Breast pain
 

Breast pain is the most common symptom that brings women to our center. In general, there are two common presentations of breast pain: cyclic and non- cyclic. Breast pain is especially common in younger, premenopausal women. Approximately 10% of the women who see us for breast pain describe it as being severe. Fortunately, the vast majority of patients with breast pain do not have breast cancer.

Cyclic breast pain occurring in both breasts a few days before the onset of menstruation is normal. At times, the pain can become more severe and extend through the entire menstrual cycle. Although there are some simple treatments that are helpful (see link), for many women, cyclic breast pain becomes a major problem. Fortunately, for the vast majority of these women, the pain seems to improve with time, no matter what the treatment.

If the pain is in both breasts and there are no other symptoms (such as a lump, spontaneous nipple discharge, or color changes in the breast and/or nipple), a woman can be reassured that the chances of cancer are extremely small. However, if the pain persists for more that two months or seems to be getting progressively worse, medical consultation is indicated.

With non-cyclic breast pain, women commonly experience pain in one breast that seems unrelated to the menstrual cycle, and is not related other obvious causes, such as trauma or pregnancy. The pains can occur anywhere in either breast, but often start in the nipple and radiate to the armpit. Many times these pains seem to occur in “jolts” that last only a few seconds. Such pains are quite common, and are probably of neurogenic origin. In my experience, this type of pain is rarely, if ever, associated with cancer. This type of jolting pain does not respond well treatment, but it usually resolves on it own. If pain persists more than two months, medical attention is indicated.

Other breast pains are more focal and persistent. If the pain is aggravated by movement, it is probably of musculoskeletal origin and treatment with over-the-counter analgesics is indicated. Again, if the pain persists for more than two months, medical attention is indicated.

Of course, the concern of any woman with breast pains is the possibility that the pain is related to breast cancer. In the vast majority of cases, breast cancer is not associated with breast pain. In most cases in which breast cancer is associated with pain, the cancer is easily diagnosed on examination or on standard breast imaging, such as a mammogram or ultra-sound.

There are, however, rare cases in which breast pain is the first symptom of a breast cancer, and the physical examination and initial imaging studies (including ultrasound) are normal. In my experience, there are some clues in the pattern of breast cancer-related pain that should lead the physician to be suspicious that a cancer might be the cause. The pains tend to be focal, i.e. in one spot in the breast. The pain also tends to get steadily worse over time. In other words, one spot in the breast is causing pain, and the pain is getting worse over a period of several weeks.

When a patient tells me that a focal pain that seems to be getting worse, I am immediately suspicious of an underlying cancer, although in most cases it will prove not to be the case. Even if the breast is normal to my examination, I order a diagnostic mammogram, which includes additional views (including magnification views and a diagnostic ultrasound). If the work-up is negative, I usually have the patient return in 4-8 weeks, and have her return immediately if there are new components to the pain. If on the return visit the pain has not improved, the next step is an MRI. If the MRI is negative, we are almost certain that the pain is not due to cancer, but we continue to follow the patient clinically. In rare cases, we will biopsy an area of focal pain in the absence of any detectable abnormalities. This decision should be made by an experienced breast surgeon, and with full understanding by the patient.

Treatment :

  • Caffeine restriction :
    • Caffeine restriction can result in dramatic reductions in cyclic breast pain in some women, especially those who drink multiple cups of coffee per day. Women with low-to-moderate intake of caffeine have a less predictable response to restriction of caffeine intake. We advise all women with cyclic breast pain to reduce or eliminate caffeine, and the majority of patients seem to experience at least partial relief of symptoms. Caffeine is also found in tea, most soft drinks, and in chocolate. There is no known relationship between caffeine intake and an increased breast cancer risk.

  • Evening Primrose oil (EPO) :
    • We have had patients who have reported dramatic benefits with EPO, and others who had no benefit. EPO comes in a capsule that is taken by mouth, and is available in most health food stores. We recommend that a patient start with 1500 mg twice a day for at least two weeks. If there is improvement in pain, this dosing is continued for at least 3 months to assess its effect over successive menstrual cycles, and can be continued as needed for symptomatic relief. If no benefit is obtained, dosing can be discontinued.

Vitamin E and other “anti oxidants”
Vitamin E, as well as many of the B vitamins, have been credited with providing relief for breast pain, but the data to support the effectiveness of their use in women with breast pain is limited.

Estrogen and Breast Pain :
One of the most common side effects of estrogen is breast pain, and one of the most common causes of breast pain in post-menopausal women is the estrogen component in hormone replacement therapy. We recommend that all post-menopausal women on estrogen take the lowest dose that will control menopausal symptoms. Breast pain secondary to estrogen intake is just one more good reason to keep estrogen doses as low as tolerable.

Fortunately, birth control pills are not typically associated with breast pain, and sometime breast pain is reduced with the use of oral contraceptives.

Diet and Breast Pain :
There is limited evidence that a low-fat diet may have some benefit on breast pain. We still recommend a low-fat diet, since it may help in lowering breast cancer risks, and is definitely of value in lowering cardiac risks and the risk of other types of cancer (i.e. colon). See the link to The American Heart Association Diet)

Breast Support :
A well-fitted bra is often of value in reducing breast pain. It is of important to get a good fit, and every woman seems to have her own favorite type of fit. There are professional fitters who can be of assistance (link to Cordelia Knott Center). In some cases, extra support can be obtained with an additional external wrap, such as with a circumferentially wrapped ace-bandage.

Iodine Replacement :
There are reports that iodine can reduce breast pain (Can J Surg 1993; 35:453-60; Iodine works). We have had patients who have reported on over-the-counter iodine-containing products which have effectively reduced breast pain, but I have been unable to confirm these reports, and do not have a specific product that I can recommend.

Other Products :
Bromocriptine (a medication which blocks the pituitary secretion of prolactin) and danazol (which blocks luteinizing and follicle-stimulating hormones) are often mentioned as agents that can be used for severe breast pain. The side-effects of both drugs are significant, and it our experience that when these side effects are discussed with patients, they have all elected not to take the drugs.

Diuretics have also been advised in the past, but we do not recommend them for breast pain.

Over-the-counter analgesics such as Tylenol, aspirin, and non-steroidal anti-inflammatories (i.e. Advil, Motrin) are often quite effective for short-term pain relief.

Surgery :
In the past, subcutaneous mastectomy was used as a treatment for extreme breast pain that was not responsive to standard treatments. We have not done this operation for decades, and believe that patients with breast pain can be handled with less invasive forms of treatment.

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