|MY BREAST CARE|
Ask the specialist:
BENIGN BREAST DISEASES
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
Situations that the GP can manage (Referral guidelines)
There are certain symptoms that are very unlikely to be 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 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
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 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 aspirin2, 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 used6, 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 pain9, 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.
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
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