Breast Pain - Sign of Danger or Diagnostic Dilemma

A. Darrell Tackett, MD, FACS

Pain is the presenting complaint for 65 to 70 percent of women being evaluated for breast problems in screening clinics in the United States. Pain was sufficiently severe to be lifestyle altering in almost half interfering with usual sexual activity in 48% and with physical (37%), social (12%) and work (8%) activity as well. Most patients present with the concern that pain represents underlying malignancy. While it is generally true that pain is not associated with cancer in most patients, pain that is unilateral, persistent and constant in location may indicate the presence of malignancy though these tumors are usually small and are easily identified with modern imaging modalities. The actual incidence of malignancy as a source for breast pain, however, is less than one percent in large series.

Studies of the severity, character and timing of breast pain as it relates to the menstrual cycle have allowed clinicians to debunk old theories of the etiology of breast pain such as water retention and psychoneurosis and define an endocrine based etiology that allows a logical plan for evaluation and treatment. Based on a thorough history and exam patients can be identified as suffering from cyclic (40%) or non-cyclic (60%) pain. Non-cyclic pain can be further separated into true non-cyclic breast pain and musculoskeletal pain.

Most women experience 2 or 3 days of premenstrual breast heaviness and tenderness each month and this should be considered normal. Pain and tenderness severe enough to limit normal activities for more than a week each month should be considered abnormal and if persistent requires treatment. Cyclic pain is invariable bilateral and is usually associated with an increase in breast nodularity which is maximal in the upper outer quadrants of the breast. Studies indicate that there is a disturbance in the hypothalamic control of prolactin secretion that may be the primary problem in cyclic painful nodular breast disease.

Non-cyclic breast pain does not follow the usual menstrual pattern and is more likely to be unilateral and variable in its location in the breast. In the absence of macrocysts or obvious infection, true non-cyclic pain is most commonly associated with the findings of coarse calcifications on mammography and duct ectasia and periductal mastitis on biopsy. Trauma, usually previous biopsy, and sclerosing adenosis have also been identified. Chest wall pain from Teitze’s costochondritis and lateral chest wall pain from underlying muscloskeletal problems can also contribute to non-cyclic breast pain and are usually associated with areas of point tenderness over joints or “trigger points” that when touched initiate the typical pain syndrome.

Approximately 85% of patients have significant resolution of symptoms with simple reassurance that they do not have cancer. For those with persistent symptoms, a variety of drug regimens are available with varying degrees of success and complication.

One simple and well tolerated remedy is Evening Primrose Oil. This herbal preparation is a rich source of essential fatty acids and has virtually no side effects. It has a 60% favorable response rate in patients with cyclic pain. Good response with non-cyclic pain is less common but because of its excellent patient tolerance, it is often a first or second line therapy in both cyclic and non-cyclic mastalgia.

Danazol affects the pituitary-ovarian axis and may interfere with FSH and LH levels at high doses. At lower doses of 100 to 200 mg daily it has a clearly beneficial effect on cyclic mastalgia and most patients do not suffer the androgenic effects of weight gain, acne and hirsutism seen at higher dose levels. It also seems to be beneficial in true non-cyclic breast pain and is the first line drug for these patients because of the lower response rate with Evening Primrose Oil.

Bromocriptine interferes with the secretion of prolactin and is effective in relief of cyclic mastalgia, perhaps by reducing the overall stimulation of the breast tissue. Many patients, however, suffer severe side effects with nausea, vomiting and dizziness. Some of the side effects can be reduced by introducing the drug slowly and avoiding doses higher than 2.5 mg twice daily. Because of its propensity to cause these problems, it is used less commonly than Danazol or EPO for either cyclic or true non-cyclic mastalgia.

Tamoxifen in doses of 10 mg daily for 3 to 6 month courses has also been used with some success in patients with refractory mastalgia.

Relapse rates with all the above drug therapies is in the range of 25% and may require several courses of drug. Multiple short courses of 3 to 6 months instead of prolonged therapy may also avoid some of the long term side effects of the drugs.

Other therapeutic approaches such as a low fat diet and avoidance of caffeine have had variable success. Multiple vitamin regimens have not been proven to be effective.

Patients with musculoskeletal pain may respond to anti-inflammatory drugs and heat. If a “trigger point” can be identified, injection with a local anesthetic and steroid has been helpful in most cases.

Mastectomy has been performed for recalcitrant cases but should be considered a last resort and unfortunately does not assure relief from pain.