELOLA DRA. A. MORENO ELOLA HOSPITAL CLINICO SAN CARLOS MADRID HOSPITAL CLINICO SAN CARLOS MADRID DESCRIPTION: oBreast pain that interferes with daily activity of a woman. oThe commonest symptom in patients attending a breast clinic (70%) •Cyclic •Noncyclic Cardiff Marks and Spencer study
- 2. MEDICAL HISTORY • Descriptive terms • Periodicity Tenderness/ heaviness/ burning Tenderness/ heaviness/ burning Related to cycle Related to cycle • Duration • Distribution in breast • Radiation • Aggravating factors • Relieving factors Physical contact Physical contact Analgesics/drugs/brassiere Analgesics/drugs/brassiere • Diurnal pattern • Disturbance of lifestyle Cardiff Mastalgia Protocol Sleep loss/ family problem Sleep loss/ family problem
- 3. AETIOLOGY In the past: Water retention Psychoneurosis Endocrine abnormalities DISTURBANCE OF HYPOTHALAMIC CONTROL DISTURBANCE OF HYPOTHALAMIC CONTROL Hyperoestrogenism: Increased secretion from the ovary And deficient Hyperoestrogenism: Increased secretion from the ovary And deficient progesterone production progesterone production Hyperprolactinaemia (PRL) Hyperprolactinaemia (PRL) Caffeine and metilxanthines: Interference with adenosine triphosphate degradation by metylxanthines Prostaglandins and essential fatty acids (EFA): Abnormality in prostaglandin synthesis due to deficient EFA intake in the diet. Deficient production of PGE1=amplification of PRL effects. Stress: Impact on hypothalamus: PRL Others: Vasospasm, ductal ectasia, tubal ligation, lack of breastfeeding,
- 4. CLASIFICATION Título del gráfico 40 30 20 10 0 CYCLIC NONCYCLIC TIETZE OTHER TRAUMA ADENOSIS CANCER
- 5. Cyclical mastalgia (CM) 68% of women*. The commonest: 40% of mastalgia. Age: the most younger. Cause: endocrin. Related to menstrual cycle and particularly with ovulation. Score chart id useful. Bilateral, both superior-outer-q Nodularity >1 week per cycle or high intensity of symptoms: obtrusive features in lifestyle. Ader et al. (2001)*
- 6. Noncyclical mastalgia (NCM) Frequency: second. Not related to cycle: pre and postmenopausal Subtypes: 1.TRUE NMC (27% of total) . Loc: Unilateral. specific, trigger Spot Age older (median 34) Less intense: Linear analogue scale Less nodularity Duration= continuous: 27-35 m • Radiological changes: ductal ectasia in 33% Rel. to cancer in 7 -12%
- 7. MNC 2. Musculoskeletal pain (11%) • Unilateral in 92%. Chronic. •Treatment: injection of steroid and local anaesthetic. •SUBTYPES: •1. Tietze´s Syndrome. (costochondral junction): Pain occurs on pressure over the affected cartilage. •2. Lateral chest wall pain: Anterior axillary line. Relates to the slips of origin of the serratus anterior muscle.
- 8. • Trauma: 8 %. Persistent pain due to previous biopsy scar. •Sclerosing adenosis: 4,5 % •Phantom symptoms. •Mondor syndrome •Cancer •Inadequate brasserie
- 9. •¿ HOW? ¿ WHO ? ¿ WHY ? •CORRECT CLASIFICATION: 85 % of success. •REASSURANCE •Medical treatment is neccessary only in 15% •Surgical treatment not indicated.
- 10. TREATMENT Reassurance and supportive measures Reassurance that is not due to cancer Well-fitting brassiere: Size. El 75 % of women do not know the exact size**. DIET: Esential fatty-acids Metilxanthines (coffe,te)* Vitamine E: 41% of improvement** Supplement of iodine >50% *Minton (1979) **Elisabeth Sanabria, XXIV Reunión de la SESPM, Orense 2005. *** KHANNA (India 1997)
- 11. •First line* •Action: Impeded androgen that acts as antigonadotrophin: FSH and LH •Approved by the FDA. Inhibits Oestrogen and progesteron receptors in hypothalamus and breast. Prevents ovulation. Success MC: 70% y En MNC:40 %. rate •Spotting,weight gain, headache, nausea , mood Side effects:20 %. changes, depression, acne and hirsutism,. •Clearly related to dose DOSE 100 mg/24 h • If not success: 200 mg/24 h up to 6 months •If success: manintenance dose of 100 mg/48h. *Wetzig NR.et al. 1994 Gestrinone: Gestrinone: ••Androgenic antiestrogenic, Androgenic antiestrogenic, antiprog. antiprog. ••Less side-effects Less side-effects ••No experience No experience
- 12. TREATMENT: DRUGS.Tamoxifen Antioestrogen*. Only licensed for breast cancer. Second-line drug for mastalgia. Acts blocking oestrogen receptors in ovary and breast. Success rate 78-98% for CM and 56% for NCM hot flashes(26%), vaginal bleed (16%)and endometrial cancer. 15 % discontinuance Side effects DOSE 10 mg/d for 3-6 months, repeated for relapse if necessary. OTHER SERMS (Receptor modulator)** Toremefine Toremefine Ormeloxifine Ormeloxifine Gel afimoxifine: (Tamogel): transcutaneus route. (1/d. for 4 cycles)*** *Faiz and Fentiman,2000, **Dhar A et al, 2007, **Mansel RE et al, 2007
- 13. TREATMENT: DRUGS.Bromocriptine Inhibitor of prolactin. Only in patients w. abnormal levels of PRL. Success rate Side effects ´ DOSAGE CM.: 78% 35%, nausea, cefalea, headache, dizziness severe: vascular (due to high dosage) discontinuance: 29% Slow introduction in incremental scheme to minimize side-effects*: 1.25 mg/d (1st w.) to 2.5 mg/d (3 months) Up to 2,5 mg/12h Cabergoline is as effective as bromocriptine for the treatment of cyclic mastalgia but has minimal side effects compared to bromocriptine**. *Deliski et al. Sofia 2000, **Yavuz Aydin et al. 2010
- 14. OTHER TREATMENTS: Evening primrose oil (EPO)* Fatty acid deficiency hypothesis: supplementary diet w. EFA EPO=Unique containing 7% of linolenic acid + 72% linoleic acid. First line in mild to moderate CM (58% response rates)* No side effects Vitex Agnus Castus (VAC)** Antioestrogen. Inhibits FSH and stimulates LH Inhibits PRL secretion. Spasmolitic First line in mild to moderate CM. Response rates close to 54% No side effects *Louiza Velentzis, J. et al. 2010. **G. Tamagno, et al.2009, Z. He, et al2009.W. Wuttke, et al 2003, Donna E. Webster et. al.2010.
- 15. NCM UNRESPONSIVE TO ENDOCRINE THERAPY: Luteinizing hormone-releasing hormone (LHRH) analogue (subcutaneous dosage of 3,5 mg/28 d. x 6 months) Topical nonsteroidal antiinflammatory agents to be safe, effective (96%), rapid and acceptable mode of treatment for cyclical and non-cyclical mastalgia. Tietze´s syndrome or chest wall pain: Steroid /local anaesthetic injection: initial relief: 70%. Continued relief: 33% Tricyclic antidepressants Surgical excision: Rarely indicated, high incidence of complications. T. Colak, T.Ipek, A.Zanik et al. 2003. Semih Kaleli et al. 2001. S. Qureshi, N. Sultan, et al. 2005. W.A.Townley, C.A.T.Durrant, D.Gault. 2004
- 16. PRINCIPLES OF MASTALGIA TREATMENT Reassurance. Exclude cancer. Define pattern. History. Cyclical (response rate: 92%). EPO (6/d) Danazol (100-300mg/d) Bromocriptine (1,25mg/d to 3,75-5mg/d) True noncyclical (overall response 64%) Danazol EPO Bromocriptine Musculoeskeletal chest wall pain Lidocaine/Steroid injection to trigger spot Surgery: last resort