BENIGN BREAST DISEASES

BREAST PAIN

FOR GENERAL PRACTITIONERS

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.  In a study quoted in the NHS guidelines, nearly two thirds of GP referrals that turned out not to be cancer were for breast pain with no lump.  It is very common for women to experience fullness, tenderness and mild discomfort in their breasts in the week prior to menstruation. 

The most frequent reasons for a woman to consult her GP with breast pain include:

An increase in the severity of the discomfort she normally experiences, in the week prior to menstruation and an increase in the length of time she experiences pain within the menstrual cycle.  Some women develop a new type of pain or discomfort they have not experienced previously which may be cyclical or non cyclical. 

Type 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 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 emanating from the underlying chest wall (costochondritis Tietz syndrome)
• Referred pain (should be appropriately investigated and treated)

 Situations that the GP can manage (Referral guidelines)

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 

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 and decrease with their periods, it is unlikely to be a cancer.  Breast pain with no lump is highly unlikely to be breast cancer. 

Which patients with breast pain should be referred to hospital?

·        Breast pain (with no lump) that does not go away with reassurance or wearing a well supporting 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 GP

·        Unilateral persistent pain in post-menopausal women

Which patients with breast pain can be treated by the GP?

Treatment should be considered in patients with 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. 

Pain and breast cancer
Many women present to hospital because they are worried that breast pain may indicate breast cancer.

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 (Edinburgh Breast Unit)

Management
Aspects of management common to both cyclical and non cyclical breast pain:

• Educating the patient about the frequency of breast pain in the general population
• Giving advice about wearing a well-fitted bra (not only during the day but also at night).
• Reassuring the patient that breast cancer is a very uncommon cause of breast pain.
• Reducing caffeine intake
• Taking regular exercise

Management at the breast center

Following this advice and reassurance, 85 % or more of patients will require no specific therapy for their pain, whereas the remaining 15 % will require treatment¹.  

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^{2, 3, 4, 5}.

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^{6, 7}. 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 recommended⁸. Gonadotropin-releasing hormone agonists have been used successfully for severe pain^{9, 10}.

Non-cyclical true breast pain

The approach discussed for cyclic pain is used. 

Tenderness in the chest wall can be demonstrated by getting the patient to lie in the lateral position and moving the breast away from the chest wall. The tenderness should be directly under the breast on the chest wall rather than in the breast itself.  Pain emanating from underlying chest wall pain responds to treatment with oral or topical NSAIDs¹¹. 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 site¹¹.

References

1. Hughes LE, Mansel RE, Webster DJT. Benign breast disorders and diseases of the breast. 2nd ed. London: W.B. Saunders, 1999. 

2. BeLieu RM. Mastodynia. Obstet Gynecol Clin North Am 1994;21:461-77.

3. Zylstra S. Office management of benign breast disease. Clin Obstet Gynecol 1999; 42:234-48.

4. Steinbrunn BS, Zera RT, Rodriguez JL. Mastalgia: tailoring treatment to type of breast pain. Postgrad Med 1997;102:183-4.

5. Wetzig NR. Mastalgia: a 3 year Australian study. Aust N Z J Surg 1994;64:329-31.

6. Fentiman IS, Caleffi M, Brame K, Chaudary MA, Hayward JL. Double-blind controlled trial of tamoxifen therapy for mastalgia. Lancet 1986;1:287-8.

7. Messinis IE, Lolis D. Treatment of premenstrual mastalgia with tamoxifen. Acta Obstet Gynecol Scand 1988;67:307-9

8. O’Brien PM, Abukhalil IE. Randomized controlled trial of the management of premenstrual syndrome and premenstrual mastalgia using luteal phase-only danazol. Am J Obstet Gynecol 1999;180:18-23.

9. Hamed H, Caleffi M, Chaudary MA, Fentiman IS. LHRH analogue for treatment of recurrent and refractory mastalgia. Ann R Coll Surg Engl 1990;72:221-4.

10. Mansel RE, Goyal A, Preece P, et al. European randomized, multicenter study of goserelin (Zoladex) in the management of mastalgia. Am J Obstet Gynecol 2004;191: 1942-9

11. Kollias J, Sibbering DM, Blamey RW. Topical non-steroidal anti-inflammatory gel for diffuse chest wall pain in mastalgia patients. In: Mansel RE, ed. Recent developments in the study of benign breast disease. London: Parthenon Publishing, 1997:119-24