Healthy Woman: Understanding Breast Pain

N E W   Y O R K -- Tender breasts are just one of the many uncomfortable and annoying symptoms millions of women experience prior to their periods.

While most women have just mild breast discomfort, others experience more severe pain each month. And some women have breast pain that is not associated with their menstrual cycle, which is known as noncyclic pain.

Sudden or severe breast pain is often a very alarming symptom for women. Breast pain is not usually a sign of breast cancer, but experts say it's important that women with breast pain, particularly severe pain associated with their menstrual cycle, or any kind of noncyclic pain, be evaluated for breast cancer.

"The reassurance is a big part of the evaluation of breast pain," says Dr. Sandhya Pruthi, the section head for the Breast Diagnostic and Cancer Clinics at Mayo Clinic in Rochester, Minn.

Below, Pruthi and other members of the team at Mayo's Breast Diagnostic and Cancer Clinics, Dr. Robin Smith, and Jennifer Hazelton, a clinical nurse specialist, talk about the most common causes of breast pain, as well as strategies for easing the pain.

What are the most common kinds of breast pain?Dr. Robin Smith: The breast pain that women experience has been broken down into three primary types. The first is called cyclic mastalgia, and this is pain that is associated with the menstrual cycle. Typically a woman's symptoms start within the two weeks prior to her menstrual cycle, worsening until the onset of her menstrual period, and then they tend to get better. Some women have pain throughout the entire month, but it improves and worsens according to the time in the cycle.

The second type of pain that women experience is called noncyclic mastalgia, which is pain that may be intermittent or constantly present, but does not appear to be associated with the menstrual cycle at all.

And the third type is breast pain that is actually pain from another source, such as the chest wall. Conditions such as costochondritis, caused by inflammation in the rib joints, can sometimes be perceived as breast pain, as can a number of other medical conditions in the same area.

How do women describe their symptoms?Smith: Women with cyclical breast pain tend to experience pain in both breasts. It is often described as heaviness, aching, or fullness. It seems as though the patients with noncyclic breast pain have pain that can involve both breasts, but it's more often one-sided, and it tends to be localized to one area in the breast. Sometimes patients will use terms such as "sharp" or "burning" to describe it.

There's a wide spectrum in terms of severity because we often pick up breast pain simply by asking patients about their breast symptoms, and most of these women are not very bothered by their pain. Other women actually do have pain severe enough to cause interference with school and work, their physical activities, leisure activities and sexual activity.

Why do hormonal fluctuations cause breast pain?Smith: I wish we had the answer to that. It seems obvious to all of us that there's a hormonal role in the cyclical type of breast pain, because it changes with the menstrual cycle and it tends to improve with changes in hormones, such as pregnancy or with menopause.

There have been a number of studies performed over many years trying to detect a hormonal abnormality that might explain why some women experience pain and others don't, or why some women experience severe pain and others have only mild symptoms. Unfortunately, there have not been consistent results. One potential explanation is that certain women may have breast tissues that may be more sensitive to normal circulating hormones.

What causes noncyclic breast pain?Smith: When someone presents with noncyclic breast pain, we carefully evaluate them to see if we can find an explanation. And of course, what the patient is usually concerned about is the possibility of cancer. Fortunately, the risk of cancer is low, but it's not insignificant. About 2 to 3 percent of women who come to a clinic for evaluation for breast pain—usually that's reasonably severe breast pain—have a cancer at the site.

So the majority of noncyclic breast pain is caused by benign conditions. Sometimes we will find benign tumors in the breast, such as a fibroadenoma, which is a common benign tumor, or a breast cyst that may have been causing her localized pain. But most of the time we don't find a clear-cut explanation for noncyclic breast pain.

Why isn't breast pain usually a symptom of breast cancer?Smith: Although pain can be a symptom of cancer, it is surprising how seldom this is the case. Cancers start out as small clusters of abnormal cells that grow over time and may spread to other sites. Malignant tumors in the breast may not cause any symptoms for months, or occasionally, years. Cancers can cause pain by inducing inflammation or swelling, by invading a region with a rich nerve supply or by putting pressure on other sensitive tissues, but this does not occur until the tumor becomes larger.

The risk of breast cancer in women with localized breast pain is low, but not insignificant, and merits appropriate medical evaluation.

Do infections cause breast pain?Smith: We do see patients with mastitis, an infection of the mammary gland, or sometimes an abscess. Quite often these occur around the time of pregnancy and lactation, and it can be very painful. Usually, these women have other clinical findings of redness, swelling, maybe some discharge from the nipple.

Dr. Sandhya Pruthi: Postmenopausal women describe pain around the areola that is called periductal mastitis. They don't always have the classic red breast, nipple discharge or even the sign of an abscess. It's just a very subtle set of symptoms where the woman says, "You know, it just hurts behind the nipple."

What role does diet play in causing breast pain?Smith: There have been some studies supporting an association between caffeine and breast pain, but other studies have really not supported a relationship. But I have many patients come in and simply tell me that they know that if they drink too much coffee or soda that has caffeine, they experience a worsening of their symptoms. Other women don't find a relationship between caffeine and their symptoms.

I think it's worthwhile, in a woman whose symptoms are severe and who has a significant caffeine intake, to undertake a trial of bringing that caffeine consumption down.

When would you advise a woman with breast pain to be tested for breast cancer?Pruthi: Right away. If a woman has breast pain, particularly if it's new, we advise her to make an appointment with their doctor and have it evaluated. Then it's up to the doctor and the patient to decide on the next workup. But definitely, any woman who says, "I'm having breast pain that's new or bothersome," should be evaluated.

Smith: In a woman over 30 to 35 we would start with a mammogram, and usually for localized breast pain, our practice has been to also perform an ultrasound of that area that is causing the symptoms. In a younger woman, we would often start by doing an ultrasound of the area and then proceed depending on what is found.

What can be done to deal with breast pain not caused by breast cancer?Smith: What we typically do is meet with our patients and go over a variety of simple measures that they can do that don't involve medication. We talk with them about their diet, wearing a supportive bra, sometimes wearing a soft bra at night that can provide support.

Jennifer Hazelton: I think a lot of women, just being women, kind of let their shopping for themselves go. And I see women with bras that have absolutely no elastic whatever left in them, and we've had a number of women call back and say, "Wow, I can't believe what a difference that made." Another thing we recommend is a cold compress to the area of pain for 20 minutes at a time. It seems to be more helpful with a focal pain that's noncyclic.

Exercise helps because endorphins are released when people exercise, which provide a natural kind of relief. But there's a lot of exercise that involves movement of the breasts, so, we recommend biking or kind of a gentle walking while wearing a very supportive bra.

Pruthi: We'll also often recommend anti-inflammatory pain medication, such as acetaminophen or ibuprofen, when a woman first comes to the clinic about breast pain.

What is the next step after lifestyle modification and pain relievers?Smith: We're still determining what the next best step is. There have been a number of medications used for cyclical breast pain, and those include tamoxifen, danazol, bromocriptine and others. The difficulty is that, while these medications are very effective in relieving breast pain, they are associated with some potentially serious and very bothersome symptoms.

The side effects of tamoxifen are usually similar to menopause (hot flashes, vaginal dryness or discharge), but also include endometrial carcinoma and blood clots. The side effects of danazol are less serious, but it can be associated with masculine side effects, including acne and an increase in facial hair or other hair growth. And so we have a great deal of interest in measures that we could use short of those very potent medications.

Pruthi: Usually if the lifestyle modifications aren't working women can try taking 400 international units of vitamin E twice a day. We say, "Try this for three months and see if it works, and then if it does, great. Keep taking it. And if it doesn't let us know."

And then my personal next step is to try capsules of evening oil of primrose, which is a gamma linoleic acid that has actually been approved in the United Kingdom for managing cyclical breast pain. We're conducing an open, randomized, double-blinded, placebo-controlled study looking at the effectiveness of vitamin E, evening oil of primrose, or a combination of the two, compared to a placebo. It is expected that the study will also open soon at other sites.

Hazelton: We are doing a study looking at the effectiveness of four acupuncture treatments over a two-week period in women with noncylic breast pain. Preliminary results are promising.

When is surgery recommended?Smith: I try everything short of surgery for my patients so they can avoid a procedure that has anesthesia risk and potentially deforming consequences. And surgery in and of itself can cause future breast pain. So a woman could remove a tender area of the breast in exchange for pain related to a scar in the same vicinity.

But sometimes we do find that our patients experience pain relief when a cyst is drained, and that can be done by using a needle to drain the fluid out the cyst. Sometimes that cyst fluid will recur, but often the pain will be relieved for quite a while or indefinitely. And a benign growth like a fibroadenoma that causes localized pain at the site can also be removed.

What is your advice to a woman who is having pain?Smith: I think that a woman who has some fairly mild symptoms of cyclical breast discomfort that is not interfering with her activities and always resolves with her menstrual cycle just needs to know that that is common and that nothing particular needs to be done with regard to evaluation and treatment. She should continue with breast cancer screen appropriate for her age.

Women who have more severe cyclical breast pain can manage the symptoms with their doctor or talk to their doctor about a referral for a consultation in a breast center. For a woman with noncylic breast pain, particularly localized to an area of the breast, I would recommend she undergo a careful evaluation in a breast center. It is also reasonable for women with a new onset of breast pain or a change in breast pain symptoms to undergo medical evaluation.