Post by on Monday, June 20, 2022

Mastalgia/Breast Pain is the most common symptom encountered in women and is defined as tension, discomfort and pain in one or both breasts.

Rising Kashmir’s special Correspondent Jahangir Sofi speaks with Dr Syed Quibtiya Khursheed, Assistant Professor Department of Surgery SKIMS Medical College Bemina to discuss the range of issues pertaining to Mastalgia/Breast pain.

What is Mastalgia/Breast Pain and what are it’s symptoms?

MastalgiaBreast pain is a commonly experienced symptom in women of all ages.It is a dull, aching pain while some women may describe it as heaviness, tightness, discomfort, or burning sensation in the breast tissue, which may be unilateral or bilateral. Most often, it is located in the upper outer quadrant of the breast. It is most common in premenopausal and postmenopausal women, but postmenopausal women can also rarely develop such pain. The breast pain ranges from mild to severe, could be intermittent or constant throughout the day, and may interfere with the female's quality of life.

Do we have any research or studies over the subject? 

Recent population based and breast clinic-based studies suggest that up to 70% of women experience breast pain in their lifetime. Of the symptomatic participants, 41% and 35% reported breast pain affecting the quality of life.

Fifteen percent of women who present to a breast clinic with Mastalgia will require treatment. Fear of cancer prompts many patients to report their pain, although risk for malignancy is low in the absence of a palpable mass or other abnormal finding on breast examination.

Can you please speak about it’s classifications?

Mastalgia is classified broadly into three types: 

Cyclic Mastalgia is associated with the menstrual cycle, is due to hormonal variation and is generally bilateral in nature. Most commonly seen in premenopausal women in the third or fourth decades of life.

Non-Cyclic Mastalgia is not associated with the menstrual cycle and does not vary with hormonal changes in the body. Instead, it is often related to internal anatomical changes, injuries, surgery, infections, or sometimes associated with other breast pathology, i.e., breast cysts or fibroadenoma. It’s unilateral, with a pinpoint localized area of involvement. Most likely affect women in their 30s and 50s.

Extra mammary Mastalgia is breast pain that originates from a location outside the breast, such as the heart, lung, chest wall, or the oesophagus. For example, pain originating from the chest wall (costochondritis), epigastric pain in GERD, or pain of gallbladder and stomach disease can be referred to give a false impression of breast pain.

What are the causes of Mastalgia?

The etiology of Mastalgia is not clearly understood. The major etiological factors mentioned in the literature include:

Two main theories that have emerged regarding the etiology of Mastalgia are Increased Estrogen secretion and deficient progesterone production leading to hormonal imbalance.

Multiple studies have demonstrated an association between Mastalgia, and various psychological symptoms, such as depression, anxiety, history of emotional abuse, and somatization.

Caffeine and methyl xanthine present in tea, coffee, cola, and chocolate cause over-stimulation of breast cells

Smoking has been attributed to increased breast pain by in-creasing epinephrine levels in the breast.

The breast tissue of women with Mastalgia is believed by some to be high in saturated fatty acids and deficient in gamma-linoleic acid (GLA), which renders it abnormally sensitive to normal hormone levels, thus resulting in pain.

What is management for breast pain?

 All patients with breast pain should have a thorough history and physical examination to determine if diagnostic imaging is indicated. History regarding the nature of pain, its location, severity, onset, and the use of a pain diary to chart out its cyclic or noncyclic pattern can provide valuable information leading towards an accurate diagnosis.

The physical examination further helps to identify and explore the chest wall along with breast examination to differentiate extra mammary pain from true Mastalgia. The breast should be examined for any lump, skin changes, nipple retraction, color change, ulceration, swelling, or edema, inflammation, scars, or abnormal nipple discharge.

What are the testing procedures done for Mastalgia?

Imaging modalities most commonly used are mammography and breast ultrasound. The primary aim of such testing is to rule out any serious pathology (breast cancer) underlying a suspicious finding.

Young females with cyclic Mastalgia, which is bilateral and non-focal, having no family history of breast cancer, and a normal previous breast screen do not require further investigation with imaging.

Breast Ultrasound is being used in patients aged less than 35 years because of dense breast tissue. However, if any suspicious finding is observed on USG, a mammogram is recommended for further evaluation.

It is an imaging modality that uses high amperage, low voltage X-rays. Females more than 35-year of age should undergo mammography if a physical exam detects a focal area of pain with an unusual thickening or a breast lump.

Breast Biopsy is done if imaging modalities show any abnormal findings. During a biopsy [preferably core needle biopsy], a sample of breast tissue is taken from the area under question and sent for further histopathology evaluation.

What are the treatments for Mastalgia?

Most women can be reassured that they do not have breast cancer if their examination ?ndings are negative and imaging ?ndings are normal.

For mild to moderate pain, a trial of conservative, non-pharmacologic strategies should be tried first. These includes some life style modifications (LSM) like- an appropriately fitting and supportive bra, avoidance of caffeine drinks, reduction of dietary fat, increase fiber rich diet, physical exercise to reduce weight , relaxation training and some nutritional supplements like oil of evening primrose (EPO)

For those with severe symptoms impacting quality of life, a trial of pharmacologic therapy can be considered after appropriate counselling for medication-related adverse effects and short-term follow-up should be coordinated to assess the need for continued therapy.

In pharmacological treatment Danazol (an anti-gonadotropin agent with mild androgenic effects.) can be used..It is currently the only pharmacologic agent with US Food and Drug Administration approval for management of breast pain.

Bromocriptine,a dopami- nergic agent, acts by inhibiting the release of prolactin from the anterior pituitary gland. It is given in patient with increased prolactin level,

Studies comparing danazol and bromocriptine showed danazol to be superior for patients with cyclic and noncyclic breast pain. Nevertheless, bromocriptine can be considered for patients who do not respond to danazol.

Very rarely, it is necessary to prescribe an anti-oestrogen, for example tamoxifen (selective oestrogen-receptor modulator SERM) or a Non –Steroidal SERMs ( Saheli/Centchroman) and Toremifene/Ormeloxifene..

Surgical interventions have a limited role in the management of Mastalgia but last-resort options for unresponsive and severe debilitating breast-pain include mastectomy with reconstruction

You being a surgeon, what will be your message?

The major primary concern of females presenting with Mastalgia is breast cancer. However, breast pain is one of the least associated symptoms of breast cancer, present only in 0.5% to 2% of patients later diagnosed with cancer.

Thus, it is important to educate patients with breast pain about the alarming signs and teach them self-breast examination techniques so that a meticulous watch is kept by the patient and any suspicious finding should immediately be reported and accessed.