- Еуромедик, Булевар уметности 29, Београд
Breast pain
Доц др Дејан Марковић
Прим др Милош Почековац
Breast pain is a frequent reason for visits to general practitioners, internists, gynecologists, and surgeons. It is common in women, but occasionally occurs in men. More than half of the population has mild symptoms of breast pain, but fortunately, only a small percentage of breast pain patients require therapy.
Mastalgia or mastodynia
The role of the diagnostician is to determine whether this pain is pathological or physiological, depending on the level of hormones, whether it requires serious therapy. Although breast pain is rarely associated with malignancy, it is a significant concern for the patient. Breast pain resolves spontaneously in 9 out of 10 patients, and even severe breast pain resolves in more than half of 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 non-cyclical pain. It is estimated that 2/3 of patients have cyclical pain.
Cyclic pain
Cyclic pain is usually an extreme form of normal breast tenderness, present in the late luteal phase of the menstrual cycle. The exact etiology of breast pain remains unknown. Mastalgia is often referred to as a component of “fibrocystic disease”. For some authors, fibrocystic changes in the breasts are a normal phenomenon because almost every woman has them, so they are mistakenly interpreted as a disease state. It has also been suggested that there are histological changes that occur in the breast that cause pain. However, findings such as fibrosis, adenosis, lymphoid infiltration are not correlated with the clinical picture, nor are histological differences observed in symptomatic and asymptomatic women.
Immunohistochemical examination after biopsies did not show differences in the expression of interleukin-6, interleukin-1 and tumor necrosis factor. Ultrasonography showed significant differences in women with mastalgia in the form of dilatation of the canal, and it was greater in women with non-cyclical pain compared to women with cyclical pain. Dilated ducts were found in all quadrants, but mostly in the retroareolar area, and the dilatation did not change during the menstrual cycle. A significant correlation was established between the degree of ductal dilatation and the severity of pain(1).
Cyclic pain usually first appears in the third decade of life. Many patients describe it as a dull, burning or sharp pain. In most cases it starts in the upper outer quadrant. It usually occurs in one breast, sometimes spreading to the armpit or arm, but also to both breasts. The cause may be related to the glands or pressure on the intercostobrachial nerves. It most often occurs on the 5th day before the menstrual cycle, although some women have constant pain that intensifies in the premenstrual period. Therefore, the palpation examination must be superficial, gentle, because palpation can be unpleasant and make a detailed examination impossible. The aim of the examination is to exclude a palpable change, changes in the skin or nipple. Considering that it is mainly about younger women, ultrasound is useful if there is a change in the location of the pain. However, in women under 35 years of age, with a palpable finding, a positive family history, as well as in older women, a mammogram should be performed.
Prolactin is one of the main culprits in the occurrence of mastalgia because it is involved in the growth and secretion of the mammary glands. The level of prolactin and its effects affect the ratio of estrogen and progesterone levels, so a more complex interaction of these hormones can be the cause of mastalgia. Exogenous factors associated with mastalgia may affect prolactin levels. However, some studies have shown that no major abnormalities were found by measuring estradiol, progesterone and prolactin in the blood(2).
The influence of hormones on mastalgia
- Increase in estrogen
- Lack of progesterone
- Changes in the ratio of progesterone / estrogen
- Abnormalities in receptor sensitivity
- Abnormalities in the level of stimulating hormone / luteinizing hormone
- Low androgen levels
- High prolactin levels
The association between caffeine and breast pain has long been known and is believed to be due to cyclic adenosine monophosphate (cAMP). Increased cAMP leads to increased cell proliferation in the breast, thus leading to pain. Caffeine does not directly affect cAMP, but it increases the level of catecholamines, which increases cAMP. Patients with mastalgia may have increased sensitivity to catecholamines, with higher levels of beta-adrenergic receptors.
Catecholamines 
cAMP cell proliferation BREAST PAIN
Apart from caffeine, other methylxanthines can cause breast pain, such as tea, Coca-Cola, chocolate.
The level of catecholamines can also be increased due to nicotine, tyramine, stress, physical and emotional strain.
There may also be links between fat and breast pain. At first it was thought that weight gain leads to increased estrogen levels and thus causes breast pain. However, it may refer to an imbalance of saturated fatty acids in relation to unsaturated fatty acids.
Many women with breast pain have lower levels of the essential fatty acid gamma-linolenic acid. This occurs as a result of inhibition of the conversion of linoleic acid to gamma linoleic acid by increased levels of saturated fat. This lack of essential fatty acids is essential because it can affect cell membrane receptors, leading to increased breast sensitivity. Reduced intake of saturated fatty acids and gamma-linolenic acid supplements may have a therapeutic effect on pain.
In women with non-cyclical pain, the location of the pain can help establish a pattern. Forty percent of women have problems with their chest muscles. Pain in the inner quadrants is often related to the chest or a greater strain on the chest muscles. Another source of chest wall pain can be costochondritis (Tietze’s syndrome) or arthritis when the discomfort or pain is localized peristernal or caused by direct pressure on the chest wall. Most of these patients can be treated with oral or topical nonsteroidal anti-inflammatory drugs.
Non-cyclical pain located in the lower outer quadrant of the breast can be caused by a vertebral, spinal or paraspinal nature. Radiculopathy can cause pain in both breasts. A respiratory infection can cause intercostal neuralgia. If the pain is in the right breast, it may be related to gall bladder diseases, and if it is in the left breast, it may be related to cardiac problems.
Several studies have confirmed that patients with severe mastalgia have psychological problems(3). Relaxation music was used, and the result was a significant reduction in breast pain(4).
Mondor’s disease or superficial thrombophlebitis of the lateral thoracic vein or its tributaries may be the cause of breast pain. It is caused by trauma, surgical interventions, mastitis or breast tumors.
Possible causes of non-cyclical pain
Breast
- cyst
- focal or periductal mastitis
- Mondor’s disease (sclerosing periphlebitis)
- inadequate bra
- trauma
- hidradenitis suppurativa
Chest wall
- costochondritis
- diffuse or localized lateral chest wall pain
- radicular pain from neck arthritis
Other causes
- Lung disease
- Hiatal hernia
- Gallbladder diseases
- Ischemic heart disease
Fine-needle aspiration biopsy with a focal source of pain can theoretically be used, but is rarely useful and is probably sometimes done to calm the patient.
Laboratory tests are rarely useful.
TREATMENT
It is important to establish the cause of the pain. Cyclic mastalgia can disappear spontaneously within 3 months in one quarter of patients, and non-cyclic mastalgia will disappear spontaneously in half of the cases.
Non-hormonal therapy
Applying hot or cold compresses can be helpful in managing breast pain.
Special bras for firming and lifting the breasts as well as the use of sports bras during exercise or physical activity can relieve pain.
Analgesics, paracetamol, and non-steroidal anti-inflammatory drugs can help. They are applied orally or locally.
Dietary changes can help. Avoiding caffeine is one of the first recommendations for female patients. It is necessary to avoid all other products containing methylxanthines, tea, Coca-Cola, chocolates… In addition to methylxanthines, it is also necessary to avoid products containing tyramines – cheese, wine, beer, spices, nuts, mushrooms, bananas. Reducing the amount of fat in your diet can relieve breast pain. However, it sometimes takes up to 6 months to achieve results.
The most common recommendation for the treatment of cyclic mastalgia is evening primrose oil as one of the richest sources of essential fatty acids. Contains 72% linoleic acid and 7% gamma linoleic acid. In some studies the positive response rate is between 45-97%. However, other studies have not shown the benefits of evening primrose oil as well as fish oil (5,6).
It is recommended that the oil be combined with a low-fat diet and taken for at least 6 months. The usual dose is 1500-3000mg per day in divided doses. The evening primrose capsule is 500 mg and it is usually recommended to take 2×2 capsules a day.
CHANGE OF LIFESTYLE AND DIET
Lifestyle
- quitting smoking
- adequate bras
- sports bras during exercise
- normal body weight and moderate physical activity
- stress control
- analgesics, topical or oral (paracetamol, non-steroidal anti-inflammatory drugs)
Diet
- avoiding methylxanthines (coffee, tea, chocolate, coke)
- reduce fat intake in the diet
- avoiding foods containing tyramine (cheese, wine, beer, spices, nuts, mushrooms, bananas)
- taking gamma-linolenic acid preparations (evening primrose oil)
IF YOU FEEL PAIN IN THE BREAST, BE SURE TO CALL YOUR DOCTOR AND DO NOT USE MEDICINES WITHOUT DOCTOR’S APPROVAL!!!
Hormonal therapy
If the cyclical mastalgia still continues, in addition to the mentioned therapy, hormonal therapy must be applied, which happens very rarely. The first step is to identify a possible exogenous cause. For premenopausal women, temporary discontinuation of oral contraceptive pills is recommended. For postmenopausal women, it is recommended to reduce estrogen doses or switch to anti-estrogens. Raloxifene (Evista) modified selective estrogen receptor. Progestins are given during the luteal phase of the menstrual cycle.
Danazol is an attenuated androgen that is effective in relieving breast pain in more than 90% of cases. It acts to reduce ovarian function by suppressing the release of gonadotropins from the pituitary gland. Danazol is used in a dose of 200 to 400 mg per day or only during the luteal phase of the menstrual cycle in premenopausal women. The effect usually comes from a few to a month. However, using danazol can lead to a series of side effects such as headache, nausea, depression, muscle pain, and irregular menstrual cycles.
Bromocriptine is a prolactin suppressor and has been used to treat mastalgia at a dose of 7.5 mg daily for a period of three months. It can alleviate mastalgia, but like danazol it has numerous side effects (nausea, vomiting, dizziness) and today it is used to stop lactation.
Tamoxifen was previously used to treat moderate to severe breast pain, but due to side effects, it is now used as an adjunctive therapy in the treatment of breast cancer.
Topical progesterone cream and oral progestin can relieve mastalgia.
Surgery treatment of mastalgia
In the past, mastectomy or quadrantectomy in women with focal symptoms was used to treat very severe breast pain. Surgical therapy of mastalgia did not give a positive response compared to other types of therapy, and today it is undesirable and rejected. It is interesting that in most women breast pain remains even after surgical therapy.
LITERATURE
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