Mastalgia effects 85% of women during their lifetime. It is rarely associated with breast cancer. Cyclical mastalgia is the most common type. It is generally self-limiting and resolves without treatment. However, treatment is available, although it is imperative that the woman herself decides on how far she wishes to go.
Breast pain, or mastalgia, effects 85% of women at some stage during their lives. While a woman is less likely to have breast cancer if she has pain than if she is pain-free, it is still a significant symptom in terms of quality of life. Those women with breast pain report a dramatic affect on their lives, including problems in relationships, at work, exercising or even simple social interactions such as hugging their children.
Previously, the attitude towards mastalgia has been very paternalistic with clinicians happy to dismiss the majority of women with reassurances that they do not have cancer. While it is true that most mastalgia disappears spontaneously, this attitude is unacceptable when treatments can be offered for what can be a debilitating condition.
There are two types of mastalgia, cyclical and non-cyclical.
As its name implies, cyclical mastalgia occurs a few days before a period is due. It is probably due to the engorgement of the breast tissue that occurs just before a period. This is under the control of the female reproductive hormones, oestrogen and progesterone. Towards the end of the cycle, they have a histamine-like effect on the blood vessels of the breast, leading to an increase in the fluid in the breast tissue. This normally resolves once the period has started. However, it can continue to varying degrees throughout the cycle, becoming worse just before the period and never completely disappearing.
Cyclical mastalgia tends to occur in puberty or just before the menopause when the hormonal milieu is at its most unstable. Despite this, it can occur at any age and may be related to external stresses that can affect the well-being of the woman concerned.
Non-cyclical mastalgia is unrelated to the period. This tends to occur in the post-menopausal patient. A significant percentage of patients are actually suffering from referred pain or chest related discomfort.
Acknowledgement by the clinician that mastalgia is an important condition with a significant impact on a woman’s quality of life is vital.
A full history will be taken and a pain chart may be required so the woman can record the severity of the pain throughout the cycle to establish whether there is a pattern.
The type of contraception is important with the Mirena coil as well as other hormonal contraceptives possibly playing a role.
Imaging will be guided according to the results of the clinical assessment but usually involves mammogram and / or ultrasound to help exclude other causes for pain such as cysts.
A full range of treatment is available, but it is imperative that the woman herself chooses which to take as the side effects can be worse than the pain and the woman is the only one who can decide as she is the one with the pain!
Simple advice like reducing caffeine intake, wearing appropriate bra sizes (including perhaps a larger comfortable bra at the end of the cycle), a healthy diet and reducing external stress etc. would not be unreasonable as a starting point.
There is some evidence that iodine can help so I normally advise some vitamin and mineral supplement.
The evidence around gamma linoleic acid (GLA) and mastalgia is controversial. However, I believe it is reasonable to try either Evening Primrose Oil or Star Flower Oil (this contains more GLA so you don’t have to take so many tablets) for a dose of around 320mg of GLA a day. As it is a food supplement, it can take a couple of months to work so, in the meantime, unless it is contra-indicated, some ibuprofen or voltarol gel massaged into the painful areas of the breast twice a day may help. The massage, along with the pain relief provided by the gel, may help reduce the congestion. Those wishing to use a more natural approach can try a Savoy cabbage leaf placed in a comfortable bra at night – there is evidence that this is as effective as the gels.
If these measures do not work then the woman must decided on whether she wishes to explore more radical hormonal manipulation. If on a hormonal contraceptive, it may be worth changing this first and if peri-menopausal and not on the pill, it may be worth starting a low dose pill to regulate the hormonal situation, provided the risks are explained and the woman can make an informed choice.
Other options include the use of drugs such as Danazol. This acts like a male hormone and around 25% of women suffer side effects such as male pattern hair growth, weight gain, voice changes, aggression and increased libido.
If this is unsuccessful then some women will choose a trial of Tamoxifen. This anti-oestrogen is not licensed for the treatment of mastalgia and, although effective, it has significant potential side effects which can be fatal and, therefore, should be fully explained.
In the premenopausal woman with resistant mastalgia, a trial of Zoladex injections could be used to stop her periods altogether and render her temporarily post-menopausal. Clearly, this decision must be made in partnership with the patient.
Surgery is very rarely indicated and not always successful. If, as a last resort, surgery is being considered, a second opinion should always be sought and psychological counselling is mandatory.
This type of mastalgia is much more difficult to treat as hormonal manipulation is less likely to work, especially in the postmenopausal woman, unless she is taking HRT. The basic advice remains the same, and the clinician will pay particular attention to any signs of sites for referred pain or general rheumatological conditions such as fibromyagia.
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