Breast Pain

Due to the increasing awareness of breast cancer, most women now seek advice from their general practitioner about breast pain symptoms. Female patients may present with a variety of symptoms that can range from relatively minor symptoms to severe symptoms significantly affecting quality of life. Heaviness and associated discomfort during the week prior to each menstrual cycle may be associated with tender, lumpy breast areas. Classically, in cyclical mastalgia, these symptoms will regress following the commencement of a period. Due to the fact that mastalgia is a common condition and occurs predominately within the reproductive years, it is best considered an alteration of the normal cyclical pattern. Therefore, a combination of reassurance and medical therapy will most often achieve a satisfactory clinical response in the majority of patients.

Symptoms

A detailed history listing potential risk factors for the development of breast pain (i.e., the use of the oral contraceptive pill (OCP) or HRT, pregnancies, menstrual history, diet and medication) is useful. It is important to define whether mastalgia is cyclical or noncyclical and also from exactly where the pain originates (i.e., from breast tissue or from the underlying chest wall.) Examples of symptoms originating from the underlying chest wall are Tietze's syndrome (costochondritis), herpes zoster and radiculopathy secondary to lower cervical spondylosis.

Signs

Clinical examination may be entirely normal apart from tenderness confined to one area of the breast. Generalized bilateral tenderness may be observed. Associated focal or generalized nodularity may be present.

Examination of both axillae is usually normal.

Investigations

In women over 35 years of age, mammography is performed and this may be normal. Women with discrete areas of focal nodularity will undergo ultrasound and if necessary FNAB/core biopsy of the area to confirm its benign nature. No specific histological appearance is associated with this symptom.

Management

Although there is no definitive scientific evidence for it, several features suggest mastalgia is secondary to an underlying hormonal abnormality. The ack of evidence may be due to the difficulty of collecting data in light of daily and circadian variations in plasma hormonal levels. Current recommendations for management of women with mastalgia are based on theories related to possible etiology. The sheet anchor of management of these patients s reassurance of the benign nature of their condition.

Reduction of Caffeine

Recommendations to reduce caffeine intake are based on the hypothesis that methylxanthines cause proliferation of cells in the breast by increasing cyclic adenosine monophosphate (cAMP). Tissue obtained from patients with breast disease has demonstrated increased sensitivity to biochemical stimulation by methylxanthines. Although there is no hard evidence that abstention of methylxanthines is beneficial to women with mastalgia, clinicians continue to recommend this to patients on the basis that anecdotal evidence does exist for improvement of mastalgia on a caffeine-free diet.