Breast pain
Introduction
Breast pain (mastalgia) is a common type of discomfort among women - affecting 70 percent of women at some point in their lives.
Breast pain occurs more frequently in younger, premenopausal women, although women who are postmenopausal can experience breast pain, too. About one in 10 women experiences moderate to severe breast pain more than five days a month. In some cases, women have severe breast pain that lasts throughout their entire menstrual cycles. This can have a major impact on daily activities, such as work, family relations and sexual relationships.
Breast pain alone rarely signifies breast cancer. Still, if you have unexplained breast pain that's causing you to worry about breast cancer or otherwise disrupting your life, get checked by your doctor.
Signs and symptoms
Breast pain may be cyclic, noncyclic or extramammary. Cyclic breast pain occurs in a pattern clearly related to the menstrual cycle. Noncyclic breast pain is constant or intermittent breast pain unrelated to the menstrual cycle. Extramammary breast pain arises from a source other than the breast, such as muscles in the chest wall, but it may feel like it's originating in the breast.
The characteristics of cyclic breast pain differ from those of noncyclic breast pain:
Cyclic breast pain. Cyclic breast pain usually occurs in both breasts and involves the entire breast, particularly the upper, outer portions, extending into the underarm area. With cyclic breast pain, you may feel tenderness, swelling or lumpiness in addition to the pain. Women often describe this type of breast pain as dull, heavy or aching. It tends to be most intense during the week or two before your period and to ease up afterward. Cyclic breast pain is the most common type of breast pain, accounting for about two-thirds of cases.
Noncyclic breast pain. Noncyclic breast pain most often occurs in only one breast and tends to be localized to a specific area in your breast. Less commonly, some women with noncyclic breast pain experience diffuse pain across the breast and underarm area. Women often describe noncyclic breast pain as burning, achy or sore.
Cyclic breast pain usually affects women who are in their 30s or 40s. Noncyclic breast pain tends to affect women who are in their 40s or 50s and who are postmenopausal.
Causes
The exact cause of breast pain cannot be determined in most circumstances, although there are several theories.
Cyclic breast pain appears to have a strong hormonal association. The fact that cyclic breast pain often decreases or disappears with pregnancy or menopause lends support to the theory that hormones play a role in the discomfort. However, no studies have identified a particular hormonal abnormality as a contributor to cyclic breast pain.
Noncyclic breast pain is only rarely associated with an underlying identifiable cause. The cause of noncyclic breast pain is more likely to be anatomical rather than hormonal, triggered by breast cysts, breast trauma, prior breast surgery or other factors localized to the breast. Noncyclic breast pain may also originate outside the breast - in the chest wall, muscles, joints or heart, for example - and radiate to the breast.
Another theory is that breast pain in general may be related to an imbalance of fatty acids within the cells. This imbalance may affect the sensitivity of breast tissue to circulating hormones. This is the rationale for taking evening primrose oil capsules as a remedy for breast pain. Evening primrose oil contains gamma-linolenic acid (GLA), a type of fatty acid. GLA is thought to restore the fatty acid balance and decrease the sensitivity of breast tissue to circulating hormone levels.
Some medications also can be associated with breast pain. These include hormonal medications used in infertility treatments and oral contraceptives. Also, breast tenderness is a possible side effect of estrogen and progesterone hormone therapy, which could explain why some women continue to have breast pain even after menopause. There have also been reports of breast pain associated with commonly prescribed antidepressants, including selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft).
Women with large breasts may have noncyclic breast pain related primarily to the size of their breasts. This type of breast discomfort is typically accompanied by neck, shoulder and back pain. Some studies have shown that breast reduction surgery can reduce these symptoms. Breast surgery itself, however, also causes pain, which may linger after the incisions have healed.
When to seek medical advice
Schedule a visit to your doctor if you have breast pain that's lasted for a long time, or if your pain comes and goes repeatedly.
If you have noncyclic breast pain that's localized to one particular spot within the breast, you should also see your doctor for an evaluation. About 2 percent to 7 percent of women with this type of breast pain have breast cancer.
Screening and diagnosis
The initial evaluation of your breast pain focuses on your medical history. You'll discuss with your doctor the location of the breast pain, any potential cyclic components and any other relevant breast history that might explain the cause of your pain.
Specifically, your doctor may ask you questions about:
How long you've experienced the pain
The intensity of your pain using a pain scale
Whether the pain occurs in one or both breasts
When you had your last mammogram
Whether you have other signs or symptoms, such as nipple discharge
What medications you're taking
Your doctor also may assess your personal risk of breast cancer, based on factors such as your age, family medical history and prior history of precancerous breast lesions.
Next your doctor will perform a physical examination to check for any unusual areas in your breasts. He or she will examine your breasts and the lymph nodes located in your lower neck and underarm area. Your doctor will probably listen to your heart and lungs and check your chest wall and abdomen to be certain the pain originates from your breast and isn't related to some other condition.
If the history and physical exam uncover nothing unusual, you may not need additional tests. If you're 35 or older, your doctor may recommend mammography - an X-ray examination of your breasts - to check for abnormalities that he or she may not have been able to feel during the physical examination.
If your doctor detects a breast lump or an unusual thickening in your breast tissue, he or she will likely recommend mammography and possibly ultrasound to evaluate the area. You might also need to undergo a breast biopsy. Younger women - those under age 30 - might undergo ultrasound to evaluate a focused area of pain whether or not suspicious breast tissue is also detected.
Treatment
Very few women require specific treatment for breast pain. If tests don't reveal evidence of breast cancer, the reassurance you receive from your doctor, along with self-care measures, may be all you need to manage your breast pain. Often, breast pain resolves on its own within a few months. In the meantime, try simple remedies such as wearing a bra with extra support and taking an over-the-counter pain medicine.
If you do require treatment, eliminating any underlying cause or aggravating factors, including medications, is the first step. Your doctor may also recommend a number of nondrug therapies for you to try. These include making changes in what you eat and drink, using hot or cold compresses and taking dietary supplements, such as vitamin E or evening primrose oil.
New studies are evaluating topical nonsteroidal anti-inflammatory drugs to determine whether they're effective in managing noncyclic breast pain. Topical medicine comes in a cream or gel, which you rub onto your breasts. Taking an oral contraceptive, or adjusting the dose if you already take one, also may help. If you're taking postmenopausal hormone therapy, stopping the medication or reducing the dose may provide relief.
For severe cyclic breast pain, you might require a more potent medication. Effective medications include danazol, bromocriptine and tamoxifen. Danazol is the only drug approved by the Food and Drug Administration for the treatment of breast pain. Each of these therapies is associated with potentially serious side effects and should only be taken if you have severe breast pain.
Self-care
Even though there is little formal research to show the efficacy of these self-care remedies, they help many women manage their breast pain. Some may be worth a try:
Use hot or cold compresses on your breasts.
Wear a firm support bra that you had fitted by a professional.
Wear a sports bra during exercise and while sleeping, especially when your breasts are extra sensitive.
Experiment with relaxation therapy. Severe breast pain may be associated with high levels of anxiety and may improve with relaxation therapy.
Limit or eliminate caffeine. Although medical studies are inconclusive, many women have noted that cutting back on caffeine improves their symptoms.
Decrease the fat in your diet. Lowering your daily fat intake to less than 20 percent of total calories may improve breast pain, perhaps by altering the fatty acid balance.
Use evening primrose oil. This supplement appears to change the balance of fatty acids in your cells, which may have a positive effect on breast pain.
Take vitamin E. Early studies showed a possible beneficial effect of vitamin E on breast pain, but the medical literature to date remains inconclusive.
Use a simple pain reliever (analgesic), such as acetaminophen (Tylenol, others), or a nonsteroidal anti-inflammatory drug (Advil, Motrin, others) to alleviate breast pain.
Also, consider keeping a pain diary. Make note of the days you experience breast pain and record any other symptoms. This can be helpful in determining whether your breast pain is cyclic or noncyclic, and it may assist your doctor in finding the right treatment for you, if further treatment becomes necessary.
