BENIGN BREAST DISEASES

BREAST PAIN

Breast pain (mastalgia) is the most common breast related complaint among women; nearly 70% of women experience breast pain at some point in their lives.  The degree of breast pain varies for each woman. For many, the pain is barely noticeable. For others, the pain is so great that it affects their day to day activities and has an impact on the quality of life. The pain might be felt in both the breasts, or in one breast. It can be present in the entire breast or in parts of the breast and can also affect the armpit area. 

What sort of pain is considered to be abnormal (not normal)?

It is very common for women to experience fullness, tenderness and mild discomfort in their breasts in the week prior to menstruation. An increase in the severity of the discomfort that the women normally experiences, in the week prior to menstruation. An increase in the length of time the women experiences pain within the menstrual cycle.  Some women may develop a new type of pain or discomfort they have not experienced previously which may be cyclical or non cyclical. 

Types of breast pain
Pain can be classified into two groups by assessing the relationship to the menstrual cycle. Three-quarters of women have cyclical breast pain that is worse immediately prior to menstruation and the remaining quarter of women have non-cyclical breast pain with no relationship to menstruation.

Non-cyclical breast pain
Non-cyclical breast pain can be classified into:

• True breast pain
• Pain from the underlying chest wall (costochondritis Tietz syndrome)
• Referred pain (should be appropriately investigated and treated)

Causes for breast pain

Majority of times the exact cause of breast pain is not known. This doesn’t mean that the pain is not real. 

Causes for cyclical breast pain

Cyclical breast pain appears to have a strong hormonal association.

Common causes for non cyclical breast pain

• Wearing a bra that doesn’t fit
• Consuming a lot of caffeine
• Stress
• Injury to the breast (this might include scarring from surgery)
• Weight gain (breasts get heavier)
• Presence of breast cysts or fibro adenomas (benign lumps)
• Exercises that puts strain on the chest, shoulder or pectoral muscles
• Conditions affecting the chest wall, ribs or muscles that lie underneath the breasts
• Pregnancy
• Infection of the breast (mastitis)
• Some forms of hormone replacement therapy may cause discomfort. 
• There is no specific association between the Pill and breast pain.
• Arthritis pain in the neck area

Pain and breast cancer
For many women the biggest worry about breast pain is that it may indicate an underlying breast cancer.  Breast pain is not often associated with cancer. In a study by the Edinburgh Breast Unit, 2.7% of patients presenting with breast pain had breast cancer and 4.6% of women with breast cancer had pain as their major presenting symptom. 

There are certain symptoms that are very unlikely to be cancer. 

• Young women with tender, lumpy breasts.
• Older women with breasts that are symmetrically lumpy on both sides    
• Minor or moderate breast pain with no lump

Breast pain with no lump is highly unlikely to be breast cancer.  It is very common for young women in their 20s, 30s and 40s to have tender, lumpy breasts before a period.  If breasts are symmetrically lumpy on both sides and the lumps increase & decrease with periods, it is unlikely to be a cancer. 

When to seek medical advice?

Seek medical advice when the pain is abnormal as described above.   

When would your doctor consider treatment for breast pain?

Treatment would be considered if you have significant pain that interferes with everyday activities.  It is important to define the pattern of pain and to have a record of the frequency of pain prior to considering drug treatment.   

Aspects of management common to both cyclical and non cyclical breast pain. 

It is important to know that breast pain is the most common breast related complaint among women; nearly 70% of women experience breast pain at some point in their lives and breast cancer is an uncommon cause of breast pain.

Tips to reduce breast pain (takes few weeks to work)

• Wearing a supportive well-fitting bra (not only during the day but also at night).
• Reducing caffeine intake
• Taking regular exercise

For moderate-to-severe breast pain the first line treatment recommendations may include the use of mild analgesic agents such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin. 

Who should be referred to breast specialists?

·        Breast pain (with no lump) that does not go away with reassurance or wearing a supportive and well fitting bra.

·        Essentially, breast pain that is persistent or refractory to first-line treatments or painkillers. 

·        Exceedingly anxious patients who are unlikely to be reassured by their General Practitioners.

·        Unilateral persistent pain in post-menopausal women. 

Management at the breast center

At the specialist clinic history is taken and then a physical examination is made.   Ultrasound of one or both breasts may be performed.  Mammogram (X ray of the breast) is performed if deemed necessary. 

Following advice and reassurance, 85 % or more will require no specific therapy for their pain, whereas the remaining 15 % will require treatment.  

For moderate-to-severe breast pain the first line treatment recommendations may include the use of mild analgesic agents such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or aspirin. 

Second line agents used in treatment of breast pain such as Tamoxifen, Danazol and Gonodotrophic releasing hormone agonists have significantly greater side effects.  Tamoxifen, at a dose of 10 mg daily for three to six months can be used. Side effects include hot flushes, vaginal dryness and vaginal discharge.

Among patients in whom there is no response to treatment with tamoxifen, a change to danazol, at a dose of 200 mg daily is recommended. Gonadotropin-releasing hormone agonists have been used successfully for severe pain.  

Non-cyclical true breast pain

Pain emanating from underlying chest wall pain responds to treatment with oral or topical NSAIDs. For costochondritis (inflammation of the costochondral junction) temporary or permanent relief is attained by the use of a combination of anesthetic and steroidal drugs injected into the tender site.

For more information contact: sasi@mybreastcare.org

This information sheet is aimed at women who have been examined by a breast specialist and found to have a breast pain (non cancerous) condition. It is not a substitute for the advice of a qualified doctor. It is intended to provide information for better understanding and reassurance.