Prof Carol-Ann Benn informs us on how to diagnose and manage breast pain.

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For some women, breast pain can be a constant interference with life. They can’t wear seatbelts, sex becomes intolerable, and ‘cancer fear’ results in continual anxiety. For most of us, breast pain is something we experience just prior to our menstrual period and other than the occasional twinges, breast pain does not feature majorly in our lives.

Breast pain is one of the hardest conditions to treat. In trying to understand if the symptoms should be acted upon, we’re taught ‘listen to your body, if something is not right go to the doctor’. Doctors find it as frustrating when taking a history about breast pain, as does the patient with the many failing medical suggestions, such as ‘take two tablets and you will be fine’. And so often, the characteristics of the pain fail to provide a specific solution around management options.

As with all breast problems, the first step is to exclude cancer as a cause or occult feature. Less than 10% of breast cancers present with pain as its primary feature, and this will be unilateral, continuous and usually associated with a mass. If there is no mass and constant pain, in only 2% of these cases will there be an associated malignancy (cancer) detected on a mammogram or ultrasound. So, the chances of there being no mammographically detected malignancy and still a missed cancer in the presence of breast pain is only 0,1%.

Classification

Breast pain can be classified according to its frequency and nature. In taking a history, it’s important to elicit when the pain is experienced and over what period of time. Some clinicians advise patients to complete a pain diary over three months, recording the incidence and severity of pain each day. Also recording the days of your menstrual cycle.

Traditionally, breast pain is either cyclic (associated with hormonal cycles) or non-cyclic, i.e. at different stages in our menstrual cycle (cyclic mastalgia – 67%) or at any time in the menstrual cycle (non-cyclical mastalgia). This accounts for only about 26% of breast pain with studies showing that 10% of breast pain is chest wall pain.

It is in my experiences that this classification is too vague, and most patients when given a pain chart, do not know how to document their breast pain. This is similar to asking people to record headaches. It is difficult for ladies to differentiate subtle different symptoms. After much frustration, I have come up with a different way of approaching breast pain.

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Did you know?

Breast pain may be due to non-breast causes, such as:

• Shingles – breast pain associated with a small rash that is incredibly painful. This is seen more frequently, particularly in HIV positive patients, but get vaccinated if you’re over 50 as it can happen to anyone.
• Cardiac problems – left-sided pressing breast pain. Remember that women over 50, present with non-typical presentations of heart attacks, such as pain in the jaw and arm.
• Respiratory problems (pneumonia, pleuritic chest pain) – a history of breast pain that gets worse on breathing requires a chest X-ray.
• Gastrointestinal problems (reflux, heartburn) – pain that wakes you at night.
• Rib inflammation (costochondritis) – pinpoint pain on either side of the breast.

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Divide breast pain into four major presenting symptoms

1. Lateral-pulling pain

Type of pain: Pain extending from the armpit down towards the nipples, along the sides of the breasts, which gets worse when the bra is removed.

Reason: The breasts hang on the pectoral muscle in a fine fascial ligament. Imagine the pectoral muscle as a coat hanger and the breast as a jacket hanging on the coat hanger. All breasts are unequal in size; this is like having something in a pocket, causing an unequal pulling down on the side of a breast. This pain is usually worse at the end of the day and may be caused by breast hygiene (poor-fitting bras) and/or large heavy breasts pulling on the breast ligaments.

Management: The solution may be to wear support at night, a sports bra during the day, or alternatively a breast reduction may help. This is a mechanical pain; pain medication does work.

Prior to undergoing a breast reduction, a mammogram or ultrasound depending on the age of the patient and a detailed consultation around scars, nipple sensation, ability to breastfed and best timing to do the procedure (before or after having children) should be undertaken with a plastic surgeon. Remember cheaper is not necessary better.

2. Isolated medial and lateral pain on pressure (Chest wall pain)

Type of pain: Pain on the area where the coat hanger and breast cross laterally (on pressure) or sternal.

Medial chest wall pain around the costochondral junctions (the ribs under the breasts) is known as Tietze’s disease. Men and women both suffer from this, however, most women perceive it as breast pain.

Pain can occur either just lateral to the breast bone or sternum or on the lateral chest wall. Studies state it’s most often unilateral, however, it may be found bilaterally as tightness or aching pain involving the breasts and chest wall.

The pain may have a pinpoint localisation or tenderness over the costochondral junctions and may be felt in one area when you press on the sides of the breasts. It is not a true breast pain but referred from the chest wall and may have an acute onset, disturbing work and sleep.

It is often associated with a feeling of fatigue and discomfort, between the shoulder blades, when lying in bed at night trying to get to sleep (achy back syndrome).

It most commonly occurs in women of athletic build but I see it more seasonally: autumn, start of winter and then season change in spring.

Reason: On examination, the chest wall is locally tender to palpation over the costochondral junctions and lateral wall. The actual cause is often not known but may be due to a viral infection flare-up. Viruses implicated are Ebstein-Barr and Cocksackie virus. Cytomegalovirus (CMV) – the virus that are implicated in fatigue is included as well. Costochondritis may also be related to or exacerbated by excessive muscle strain (sport).

Management: Treatment is to abstain from doing the implicated sport for a few weeks or take non-steroidal anti-inflammatory drugs (NSAIDS). Arnica oil or cream applied topically may also be of help for this. Topical anti-inflammatories and oral zinc is good.

3. Burning, shooting pains, periductal inflammatory pain (Breast Asthma)

Type of pain: Patterns of non-cyclical breast pain, involving a pain more localised to the retro-areolar region and central breast. Pains are more typified as ‘burning’, ‘shooting’, or ‘stabbing’ and may radiate to or from the nipple region.

There is often also an itchy sensation in the nipples. Some patients complain of hot poking pains in the breast.

Reason: The breast ducts are lined by fine hairs. Inflammation in the breast ducts is similar to asthma or emphysema in the lungs. Note, the breasts cant cough. This causes the ducts to block or clog (duct dilatation (ectasia)). Causes of this are smoking and environmental pollution.

Management: An ultrasound and mammography may reveal duct ectasia. Local antibiotic ointment on the nipples can reduce the pain and itching. Topical bactraban (can sometimes cause sensitivity in some with sulphur allergy) dabbed on the nipples may help. Anti-oxidants seems to improve the discomfort in some women.

Singulair, an asthma treatment, provides spectacular relief and only needs to be used for about three months.

4. Full, heavy uncomfortable breasts

This is classic hormonal breast pain that can occur at any time of the cycle. It feels like ‘you need to feed a baby’.

In part two, cyclical mastalgia and non-cyclical hormonal mastalgia will be discussed as well as more treatments options.

• Cyclical mastalgia

Two thirds of breast pain is caused by cyclical mastalgia, which is pain experienced prior to menstruation as part of the normal menstrual cycle.

Type of pain: It is well-known that breast function is a balance between oestrogen and progesterone stimulation in the breast but the exact nature of the imbalance that precipitates breast pain is still not known.

Reason: Common theories are the increased vascularity and stromal oedema that is associated with oestrogen stimulation towards the end of the menstrual cycle, and an association with increased prolactin secretion, which has been linked with painful nodular breasts. Other theories include overconsumption of methylxanthines, such as caffeine, although this has not been well proven.

Patients may experience symptoms of heaviness or tenderness of the breast, particularly in the upper outer quadrant; this is associated with increased nodularity in the tissue. The changes are transient and resolve soon after onset of menses.

• Non-cyclical hormonal mastalgia

One quarter of patients with breast pain will show no correlation with their menstrual cycle.

Type of pain: This pain is similar to cyclical breast pain, with tenderness and heaviness present; it still hormonal in nature and may be due to an increased sensitivity of breast tissue to circulating hormones, or an imbalance in the hypothalamic control leading to increase in prolactin secretion.

Reason: This pain can be prompted by stress (physical, emotional, and mental), illness or simply occur with no trigger. It is important to check thyroid function as an underactive thyroid causes similar breast discomfort. Prolactin levels and medication, such as some anti-depressants, may also play a role.

Management: Evening Primrose Oil (EPO, 3000mg per day), vitamin E (1200IU per day) or a combination of both has been shown in some trials to be better than placebo.

No conventional pain medication works for this type of breast pain. Successful management is by understanding the cause. Evening Primrose Oil and B6 combinations are the first line of treatment.

• Mondor’s disease

Type of pain: A rare and unusual breast pain associated with a cord like structure running over the breast. The pain is in the lower or lateral aspect of the breast from a thrombophlebitis (blockage of a vein crossing within the breast tissue). When you lift your arm, you can see the cord on the breast.

Management: Anti-inflammatory drugs (NSAIDS) and aspirin may give relief. This unusual condition can be associated with an underlying breast cancer, so please ensure you have been for your breast investigations.

Treatment for breast pain entails the following principles:

If your breast pain does not settle, please see a general practitioner or specialist with an interest in breast health.

Ensure that you have been for age appropriate investigations, such as mammograms, ultrasounds and blood tests.

If your breast pain is affecting your day-to-day life, recording your breast pain on a pain chart for four months with its variations over the menstrual cycle may help your doctor identify the cause.

The concept of breast hygiene needs to be addressed when dealing with breast pain. Ill-fitting bras or old bras, combined with large breasts, result in pain under breasts and down the side of the breast. Particularly, as the day progresses, and as gravity takes its toll on the breast ligaments.

Medication that can be tried at home include:

Vitamin B6 (pyridoxine) and EPO (gamma linolenic acid) should be tried first. The dose of EPO is two capsules daily. The B6 and EPO should be taken in combination. Treatment is continued for a minimum of three months; over 70% of patients have a good response.

Some studies suggest taking up to six capsules per day, but please note this can give you diarrhoea and headaches at this dose….remember these are medicines too.

Another over-the-counter herbal medication that helps breast pain is a supplement, called indole-3-carbinol, which is the active ingredient in the cruciferous vegetables. It may help as this substance mimics the action of tamoxifen on breast tissue.

Your doctor once checking the relevant tests will, if you are young and on the contraceptive pill, suggest an alternative contraceptive pill. Sometimes using an oral contraceptive pill can decrease breast pain.

Other preparations with proven success include: Bromocriptine (anti-prolactin hormone) Cabergoline and Danazol. For use in breast pain, Danazol can be given at a low dose of 200mg per day. But it still has such significant and unpleasant side effects that its use is limited to severe and refractory pain, as part of a multi-disciplinary approach in a specialist unit.

Breast pain that does not respond to the above may be treated with:

Low-dose anti-oestrogens are also used to treat breast pain (tamoxifen, Fareston). Although these do not have FDA approval in the USA. Tamoxifen at very low doses is incredibly useful in premenopausal women with refractory breast pain (10mg per day, which is half the dose given to breast cancer patients) given orally.

Some studies suggest crushing these and mixing them in K-Y jelly and applying them topically to the breast tissue. Tamogel or using a tablet crushed in gel allows for better penetration at a lower dose (by avoiding hepatic metabolism).

In post-menopausal women, a sister drug called raloxifene (Evista) works in a similar way and decreases breast pain. This medication may have the added benefit of decreasing risk of breast cancer as does tamoxifen.

Surgery and breast pain

Breast pain that does not respond to any treatment should never be treated with surgery. Fifty percent of women who have breast surgery for breast pain have continuous pain post- surgery.

I often see women referred for subcutaneous mastectomies for breast pain and a strong family history of breast cancer. This operation involves leaving the nipples, taking 7/8 of the breast tissue usually through a breast reduction pattern, and placing silicone prostheses in. This is neither a cancer-risk reducing operation nor an operation for breast pain.

The only type of breast pain that is improved by surgery is lateral-pulling pain. A breast reduction is helpful in some of these women.