Benign breast pain

Benign breast pain is either cyclical or non-cyclical. The first follows the pattern of the menstrual cycle; the second is random in timing.

Cyclical pain:

• Most commonly affects women <35 years of age
• Onset is during the early phase of the cycle; intensity gradually worsens to reach a peak just before menstruation, easing with the start of the period
• In mild cases, the pain affects the upper outer quadrants of the breasts
• In severe cases, the whole breast may feel engorged, tender and heavy and physical contact can be unbearable
• Post-menopausal women on HRT can get cyclical breast pain

Examination:

• Tenderness and a firm nodular feel in the upper outer quadrants of the breast

Investigation of cyclical breast pain:

• In the presence of a typical history of bilateral cyclical pain, there is often little reason to embark on any investigations

Management of cyclical breast pain:

• The most important aspect is reassurance that the condition is entirely benign and is not associated with either carcinoma or a tendency to its development in later life
• Many women are content to live with their discomfort if they can be reassured on both these counts

Three drugs are commonly used:

• Gamma-linoleic acid (evening primrose oil):
• 320mg daily po
• An essential fatty acid
• Thought to render breast cells less sensitive to the effects of sex hormones
• 60% of sufferers experience relief
• Needs to be taken for 3-4 months before relief is experienced
• Danazol:
• 200-300mg daily po
• Interferes with the action of oestrogen on breast tissue
• Bromocriptine:
• Gradually increasing doses up to a maximum of 5mg daily po
• Blocks the pituitary drive to produce FSH and LH

Bromocriptine and Danazol can cause menopausal-like symptoms

Non-cyclical pain:

May be intermittent or constant and is confined to localised areas of one breast. It can be caused by conditions both within and without the breast, including:

• Mammary duct ectasia
• Periductal mastitis
• Trauma
• Tietze’s disorder – characterised by tenderness over costochondral junctions

It is often difficult to identify a specific cause of non-cyclical pain

Investigation of non-cyclical breast pain:

• As with cyclical breast pain, investigation in those <35 years of age is limited to clinical assessment
• In older women, mammography is often a wise precaution, particularly if the pain is consistently localised to one spot or is associated with a lump
• 10% of patients with such features have an underlying carcinoma

Management of non-cyclical breast pain:

• Is much more resistant to treatment than is cyclical pain

The following may be helpful:

• Simple NSAIDs
• Treatment of inflammatory conditions
• Local lignocaine/steroid injection

Most patients end up having to live with their pain until it resolves by itself, which in the great majority it eventually does