A 38-year-old woman comes to the office due to breast pain. For the past 2 months, the patient has had intermittent bilateral breast pain that usually begins the week prior to menses and subsides on the first day of her menstrual cycle. The pain is primarily in the bilateral upper outer quadrants and does not radiate to the back or neck. Six months ago, the patient started a new job that requires long hours of sedentary work; she has gained 4.5 kg (10 lb). She has no chronic medical conditions and takes no daily medications. The patient has regular monthly menses, and her last menstrual period was a week ago. BMI is 26 kg/m². Vital signs are normal. Breast examination shows bilateral, symmetric, large breasts with slight tenderness over the upper outer quadrants. There are no skin changes, nipple discharge, masses, or axillary lymphadenopathy. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9a9_22c2_bc81_df3493fa6dba_MD0003_00 Mastalgia (breast pain) is common in women and typically classified as either cyclic or noncyclic: Cyclic breast pain is benign and due to estrogen and progesterone changes associated with the menstrual cycle. The cyclic pain usually begins up to 2 weeks prior to and subsides with the onset of menses. The pain is typically described as heavy, diffuse, dull, and bilateral. Patients may have increased pain or tenderness of the bilateral upper outer breast quadrants; however, there are typically no examination abnormalities (eg, breast mass, skin changes, axillary lymphadenopathy). Noncyclic breast pain, in contrast, is not associated with menses, often has a variable location, and involves a single breast. Patients may have an associated breast mass. Patients with noncyclic, unilateral, or focal breast pain and those with abnormal examination findings (eg, breast mass) require further evaluation with breast imaging or biopsy (Choice B). Patients with cyclic breast pain with no associated mass are at low risk for malignancy. Therefore, they are managed with reassurance, observation, and symptom management such as the use of a supportive bra (which minimizes breast movement) and nonsteroidal anti-inflammatory drugs. (Choice A) Breast-reduction surgery may be indicated in patients with large, heavy breasts and associated chronic pain of the neck, shoulders, or back. These patients typically have noncyclic breast pain exacerbated by activity (eg, exercise); this patient's cyclic pain would not benefit from surgery. (Choice C) Combined estrogen/progestin oral contraceptives are a potential cause of cyclic breast pain due to alterations in estrogen and progesterone levels; they are not used for treatment. (Choice D) Selective serotonin reuptake inhibitors are used to treat premenstrual syndrome, which can present with cyclic breast pain occurring in the luteal phase of the menstrual cycle. However, the diagnosis requires both somatic and behavioral (eg, irritability, emotional lability) symptoms related to menses, which are not present in this patient. Educational objective: Breast pain is typically benign when it is cyclic (ie, associated with menses), bilateral, and diffuse with no associated examination abnormalities (eg, breast mass). Patients benefit from reassurance and symptom management (eg, supportive bra, nonsteroidal anti-inflammatory drugs). References: Breast pain. (http://www.ncbi.nlm.nih.gov/pubmed/21477394) Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023)

A 38-Year-Old Woman Comes to the Office Due to Breast