MASTALGIA (BREAST PAIN)

Breast Pain Aetiology:
Mastalgia (or breast pain) with or without lumpiness remains the most frequent reason for breast consultation in general practice. Approximately 70% of all women experience breast pain to a greater or lesser degree during their reproductive lifetime. Therefore, the symptom complexes should not be regarded as a disease but rather as an aberration - most usually of normal cyclical changes.

Classification:
1. Cyclical mastalgia
This pain occurs in a predictable fashion with the menstrual cycle often premenstrually and gets better after the periods
2. Non-cyclical mastalgia
This is a constant or intermittent pain with irregular exacerbation and no relation to menstruation.
3. Non breast mastalgia
This pain arises from the underlying chest wall and specific are of tenderness can be elicited from the rib cage.

While cyclical and non-cyclical mastalgia have their origin from breast non-breast mastalgia arises from underlying chest wall.

Aetiology:
The aetiology is poorly understood though many theories have been put forward.
1.Hormonal
Because the breast pain is common in premenopausal women and its resolution with menopause unless the patient is on HRT female hormones are often blamed. Rather than the abnormal hormonal levels, an increased sensitivity of breast to normal hormonal levels might account for breast pain.
Increased prolactin levels have also been found to be responsible in some of the studies.
2. Essential Fatty acids
There is some evidence to suggest that a deficiency in unsaturated fatty acids and increase in saturated fatty acids may play an important role suggested by response to this medication by a proportion of patients.
3. Lifestyle and environmental factors
Role of dietary factors such as caffeine and fats cannot be discounted though there is no large scale studies to prove this. Reduction of fat intake (to <15% of total calories for 6 months) has been associated with improvement in pain.
Sedentary lifestyle has been reported in upto 80% with mastalgia. For these women increasing exercise levels may improve chronic pain via release of endorphins.
State of acute stress can increase the prolactin level and may form a physiological basis for pain in these situations.

Risk of subclinical cancer:
There is no evidence at present to say that mastalgia is an increased risk for cancer. Breast cancer presenting with pain as a sole symptom is about 0.2% to 2% only. Cancer has to be considered seriously as a diagnosis only if a patient present with localised, unilateral constant pain the exception being inflammatory cancer where the pain can be generalised but will be associated with other typical signs of inflammatory cancer.

Management:

Click here to see Management Protocol

It consists of Good history and clinical examination, advocating pain charts to characterise the pain, information about breast pain, advise about change in life style measures, medical treatment and a lot of reassurance.

History and clinical examination:
It is to determine if it is cyclical or noncyclical pain or pain originating from chest wall. A full history and examination are also required to exclude non-breast problems (for example, angina, pleurisy or hiatus hernia).

Using pain charts will accurately determine the character of pain and also many patients find the remission of pain over period of months.

It is also necessary to quantify the pain as how much it affects the normal life style. In some patients it can interfere with sexual activity, physical activity, social activity and work/social activity. This is also an occasion to rule out any lumps which would otherwise require further investigations. The chest wall tenderness can be elicited by pressing on rib cage on specific points. A pregnancy test should be completed whenever necessary.

Further investigations and referral may be warranted if
1. There is a palpable abnormality.
2. Patients above 35 years with a new symptom of pain.

Surprisingly majority of patients will not require any further treatment apart from reassurance, which proves that they seek medical help to dispel the fear of cancer.

Life style modifications:
Patients, who do exercise vigorously, a well fitting supporting bra can provide substantial relief because active breast movement of weak suspensory ligament may contribute considerably to mastalgia. Patients who lead a sedentary life style should be encouraged to do exercise as they may get relief from release of endorphins.
Avoiding methylxanthines (coffee, tea, chocolate, cola beverages) and reductions in dietary fat intake can be of some additional help.

Evening Primrose Oil:
It can be rightly perceived as not a medication as it is a natural product. It is rich in Gamma-linolenic acid (GLA) a precursor of prostaglandin E1. It is more effective in cyclical mastalgia and has slow response requiring long courses (more than 4 months). It is ideal for young patients who may need long term treatment as well as those desire pregnancy, who choose to continue using oral contraceptives or wish to avoid hormonal treatment. It has few side effects and no contraindications. 40-50% show improvement and another 20% say stabilisation of symptoms.

Evening primrose - Oenothera erythrosepala

Endocrine Therapy:
Danazol:
It is a synthetic derivative of testosterone recommended in low dose if other measures fail. Upto 60-80% of patients respond to danazol. However the side effects can be severe though they are dose related. Also the relapse rate is quite high (nearly 70%). Danazol is contraindicated in women with thromboembolic disease, can interfere with oral contraceptives and may need mechanical contraception. They are also teratogenic. In general they are no the first line of treatment because of cost and side effects.
Tamoxifen:
It can provide relief in 60-70% of patients. Long-term treatment are associated with adenocarcinaoma of the endometrium but no risk has been demonstrated with short term (<6months) treatment. Relapse rate is upto30% and it is prescribed under a close supervision for a limited period of time for patients with severe symptoms in whom all standard treatment have failed.
Bromocriptine:
It is an ergot alkaloid that blocks the secretion of prolactin and the response rate vary from 50-65%. Gradually increasing dose is advised as many patients have side effects. It is contraindicated in patients on diuretics and hypotensives. They are indicated when danazol is contraindicated or discontinued because of side effects.
Others:
LHRH analogues like Goserelin are said to provide 80% relief. However they have both short term and long-term side effects for regular use.
Gestrinone is an androgen derivative. The profile of side effects is similar to danazol. It has also weak oral contraceptive action. They are not yet widely available.
Non Hormonal options:
Injection of 1% lignocaine and methyl prednisolone can be used for trigger points in chest wall mastalgia. Upto 50% may require a second injection 2 to 3 months later. Since stress can aggravate breast discomfort a trial of antidepressants might be useful.
Natural history of Breast pain:
Both cyclical and non cyclical pain run a chronic relapsing course. However the severity of the pain tends to decrease over time. Patients should be informed that mastalgia is resistant to any treatment in 20% of the patients and can recur after the medications are stopped. With the majority of patients, once malignancy has been excluded, reassurance remains the mainstay of treatment.

If you require further advice or information please contact the
Macmillan Breast Care Nurses, Hazel Ricard and Hilary Rickwood on 020 8565 5885