BREAST PAIN

Primarius Milos Pocekovac MD, PhD

Ass. prof. Dejan Markovic MD, PhD

Breast pain is often the reason for visiting surgeon.  More than a half of the population has mild symptoms of chest pain, but luckily, only in a small percentage of patients with breast pain is the treatment necessary.

MASTALGIA OR MASTODYNIA

The role of the diagnostician is to determine if this pain is pathological or physiological, and depending on hormone levels, does it require serious treatment. Even though breast pain is rarely connected to malignancies, it represents a significant concern for the patient. Breast pain passes spontaneously in 9 out of 10 patients; even a strong breast pain is resolved in more than half of the patients.

There are two types of breast pain. One is related to the menstrual cycle and we call it cyclical pain, and the other is a noncyclical pain. It is estimated that 2/3 of patients have cyclical pain.

Cyclical pain

Cyclical pain is usually an extreme case of normal breast tension, present in the late luteal phase of the menstrual cycle. Precise etiology of the breast pain remains unknown. Mastalgia is often labeled as a component of “fibrocystic illness”. For some authors, fibrocystic changes in breasts are a normal occurrence because nearly every woman has them, therefore, they are wrongly interpreted as an illness. It is also suggested that there are histological changes appearing in breasts that are causing the pain. However, finds like fibrosis, adenosis, and lymphoid infiltration are not in correlation with the clinical finding and neither are histological differences noticed between symptomatic and asymptomatic women.

Immunohistochemical examination after biopsies didn’t show differences in expression of interleukin-6, interleukin-1, and tumor necrosis factor. Ultrasound showed significant differences in women with mastalgia related to dilatation of the canal, which is especially large in women with noncyclical pain compared to women with cyclical pain. Dilated canals are found in all quadrants, but mostly in the retro-areolar area, and dilatation didn’t change during the menstrual cycle. Significant relation has been determined between the degree of ductile dilatation and severity of pain.

Cyclical pain usually appears for the first time in the third decade of life. Many patients describe it as boring, burning or sharp pain. In most cases, it starts in the upper outer quadrant. It is often found in one breast, sometimes with propagation into the armpit or the arm, but also in both breasts. The cause may be related to glands or pressure on intercostal and brachial nerves. It is most often found 5 days before the menstrual cycle, although some women have constant pain which intensifies in the premenstrual period. Because of that, the palpatory examination has to be superficial and gentle because palpation can be unpleasant and can make detailed examination impossible. The objective of the examination is to exclude palpable changes, changes on the skin or the nipple. Considering that this is mostly related to younger women, ultrasound is useful if there are changes located on the painful spot. However, with women younger than 35 years, with palpatory findings, positive family anamnesis and older women as well, it is necessary to perform mammography.

Prolactin is one of the main causes of the appearance of mastalgia because it is involved in the growth and secretion of milk glands. Levels of prolactin and its effects influence the ratio of levels of estrogen and progesterone, so the complex interaction of these hormones can be the cause of mastalgia. Egsogenic factors which are related to the mastalgia may influence the level of prolactin. However, some studies have shown that by measuring estradiol, progesterone, and prolactin in the blood, no larger abnormalities were found.

Influence of hormones on mastalgia

  • Increase of estrogen
  • Lack of progesterone
  • Changes in the ratio of progesterone / estrogen
  • Abnormalities in sensitivity of receptors
  • Abnormalities in levels of stimulating hormones / luteinizing hormones
  • Low levels of androgens
  • High level of prolactin

The relation between breast pain and caffeine has been known for a long time, and it is believed to be related to cyclical adenosine monophosphate (cAMP). Increased cAMP leads to the increase of cellular proliferation in breasts, and in that way leads to pain. Caffeine does not directly influence cAMP, but it increases the level of catecholamine, which increases cAMP. Patients with mastalgia may have increased sensitivity to catecholamines, with higher levels of beta-adrenergic receptors.

    Catecholamines   cAMP Cellular proliferation  BREAST PAIN

Besides caffeine, other metilcsantines like tea, Coca-Cola and chocolate may lead to breast pain.

Level of catecholamine may also be increased due to nicotine, tyramine, and stress, physical and emotional strain.

There may also be a connection between increased body weight and breast pain. It was believed that increase in body weight leads to increased levels of estrogen which leads to breast pain. However, it can refer to disbalance of saturated fatty acids compared to unsaturated fatty acids.

Many women with breast pain have lower level of essential fatty acids like Gama linoleic acid. This appears as a result of inhibition of conversion of linoic acid into Gama linoleic acid by an increased level of saturated fats. This deficit of essential fatty acids is the most important because it can affect the receptors in the cell membranes which leads to increased breast sensitivity. Decreased intake of saturated fatty acids and Gama linoleic acid supplements can have a therapeutical effect on the pain.

With women with noncyclical pain, location of pain may help determine the cause. Forty percent of women have problems with the muscles of the chest area. Pain in the inner quadrants is often related to the chest or greater strain of chest muscles. The second source of pain in the area of thoracic wall may be osteochondritis (Tietze-s syndrome) or arthritis when discomfort or pain is localized behind the sternum or caused by direct pressure on thoracic wall. Most of these patients can be treated orally or by local nonsteroid anti-inflammatory medicine.

Noncyclical pain which is found in lower outer quadrant of the breast may be of vertebral, spinal or para-spinal nature. Radiculopathy may lead to pain in both breasts. Respiratory infection may cause intercostal neuralgia. If the pain is in the right breast, it may be related to diseases of the gall bladder, and if it is in the left it may be related to cardiological problems.

Several studies have confirmed that patients with intense mastalgia have psychological problems. In the presence of relaxing music, the result was a great decrease in breast pain.

Mondor’s disease or superficial trombo phlebitis of veins and their tributaries may be the cause of breast pain. It is caused by trauma, surgical intervention, and mastitis or breast tumor.

Possible causes of noncyclical pain

BREAST


  • Cysts
  • Focal or peri ductal mastitis
  • Mondor’s disease (sclerositing peri phlebitis)
  •  Inadequate underwear
  • Trauma
  • Suppurative hydro adenitis

THORACIL WALL


  • Costochondritis
  • Diffuse or localised lateral pain in the thoracic wall
  • Radicular pain spreading from the arthritis

 OTHER CAUSES


  • Lung disease
  • Hiatal hernia
  • Gall bladder disease
  • Ischemic heart disease

Aspirational biopsy with a thin needle with at the focal source of pain, in theory, may be used, but it is rarely useful and is probably sometimes performed to calm the patient

Laboratory tests are rarely of any use.

TREATMENT

It is important to determine the source of pain. Cyclical mastalgia may spontaneously disappear within 3 months with one-quarter of the patients, and noncyclical mastalgia will spontaneously disappear in half of the cases.

Nonhormonal therapy

Application of warm or cold dressing may be helpful in resolving breast pain.

Special brassieres for stiffening and lifting of the breasts as well as the use of sports bras during exercise or physical activity may reduce pain.

Analgesics, paracetamol, and nonsteroid anti-inflammatory medicine can help. They are applied either orally or locally.

Changes in diet can be helpful. Avoiding caffeine is one of the first recommendations for patients. It is also necessary to avoid all other products that contain metilcsantines – tea, coca-cola, chocolate… Besides metilcsantines, it is also necessary to avoid products that contain TIRAMINE- cheese, wine, beer, spices, nuts, mushrooms, bananas. The decrease in the intake of fats in the diet may reduce breast pain. However, sometimes it is necessary up to 6 months to see the result.

The most common recommendation for treatment of cyclical mastalgias is the oil of yellow night flower as one of the richest sources of esential fatty acids. It contains 72% linoleic acid and 7% Gamma linoleic acid. In some studies, the rate of positive response is between 45-97%. However, other studies have not shown the benefits of oil of yellow night flower as well as fish oil.

It is recommended to combine the oil with a diet with low-fat content for at least 6 months. The usual dose is 1500 – 3000mg a day in divided doses. A capsule of night flower contains 500mg and the recommendation is to take 2×2 capsules a day.

Change in lifestyle and diet

Lifestyle


  • Stop smoking
  • Appropriate braziers and sports bras during exercise
  • Normal bodyweight and moderate physical activity
  • Stress control
  • analgetics – locally and orally (paracetamol, nonsteroid anti-inflammatory medicine)

Diet


  • Avoid metilcsantin (coffee, tea, chocolate, Coca-Cola)
  • Decreased intake of fats in the diet
  • Avoid food that contains tyramine (cheese, wine, beer, spices, nuts, mushrooms, bananas)
  • Taking medication containing gamma linoleic acid (evening primrose oil)

Hormone therapy

If cyclical mastalgia persists despite above-mentioned therapy, even though it happens rarely, it is necessary to administer hormone therapy. The first step is to identify possible egsogenic cause. For women before menopause, it is recommended to temporarily stop taking oral contraceptive pills. For women in postmenopause, it is recommended to lower the dose of estrogen or to switch to antiestrogens. Reloksifen (Evista) is a modified selective estrogen receptor. Progesterone should be given during the luteal phase of the menstrual cycle.

Danazol is an attenuated androgen which is efficient in relieving the breast pain in more than 90% of cases. It works on lowering ovarian function by performing the suppression of the release of gonadotropins from hypophyisis. Danazol is used in doses of 200 to 400mg daily or only during the lutel phase of the menstrual cycle in premenopausal women. The effect is usually felt between a few days and a month. However, the use of danazol may lead to an array of unwanted side-effects such as headache, nausea, depression, muscle pain, irregular menstrual cycle.

Bromocriptine is a suppressor of prolactin and it is used for the treatment of mastalgia with a dose of 7.5mg a day for a time period of three months. It may mitigate mastalgia, but, like danazol, it has many unwanted side effects (nausea, vomiting, and lightheadedness) and today it is used to stop lactation.

Tamoxifen was used for the treatment of moderate or strong breast pain but because of the side effects, today it is used as additional therapy in the treatment of breast cancer.

Progesterone cream on the outside and orally progestin may mitigate mastalgia.

Surgical treatment of mastalgia

In the past, mastectomy was used for the treatment of very strong breast pain or quadrantectomy in women with focal symptoms. Surgical therapy of mastalgia didn’t give positive answers compared to other forms of therapy and today it is unwanted and no longer used. It is noteworthy that with most women, breast pain remains even after the surgical therapy.

PLEASE HAVE THINGS YOU ARE IN THE VID!

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders.

If you feel you have any of these symptoms, please contact your doctor. DO NOT use these therapies yourself without prior consultation with a doctor!

REFERENCES

1. Jay R. Harris, Marc E. Lippman, Monica Morrow, C. Kent Osborne. — Diseases of the breast Fifth edition 2014

2. Wang DY, Fentiman IS. Epidemiology and endocrinology of benign breast disease. Breast Cancer Res Treat 1985;6:5. 5

3. Preece PE, Mansel RE, Hughes LE. Mastalgia: psychoneurosis or organic disease? BMJ 1978;1:29

4. Fox H, Walker LG, Heys SD, et al. Are patients with mastalgia anxious, and does relaxation help? Breast 1997;6:138

5. Budeiri D, Li Wan Po A, Dornan JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clinic Trial 1996; 17:60

6. Blommers J, DeLange-deKlerk ESM, Kulk DJ, et al. Evening primrose oil and fish oil for severe chronic mastalgia: a randomized double-blind controlled trial. Am J Obstet Gynecol 2002;187:1389–1394.

7. Huges, Mansel & Webster Benign disorders and diseas of the breast third edition, 2009, 107-138