A 28-year-old woman comes to the office due to bilateral breast discomfort that occasionally interferes with physical activity. The pain begins the week prior to menses and subsides on the first day of her menstrual cycle, which occurs every 30 days; her last menstrual period was 3 weeks ago. Two years ago, she was diagnosed with leg vein thrombosis after an ankle fracture and was treated with a direct oral anticoagulant for 3 months. Family history is significant for osteoporosis in her grandmother and aunt.
Vital signs are normal. BMI is 26 kg/m². Physical examination reveals bilateral, mildly tender nodularity of the upper lateral breast quadrants. There are no skin changes, palpable lymph node enlargement, or nipple discharge.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97e4_94ad_853d_c3cc2c1779e8_MD0002_00 Mastalgia (breast pain) is a common and benign symptom that most women experience due to estrogen and progesterone changes associated with the menstrual cycle. The pain is often cyclic, beginning up to 2 weeks before menses and usually subsiding by the onset of menses; it is typically described as heavy, diffuse, dull, and bilateral. Generalized swelling and mildly tender nodularity may be present, but there are no discrete masses or nipple discharge. Symptomatic relief can be achieved by wearing a properly fitted bra with good breast support that minimizes breast movement. Acetaminophen or nonsteroidal anti-inflammatory drugs (eg, ibuprofen) can also be administered for pain relief. In addition, danazol is currently approved by the Food and Drug Administration for mastalgia; however, it may cause permanent androgenic side effects (eg, hirsutism) and increases the risk of thromboembolism. (Choice A) Imaging with either a breast ultrasound or a mammogram is required in the evaluation of unilateral, noncyclic, or focal breast pain with no associated palpable mass. This patient's bilateral mastalgia and normal clinical breast examination require no further evaluation. (Choice B) Progestins are indicated for secondary amenorrhea, abnormal uterine bleeding, and endometriosis. Breast tenderness is a common side effect of progestin use. (Choice C) A panel of serum estradiol, FSH, and prolactin levels is indicated in the evaluation of secondary amenorrhea. Prolactin levels are ordered in patients with bilateral nipple discharge but are not indicated in breast pain evaluation. (Choice E) Tamoxifen is a selective estrogen receptor modulator that may be used in patients with mastalgia unresponsive to conservative therapy. Tamoxifen is contraindicated in patients with a previous thromboembolism. In addition, tamoxifen has multiple side effects (eg, hot flashes) that limit its usefulness. Educational objective: Mastalgia is a benign breast condition characterized by bilateral breast pain and tenderness that occurs up to 2 weeks prior to menses and wanes with the onset of menses. Symptomatic relief can be achieved by wearing a properly fitted bra that provides adequate breast support. __________ References: Benign breast disorders. (http://www.ncbi.nlm.nih.gov/pubmed/24021252) Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023)

A 28-Year-Old Woman Comes to the Office Due to Bilateral