In clinical practice, 50% to 70% of patients presenting to the breast clinic with breast pain, and 20% to 30% of these patients complain of moderate to severe breast pain that lasts for more than 5 days per month. Most of the women who present with benign breast disease complain of associated breast pain. These patients’ breast pain problems can sometimes seriously interfere with daily activities, social life and work, and even cause psychiatric disorders (e.g., anxiety, insomnia, depression).
Breast pain disorder is a clinical type of lobular hyperplasia/mastocytosis.
Breast pain disorder is a more general umbrella term for a clinically painful breast condition that is regularly associated with the menstrual cycle. Breast pain disorder is mostly a chronic clinical process that continues to occur intermittently in many women until the patient goes through menopause. It is characterized by breast pain as the main symptom. In typical breast pain, the pain is not only noticeable when the breast is examined by touch, but also persistent and even quite severe even when the breast is not touched. Breast pain is usually noticeable before the onset of menstruation and decreases or disappears when menstruation begins. It is important to note that mild breast pain can occur in many women during the premenstrual period and is a normal physiological phenomenon.
Etiology and classification
The etiology of mastalgia has not yet been determined, but is mainly divided into endocrine etiology (functional changes in the ovaries, trace endocrine changes, malfunctioning endocrine response to stimuli, abnormal sensitivity of end organs to minor endocrine changes and changes in local hormone receptors.) , psychological basis (mental-emotional state), sexual life, and environmental changes are related. In a few cases, psychological factors may also play a more dominant role, so psychological support may be needed for those patients for whom extensive treatment has failed.
Mastalgia can be divided into cyclical, non-cyclical mastalgia and extramammary pain
1. Cyclical breast pain
Cyclical breast pain is associated with the menstrual cycle and increases before the start of the menstrual cycle. In severe cases, the pain may last for most of the cycle but subsides at the start of menstruation. Periodic breast pain is the most common type of breast pain and responds best to treatment. The average age of patients with cyclical breast pain is about 35 years. Periodic breast pain is usually bilateral and most often located in the outer upper quadrant and can also be associated with breast nodes. It is usually described as a mild or heavy swelling pain. It may also radiate to the medial aspect of the upper arm where the intercostal brachial nerve belongs.
2. Non-cyclic breast pain
Non-cyclic mastalgia is pain located in the mammary gland that is significantly unrelated to the menstrual cycle. The pain is asymmetrical, often unilateral, and is often described as burning, drawing and throbbing pain. It occurs in a slightly older population, most often in the 40-year-old age group. The pain is mostly localized in this group and pressure on this point can cause severe pain, but the rest of the breast is normal.
3. Extra-mammary pain
Some patients complain of extramammary pain, but the pain may not be from the breast. 90% of patients with this pain are unilateral. Non-cyclic breast pain needs to be differentiated from musculoskeletal pain, which is almost always unilateral, and the site of pain is the costal cartilage joint or the lateral chest wall. These patients tend to have costochondritis, or Tietze syndrome, which is typically characterized by marked tenderness of the costal cartilage. Other non-breast pain causes include sore throat, cervical nerve root compression, cholecystitis, and gastroesophageal reflux disease. Treatment is directed at the cause and symptomatic management. Pain in these patients requires further study and referral to general surgery or physical therapy.
Diagnosis and evaluation
Patients with breast pain should be carefully evaluated to exclude breast cancer and treatable benign breast disease.
1. Ask for medical history
A complete medical history should be obtained, including description of the pain, aggravating and relieving factors. The history should include menstrual and pregnancy conditions, recent and past hormone applications, medication and previous breast surgery or recent breast trauma, dietary fat and caffeine intake, and a history of any other breast symptoms. It also yields useful information about the patient’s reason for the visit. The usual motivations for a visit include concerns about the possibility of breast cancer, severe pain, or interference with daily life. The patient’s description of the pain and its relationship to the menstrual cycle is helpful.
2.Physical examination
Patients should have a thorough clinical breast examination. Any isolated or obvious masses require careful examination. Patients with breast pain often have cystic hyperplastic changes in the breast and may have palpable nodules on examination. The examination should include whether the bra worn is the right shape and size, whether the sling is the right length of elasticity and whether the lower edge of the bra with the arch is on the chest wall or on the breast tissue. During the examination, a painful trigger site may be found, which is an isolated, localized area with significant tenderness. This clinical sign is different from localized breast pain and there are no signs of all-over breast pain.
The rib cartilage and ribs should also be examined gently. If there is chest wall pressure, the patient should be positioned on his or her side so that the mammary gland drops away from the chest wall. If the pain persists, the lesion is not in the breast; if there is no longer chest wall tenderness, the lesion may originate in the breast. In some cases, an obstetrical and gynecologic examination may be required to rule out estrogen-secreting ovarian tumors. If pregnancy is suspected, a pregnancy test should be considered.
3. Imaging
In cases of breast pain and palpation abnormalities, appropriate breast imaging is required, either mammography or ultrasound, depending on age. Ultrasound may also be useful to examine the point of tenderness to rule out non-palpable lesions. One study showed that pain as a symptom and pain as the only symptom in 7% of patients with operable breast cancer.
Clinical management
The choice of treatment for breast pain should be based on patient factors and the severity of symptoms. Breast cancer must be ruled out at the outset. Mild cases of breast pain do not require treatment, but moderate to severe pain that lasts more than 5 days per menstrual period for more than 3 months requires examination and treatment. For moderate, severe or persistent pain, medication must be considered. Regular follow-up, psychological support, and lifestyle improvement are also important components of treatment. In addition, it is very important to give appropriate management to pain that is not caused by the breast itself.
1. Regular outpatient follow-up and review
Many patients with breast pain seek medical attention for fear that the pain is related to cancer. After taking medical history, physical examination and imaging, it is determined that there is no breast cancer as well as other related diseases to exclude the concern. Therefore, some scholars even describe the usual characteristics of patients with breast pain as fear of cancer. Although most patients with breast pain only need to be followed up, it is appropriate to consider treatment measures for those with persistent severe pain that affects daily life.
2.Changing lifestyle and eating habits
A healthy diet, reasonable rest, good sleep and a peaceful lifestyle are conducive to the natural relief of breast pain. Inappropriate bras may aggravate breast pain in some women, and suitable support bras or sports bras may be beneficial for breast pain patients.
3.Medication
(1) Traditional Chinese medicine treatment (recommended)
Traditional Chinese medicine associates premenstrual breast pain with liver depression and spleen injury, qi stagnation and blood stasis, and treatment is mostly based on tonifying the kidneys and regulating flushing, draining the liver and qi, activating blood circulation and eliminating blood stasis, resolving phlegm and dispersing nodules. Some proprietary Chinese medicines have more significant effects on breast pain, such as our homemade preparations – breast elimination and depression oral liquid, Pingxiao tablets, mastication, breast fetish elimination, etc.
(2) Hormone regulation drugs (used with caution)
Drugs such as tamoxifen, danazol and bromocriptine are representative. For example, tamoxifen (triamcinolone) is very effective in reducing breast pain, but it should be used with caution due to potential serious side effects.