Breast pain (mastalgia) is the most common breast related complaint among women. Almost 80% of women experience pain in the breast/axilla, during there lifetime. But only 10 to 20% need treatment. Though 90% of breast pain is not due to breast cancer the woman should consult in the event of breast pain.
There are two main types of breast pain:
| Sr. No | Breast Pain (Cyclical) | Breast Pain (Non Cyclical) |
|---|---|---|
| More common | Less common | |
| Related to menstrual cycles | No relation to menses | |
| Occurs in both breasts | Pain is more localised | |
| Occurs due to hormonal imbalance | Pain is burning/dragging type | |
| Main Complaint - Heaviness and nodularity in breast which increased before menses |
Mainly musculoskeletal | |
| Poorly localised pain | More common in middle and elderly age | |
| Treatment helps | Treatment not successful |
This type of pain has characteristic features, which varies from one woman to other, and is individualised. Typically there is feeling of heaviness in breast mostly bilateral (though patient may feel more pain in one breast than opposite), usually diffuse starts just before menstrual cycle or exaggerated if already continuous pain is present. Increase in pain is present during the period for 2-5 days and then subsides with end of cycle. The cause of this premenstrual pain is due to hormonal (estrogen and progesterone), Mediated water retention in the breast tissue and distension of the ducts and glands within breast. This pain may be associated with feeling of swelling or lumpiness, then it is termed as fibrocystic disease. This pain subsides after menopause. Though the pain is due to hormonal changes, many factors like stress, weight gain, diet and life style determine the pattern of pain particular person, which can only be clarified by monitoring pain chart monthly and treating the individual accordingly after ruling out cancer.
This is a less common type of pain which may occur due to causes within breast or outside. Usually seen in middle or elderly women. It may also occur in younger women with history o f injury, operation on breast. This is typically localised to one part of breast and patient can often pinpoint the site. It may be tender to touch. It is not due to hormonal changes except in few postmenopausal women tking hormonal replacement therapy. It is not influenced by pattern of menstrual cycles and may persistent. A special and common type of Non-cyclical breast pain is Tietz syndrome (Costochondritis), due to inflammation (Arthritis), of Costochondral junction (junction of rib with cartilage), occuring >40 years. This pain is actually outside breast but is felt through breast. The other causes are increasing age, osteoporosis, poor posture, ill-fitting bra, biopsy and old trauma to chest.
Once a woman is suffering from persistent breast pain she should consult a physician, who will evaluate the pain by detailed clinical history and examination, followed by mammography&/or ultrasonography supplemented by biopsy if needed, all these methods used according to the findings and need. After diagnosing and once breast cancer is excluded, the appropriate treatment is instituted after discussing with the patient.
Most of the women don’t need any specific treatment the form of drugs or surgery. Nearly 70% of women can controlled with reassurance and life style modification. Usually a step by step approach with increasing complexity is used depending on motivation and response of the women.
Re assurance --> Pain chart and life style modification -> Mild analgesics -> Primrose oil, Vitamin E ? -> Danazol -> Bromocriptine -> Amoxifen, Goserelin, Buserelin --> Surgery
The reassurance includes explaining the woman that the pain is not due to cancer or any surgical disease and is a benign condition without harm to life. Then motivating her to mark the severity and timing of pain on pain chart daily 3 times. This is red by the physician and advises the appropriate measures.
Minor life style modifications include:
All these measures help in red uction of pain score in most of the patients. If it is still persistent then primerose oil is advised. Some physicians advie vitamin E and its role is doubtful. With reassurance, pain charting, adjustments in diet and habits most women respond.
If still pain is persistent then, prescription of medication is thought off. The breast pain is mostly influenced by psychology of the person. There is low threshold for prescription of the drugs, as the benefit with many drugs available for breast pain are marginal or temporary and are associated with many other serious side effects and are not cost effective for many women.
The drugs like danazol, bromocriptine are not well tolerated by many and associated with menstrul disturbances and fertility problems as their mechanism of action is by blocking the hormonal activity. Other drugs like Tamo xifen and LHRH agonists like Goserelin also act by interfering with hormone action at different site in the body, proved to be useful only in few patients nd thus not widely used for breast pain. Last resort that is surgery is attempted for cyclical pain only if pain associated with definite lump. Mastectomy (removal of breast breast) is rarely done as last attempt.
Non cyclical pain is usually treated with on the similar lines, but in addition analgesics are more frequently prescribed as they are localised and musculoskeletal in origin. Pain is also self limited and subsides after 2 -3 years and with postural adjustments. So metimes in severe pain such as costochondritis, local steroid injection is given. Rarely surgery is done but it is not advisable as it may exaggerate the pain after operation.
Nodularity of breast is usually complained as lumpiness in breast. This is a benign d isease variously called as fibrocystic breast disease or fibroadenosis.
The features of this condition are :
After thorough clinical examination, the usual treatment advised is reassurance as in benign breast pain and kept under follow-up. But if there is persistent or localised nodularity or unilateral, then such cases should be submitted for TRIPLE ASSESSMENT.
Once malignancy is ruled out, then the treatment is just as in cyclical breast pain.
Most of the women don’t need any specific treatment the form of drugs or surgery. Neaarly 70% of women can controlled with reassurance and life style modification. Usually a step by step approach with increasing complexity is used depending on motivation and response of the women.
The reassurance includes explaining the woman that the pain is not due to cancer or any surgical disease and is a benign condition without harm to life. Then motivating her to mark the severity and timing of pain on pain chart daily 3 times. This is read by the physician and advises the appropriate measures.
Minor life style modifications include
All these measures help in reduction of pain score in most of the patients. If it is still persistent then primerose oil is advised. Some physicians advie vitamin E and its role is doubtful. With reassurance, pain charting, adjustments in diet and habits most women respond.
If still pain is persistent then, prescription of medication is thought off. The breast pain is mostly influenced by
psychology of the person. There is low threshold for prescription of the drugs, as the benefit with many drugs available for breast pain are mrginal or temporary and are associated with many other serious side effects and are not cost effective for many women.
The drugs like danazol, bromocriptine are not well tolerated by many and associated with menstrual disturbances and fertility problems as their mechanism of action is by blocking the hormonal activity. Other drugs like Tamo xifen and LHRH agonists like Goserelin also act by interfering with hormone action at different site in the body, proved to be useful only in few patients and thus not widely used for breast pain. Last resort that is surgery is attempted for cyclical pain only if pain asso ciated with definite lump. Mastectomy (removal of breast breast) is rarely do ne as last attempt.
Once a lump in the breast is identified during self-examination or clinical examination the primary concern is to exclude breast cancer. Though lump is the commonest symptom of cancer, most common lumps are due to Benign Breast disease. There are many varieties of benign breast lumps with distinct features, though underlying process is due to physiological cyclical hormonal fluctuations and phasic changes in physiology during menses, pregnancy, lactation all put together in term known as ANDI (Abnormalities in normal development and involution).
The many varities of benign b reast lumps are :
The following are the features:
Simple cyst is a fluid filled, thin walled cavity within the breast tissue.
The features of breast cysts are :
A cyst should be suspected as malignancy in following situations :
They are not usually palpable but quite a common finding which is commonest cause of bloody nipple discharge. They are benign projections of ductal epithelium in to the lumen of lactiferous ducts. Occassionally multiple duct papillomas may present as nipple discharge from multiple ducts. The treatment approach for this duct pap illoma is excision of the concerned duct-acinar unit lodging it. For this the duct is cannulated with a lacrimal probe or a nylon thread from the nipple end of duct. Then with a circumareolar incision nipple-areola complex is raised and the probe is followed and the the duct system is excised (Microdochectomy). If multiple duct p apillomas are present, Macrodochectomy or in later premenopaussal ladies mastectomy done because of slight risk of malignancy.
These are lesions found less commonly and if associated with features of atypia of cells , carry a high risk for breast cancer development. Then it is called Atypical epithelial hyperplasia. They are to be closely monitored after excision.
It is a rare benign breast disease usually occurs >35 years and is not premalignant.
Fibrosis is not a specific entity, but is be found in all breast conditions in varying proportions. Sometimes a localized lump may wholly be composed of fibrous tissue with few scattered cells. This is not premalignant may need excision fr cosmetic reasons as it fibrotic process may distort breast form.
Duct ectasia occurs in >35 years age group and may persist for decades. It cause nodular lump, distortion of breast form and most importantly presents as nipple discharge. Characteristically, the nipple discharge is greenish in colour and may be mixed with blood. It is also called as Plasma cell mastitis due to histological features of macrophages and plasma cells surrounding degenerated duct remnants with ductal dilatation, the findings similar to bro nchiectasis in lung.
Nipple discharge is the third most common breast complaint for which women seek medical attention, after lumps and breast p ain. A woman's breasts have some degree of fluid secretion activity throughout most of the adult life.
The difference between lactating (milk producing) and non-lactating breasts is mainly in the degree or amount of secretion and to a smaller degree in the chemical compositio n of the fluid. In non-lactating women, small plugs of tissue block the nipple ducts and keep the nipple from discharging fluid.
The majority of nipple discharges are associated with non-malignant changes in the breast such as hormonal imbalances. However, any woman with a suspicious or worrisome nipple discharge should consult her physician.
Suspicious nipple discharge is due to a malignant (cancerous) lesion just ten percent (10%) of the time. Discharge caused by a malignant condition is almost always on one side only (unilateral). Discharge that is coming from both breasts (bilateral) is usually benign. Papilloma usually causes discharge from a single breast duct.
| Sr. No. | Type of discharge | Common cause |
|---|---|---|
| Serous | Duct papilloma, duct ectasia. | |
| Milk | Lactation, Prolactin excess states | |
| Grummous | Ductectasia | |
| Bloody | Duct papilloma, duct ectasia | |
| Greenish | Breast abcess |
A blood test of prolactin levels is often made to determine hormonal causes of excessive milky discharge (galactorrhea). A hormone imbalance, pituitary tumor, and certain drugs such as sedatives, tranquilizers, hormone replacement or birth control pills may cause excessive prolactin levels. If there is a suspicious nipple discharge , Clinical breast exam (CBE) is first performed. If a discharge can be produced during the examination, some of the fluid may be collected and examined under a microscope to see if any blood cells or cancer cells are present. This test is called a nipple smear. The discharge may also be examined for signs of infection such as pus. Papillomas may be seen with microscopic examination of a nipple discharge, but this test may be inconclusive.
If the discharge is bloody or serous, a mammogram is often the first test to be performed. Even when no cancer cells are found in a nipple discharge, it is not possible to rule out breast cancer or other condition such as papilloma.
If a patient has a suspicious mass together with nipple discharge, evaluation of the mass should be performed using mammography, adjunctive imaging and biopsy as necessary. If these tests are negative and show no malignancy, nipple smear should be evaluated.
Duct excision is usually performed on an outpatient basis with local anesthesia. The procedure is usually done through a small circular incision near the areolar border around the nipple. It is not uncommon for the pathology found to be so microscopic that it is invisible without the assistance of a microscope. Typically, nursing ability and nipple sensation are preserved after duct excision. Breast-feeding in the other breast should have no affect from the duct excision in the opposite breast. If multiple ducts are involved and in refractory cases excision of all major duct system is done which is known as Macrodochectomy. But with this nursing ability is lost and nipple sensation is lost partially.
The above information details are general guidelines. If you have nipple discharge that is worrisome, please do not hesitate to contact your physician or healthcare provider about it. However, keep in mind that most nipple discharge is not caused by breast cancer.