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MASTALGIA, EMILIA DIEGO, MD
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Good morning everyone, my name is Mia. Thank you very much Dr. Arenth and Dr. Bonaventura for
having me, and thank you everyone for coming to attend this symposium. I’m going to talk to you
very briefly about breast pain. And here is an outline of what I hope to discuss with you in the next
20 minutes or less.
Breast past is a very common problem, in fact when I was making this talk I had breast pain. In a
survey done by Minton in the 1980s of working women in South Whales he actually came to realize
that about 60% of women will complain of some breast pain, and that 20% of them will actually
report it to be severe. Interestingly enough though only half of these women who complained of
breast pain actually went to see a physician for it. We find that in primary care physician’s offices
more than, close to half of patients who come to see a doctor for breast complaints will be related to
breast pain, and this is likely due to the fact that there is an increasing awareness of breast cancer and
there is always the fear that breast pain could be one of the symptoms.
It has been very difficult to pinpoint a single cause for breast pain, and there is – because there is
constant epithelial and stromal activity in the breast and so for patients who have undergone breast
biopsies for reasons other than beast pain we have come to find that there is no histologic difference
between patients who have breast pain and those who don’t. So we know that hormonal influences
clearly play a part in breast pain as evidenced by the fact that we more frequently see this in patients
who are premenopausal and we do frequently see this in relation to their menstrual cycles. Here is a
list of some of those hormones that have been proposed to be mechanisms for breast pain, and there
are enough studies to both prove and disprove these theories. There are – there also are other
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nonhormonal influences that have been postulated to contribute to breast pain and some of them
include that the breast is hypersensitive to increasing circulating catecholamines or that there is an
imbalance in our circulating fatty acids.
Breast pain can be classified into cyclic breast pain, noncyclic breast pain or extramammary or
referred pain. And there is some other characteristics aside from just the relationship to the
menstrual cycle that can help distinguish these three types of pain. In this table I’ve tried to classify
for you to help contrast and distinguish the three different types of breast pain.
You can see that cyclic breast pain on the left is what we are going to see more frequently, it’s
usually related to your menstrual cycles. More often than not the patient will complain that it’s
bilateral and usually in the upper outer quadrants because this is where most of our breast tissue lies.
Sometimes there will also be an axillary radiation if only because there also is breast tissue in the
axillary tail. They will complain that it’s dull, heavy or aching and more often than not you’ll see it
in younger women. The good news is that more often than not this will resolve at menopause and if
not 90% of patients will respond to treatment with cyclic breast pain.
For noncyclic breast pain about a quarter of patients will have this, it’s not usually related to the
menstrual cycle, it can be unilateral but it also may involve both breasts. It can focal or diffuse. They
will complain that it’s a feeling of tightness, soreness or burning and more frequently seen in older
women in their 40s. Fifty percent of these may resolve on their own and only sixty-five percent of
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them will respond to treatment contrasting it to cyclic breast pain which you will see more people
respond to treatment.
And lastly, extramammary pain which will also have no relation to your menstrual cycle, which will
be focal, typically ranging anywhere from dull to sharp, can happen at any age and typically resolves
when the etiology is addressed.
Here is a list of some causes of noncyclic breast pain some of which can be more easily addressed
than others. So when taking a history for breast pain it may be – it may be helpful to ask the patient
to keep a log in relation to the menstrual cycle to gain an understanding of what the temporal
relationship is to it. Use of the visual analog scale may also help to gauge for severity and allow the
patient to understand that those who have mild pain that lasts for less than 5 days and come before
their normal – before their menstrual periods is actually normal pain. The severity, the disruption of
daily activities and the disruption of the sleep-wake cycles is also consideration when taking a
history, and it’s sometimes helpful to reassess the patient during a different time in their cycle
because that also gives them a gauge that maybe their pain is not always – is not a daily occurrence
but more related to their menstrual cycles.
Here is an example of a breast pain chart, which many of you most likely already use. And here is an
example of it that has been accomplished by a patient which makes it visually easier to see as well
what the temporal relationship of breast pain is to their menstrual cycle. As you can see the chart
above shows you a patient who is experiencing a significant amount of breast pain, and on the lower
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half you can see a patient who is having breast pain that is more likely normal and related to their
menstrual periods.
Some of the things that we also ask when we do a history is an investigation into the patient’s
methylxanthine intake or caffein intake, which is related to their use of coffee, chocolates, tea and
dark colored sodas, or new medications that they may have started taking including hormones and
antidepressants as well as some cardiac drugs and some antifungal drugs as well as somantadine
which has been known to also cause breast pain. A history of their recent stress or new habits may
also be helpful and a good history should also be able to exclude other conditions such as referred
pain, an MI, pneumonia or pleuritis, a history of reflux disease or gallstones. In addition to the
history a clinical breast exam and targeted imaging will help if focal findings are to be investigated.
So if a cause is able to be determined then it should be fairly straightforward to treat. The problem is
that in most women it’s very difficult to actually determine the cause of breast pain. The good news
is a lot of them will resolve spontaneously and on top of that about 20% of patients will respond to
placebo treatment if we actually start anything.
I think the most important thing that they want to hear from us is that the reassurance that there is
nothing wrong with them particularly after a normal history and physical exam as well as appropriate
imaging have turned out to be normal because more often than not breast pain by itself is now almost
never associated with a malignancy. We will find that about eight-five percent of patients who come
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to the Breast Clinic for breast pain and are reassured are happy to receive no other treatment, and are
happy to go home and just deal with their breast pain which ultimately does go away.
So strategies to treat breast pain can be either supportive, nutritional or pharmacologic. For
supportive measures one of the first steps to take is to have a bra fitting because a good number of us
are actually wearing the wrong size bra. Underwire patients for pendulous breasts is another
suggestion as well as a sports bra for exercise. Two other supportive measures that are helpful would
be heat or cold compress in addition to gentle massage as well as relaxation techniques have been
shown to improve breast pain and I’m sure many patients will be happy to hear that they just need
some time to themselves and they will be happy to oblige the whole theory that taking some time off
may actually help their breast pain.
Dietary strategies may also be helpful so in addition it’s the least expensive, it has the least side
effects but it is also the hardest to institute. Again the theory behind it is that I had previously
mentioned that an increase in methylxanthines in your diet may increase the risk of breast pain, so
looking into the possibility of cutting down on coffee or tea, chocolates or dark colored drinks,
respiratory medications if there are any may improve their breast symptoms. Minton in the 1980s
had such suggested in a nonrandomized trial that about sixty percent of women who had cut down on
these substances had actually seen an improvement in their breast pain; however, there are also
randomized trials to prove that there is no difference in their breast pain. That being said, I think that
if your patient is willing to try it I don’t think it hurts to try it, again there is a placebo effect as well
that comes along with it and so a lot of people may actually experience some relief from their breast
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pain. That being said, it’s very difficult even personally I would think if I had to cut down on all of
these things. And you have to understand that cutting down you don’t get the relief from the breast
pain after abstinence for about a week, we are talking about abstinence for anywhere from three to
six months before they may actually feel a substantial relief in pain.
Other things that have been proposed is a low fat diet. Again we see a very low incidence of breast
pain in Eskimos because their dietary fat intake is less than fifteen percent of their total calories,
which I think is again something very difficult to achieve but if it can be done then there is a
significant decrease in their breast pain. This is very difficult not only to achieve but to comply and
monitor as well.
Lastly in terms of nutritional measures the very popular evening primrose oil and gammalinolenic
acid has been prescribed very – for a very long time now for breast pain because of the theory that
there are abnormal blood levels of essential fatty acids in women with breast pain and that this
actually controls prolactin to a certain degree. We’ve seen a response in both cyclic and noncyclic
breast pains and the dose is usually about 3000 mg a day in divided doses. There is a metaanalysis
that recently came out that demonstrates that there is no effective value to the administration of
evening primrose oil and therefore the UK has actually withdrawn it as a medication for breast pain
because of its lack of clinical efficacy. And what I just recently learned as I was doing this talk as
well there should be a caution because evening primrose oil may decrease the seizure threshold,
which I just learned.
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In terms of nonendocrine therapy analgesics in the form of acetaminophen or NSAIDs has been
effective and there is a topical NSAID that can actually be used for both cyclic and noncyclic breast
pain with some relief. And lastly if it is at all possible to abstain from those medications that may be
causing the breast pain if at all medically possible then that is another strategy that can be tried.
When we talk about endocrine therapy the only FDA approved drug for breast pain is Danazol. It’s
an attenuated androgen whose mechanism of action in breast pain is largely unknown. The dose is
usually started at 200 mg a day but you can go up to 400 mg a day if necessary. But if there is no
response seen then the medication should be changed and patients should not be on Danazol for
more than 6 months. And when you are ultimately going to take the patient off Danazol a taper is
recommended where you start from 200 a day to maybe 100 a day, to 100 every other day then taper
it off to maybe 100 a week and ultimately get off it.
Patients have to be warned that there are side effects that come along with Danazol some of which
are amenorrhea and weight gain, which a lot of women of course would not like to go through. And
muscle cramps, hot flashes, acne or oily hair have also been reported. This drug is contraindicated in
patients with thromboembolic disease.
Lastly for patients who have refractory mastalgia Tamoxifen has been shown to be effective in a
metaanalysis at a dose of about 10 mg per day, and most literature out there will actually suggest that
this should probably be first line treatment for breast pain at this point but because of the side effects
a lot of women are still hesitant to take it including the dreaded you know endometrial cancer and
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DVT which is what most women are particularly concerned about when initiating the theory of
medication for something that really has a very difficult cause to treat.
So lastly, in some patients with refractory breast pain a small group of patients have actually been
shown to have other psychiatric problems such as anxiety or depression that may be a cause of their
breast pain and they may benefit from a psychiatric referral.
So this is just a small algorithm which projects clearly of what we just discussed in the last few
minutes. And so lastly I will do a shameless plug for one of my partners who if you are tired of
taking care of your breast pain patients would be happy to see her in our clinic at Magee. Thank you.