Devant des mastodynies cycliques : FAITES /NE FAITES PAS

Les mastodynies dites « cycliques » concernent la majorité de femmes dans les sociétés occidentales : elles sont 60 à 70% à s’en plaindre à un moment ou un autre de leur vie.

Il s’agit du symptôme mammaire le plus souvent rencontré dans les consultations de sénologie et il n’est généralement pas lié à une étiologie maligne. Les progestatifs ont longtemps été le « traitement star » de ce symptôme mais ils sont aujourd’hui, on le sait fortement remis en cause. Certaines pratiques non conventionnelles à visée thérapeutique trouvent de plus en plus leur place dans ce contexte. Ci-dessous chacune des phrases constituant la conduite à tenir est le fruit d’une bibliographie exhaustive faite de 240 publications scientifiques consacrée à ce sujet.

FAITES

1. Distinguez les mastodynies parmi les « cycliques » et les « non cycliques ». Les cycliques sont en général fonctionnelles.

 

2. Rendez-vous compte: elles sont 60 à 70% à s’en plaindre à un moment ou un autre de leur vie.

 

3. Approchez le diagnostic dès l’interrogatoire : elles sont bilatérales, prémenstruelles et disparaissent après les règles.

 

4. Oubliez (pour la majorité des cas) la théorie de l’hyper-estrogènie ou de l’hypo-progestéronémie ou d’une éventuelle hyperprolactinémie (en dehors des situations d’hyper- estrogènie endogène ou iatrogènes).

 

5. Accusez le stress largement impliqué dans la mesure où il provoque un dysfonctionnement complexe induisant des actions biologiques en chaines à partir de l’axe hypothalamo- hypophysaires- surrénalien.

 

6. Faites du « sur-mesure » lors de vos prescriptions éventuelles de contraception ou de THM… En sachant en modifier les molécules/doses d’estrogènes (et de progestatifs).

 

7. Ne perdez pas de vue que seule une minorité de femmes pour lesquelles le symptôme a impact négatif sur la qualité de vie nécessite un traitement.

 

8. Restez prudent(e)s: il n’est toujours pas possible aujourd’hui de répondre à la question concernant l’impact éventuel des progestatifs sur le risque de cancer du sein lorsqu’ils sont prescrits seuls sans estrogènes.

 

9. Convenez que les PNCAVT (Pratiques Non Conventionnelles A Visée Thérapeutique) peuvent s’avérer efficaces soit parce qu’elles ont des vertus thérapeutiques réelles dont elles n’ont pas fait la preuve soit par effet placebo. L’absence de preuves d’efficacité n’est pas la preuve de l’absence d’efficacité.

 

10. Méditez sur le paradigme : si le bénéfice de certaines pratiques non conventionnelles à visée thérapeutique ne peut sans doute être attribué qu’à un effet placebo, il n’en reste pas moins un bénéfice.

 

11. Notez bien que certaines molécules pourraient être classées comme probablement plus actives que le placebo pour soulager les mastodynies cycliques telles que les baies de gattilier, les graines de lin, le curcuma et l’arnica.

NE FAITES PAS

1. Ne négligez pas si opportun de conseiller un soutien-gorge bien adapté.

 

2. Ne confondez pas avec les « non cycliques » contemporaines des mastopathies ou les fréquentes algies costales, intercostales… extra mammaires.

 

3. Ne doutez plus: c’est le polymorphisme génétique de récepteurs hormonaux de chaque femme qui explique aujourd’hui la genèse de ce symptôme.

 

4. Ne pensez pas que la preuve d’une augmentation du risque de cancer du sein dans ce contexte soit validée : si elle existe elle est de faible amplitude.

 

5. Ne soyez pas généreux en prescriptions d’imagerie, elles ne sont en général ici pas nécessaires, sinon pour éventuellement rassurer la femme, mais cette médicalisation peut alors être aussi source d’anxiété.

 

6. N’entreprenez pas de réaliser des biopsies anxiogènes qui ne montrerait qu’œdème stromal et dilatation canalaire.

 

7. Ne soyez pas pressé(e), prenez le temps d’expliquer à la patiente avec pédagogie la genèse de ces douleurs : il s’agit là d’un temps « thérapeutique » essentiel pour effacer sa crainte du cancer et de justifier qu’on en restera là, sans prescription d’examens complémentaires.

 

8. Ne soyez pas étonné(e) d’apprendre que la progestérone ou la dydrogestérone en phase lutéale, ne sont pas parvenues à montrer une réelle efficacité et qu’elles peuvent même parfois avoir un effet aggravant sur le symptôme.

 

9. N’oubliez pas qu’en ce qui concerne les macro-progestatifs, les seules preuves validées d’efficacité le sont avec progestatifs antigonadotropes pendant 20 ou 25 jours par cycle, voire en « non-stop ».

 

10. N’ignorez pas l‘étude EPI-PHARE récente qui montre que l’acétate de nomégestrol et de chormadinone augmentent de façon significative le risque de méningiome.

 

11. Ne prescrivez pas les analogues de la LH-RH, le tamoxifène, la bromocriptine, le danazol, les AINS ou le paracétamol… qui n’ont pas l’AMM en France.

 

12. Ne « balayez pas d’un geste » les PNCAVT non reconnues au plan scientifique par la médecine conventionnelle, ni enseignées au cours de la formation initiale des professionnels de santé. Elles séduisent de plus en plus nos patientes. Elles peuvent être complémentaires, alternatives ou intégratives.

 

13. Ne méprisez pas systématiquement l’homéopathie, l’acupuncture, l’huile d’onagre, l’administration de vitamines E ou B6, dont l’action est comparable à l’effet placebo – effet qui reste bénéfique dans le contexte de mastodynies cycliques.

 

14. Ne croyez plus dans les vertus de la diminution des graisses alimentaire ou en l’abstention ou la diminution de caféine, stratégies, ayant fait la preuve de leur inutilité dans ce contexte.

L’auteur déclare ne pas avoir de liens d’intérêt vis-à-vis de cet article.

David Elia, Gynécologue Paris

 

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