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Mastalgia (breast pain) is very common. Most women experience breast pain in the few days leading up to their menstrual cycle. This usually requires no treatment.

Breast pain that lasts for more than seven days per menstrual cycle, that is moderate to severe and not responsive to simple remedies, should be assessed in a specialist clinic. Breast pain can either be cyclical (varies with the menstrual period) or non-cyclical. Cyclical breast pain is most marked in the days before the start of the menstrual cycle, which provides relief soon upon onset of menstruation.

Breast pain can affect one side, part or the whole of both breasts. Areas that are most often involved are centrally and in the tail of the breasts towards the armpits.

Possible causes

Cyclical mastalgia is probably associated with benign breast changes that are accentuated by normal hormonal variation through the menstrual cycle. There is no consistent relationship between any pathological (when tissue is examined under the microscope) breast changes and mastalgia. Fibrocystic change and mastalgia are both very common and overlap of groups of women who have both are therefore frequent. Large simple benign cysts that are tense may account for localised breast pain. Inflammation within the ducts behind the nipple areolar complex (periductal mastitis) may cause pain in this distribution. There is no clear relationship between breast pain and abnormalities in circulating hormone levels in women who have breast pain. This may be due to a differential response of breast tissue to normal hormonal levels between women with and without breast pain

True non-cyclical mastalgia may arise from breast tissue and the aetiology of this overlaps with cyclical mastalgia. Non-cyclical breast pain may, however, arise from the chest wall. Tietze's syndrome is localised pain arising from the junction between one or more ribs and the breast bone. Such breast pain is sited in the inner half of the breast and usually unilateral. Non-cyclical pain may also arise from strain of the chest wall muscles at the point of their attachment to the ribs. As some of these muscles are also attached to the arm, such as the pectoralis major, such apparent breast pain may be aggravated by excessive physical strain. The underwire of a bra or ill-fitting support may cause pain in the lower half of the breast that is unrelated to the cycle.

Management of mastalgia

Many women derive considerable benefit from simple life-style changes, dietary manipulation and non-prescription medication (often natural products).

" Dietary fat intake influences the fatty acid components of the breast, and breast pain may arise from alteration in fat metabolism. A reduction in saturated or animal fats in particular may be helpful. Specifically, dietary reduction should be applied to animal fats, full cream milk, fatty cheeses and butter.

" Methylxanthines are a group of chemicals that include caffeine and theobromine. These substances are found in common dietary products including coffee, tea, chocolate and cola, as well as non-proprietary medicines to reduce drowsiness in common cold remedies and antihistamine preparations. Reduction of dietary components that contain these derivatives often improve the symptoms of mastalgia.

" A well supporting bra helps and you may find fitting by an expert in a reputable high street store of benefit. If breast pain is sited inferiorly in the breast, change in the type of bra used often helps, particularly avoiding those with an underwire.

" Smoking should also be reduced or stopped as this can aggravate periductal mastitis.

" Evening primrose oil (EPO) is used in the treatment of mastalgia because breast pain may be associated with reduced levels of essential fatty acids in blood and breast tissue. EPO is a natural product and there are very few side effects at the doses used. It can be obtained from a chemist without prescription and used at 1000 mg per day for three months. EPO should then be discontinued and if breast pain recurs, often months or years later, a further three-month course can be used. An alternative to EPO is Star Flower Oil that contains similar chemicals and is available without prescription. Star Flower Oil should be used at a dose of 2 or 3 500mgs daily for three months. Then reduce to 1 or 2. Purified forms of evening primrose oil, such as gamma-linolenic acid, are available in preparations such as Efamast or Epogam.

The majority of women have relief of mastalgia symptoms with this combination of simple treatments. If there has been no relief, one or more of the following treatment categories may be used.

Endocrine therapy

Danazol is a chemical derivative of the male hormone testosterone. It works by inhibiting oestrogen and progesterone receptors in the breast and brain, thus inhibiting enzymes involved in ovarian steroid production. The net effect is a reduction in a hormone called leutinising hormone (LH) in younger women, and reduces gonadotrophin levels in post-menopausal women.p Danazol requires a prescription and is used at doses of 200 mg to 300 mg daily, starting after a period. The dosage may be reduced to 100 mg and the total length of treatment is usually six months.

Bromocriptine is used as an alternative to danazol. If danazol does not work, bromocriptine may be tried and vice versa. Bromocriptine reduces prolactin secretion by acting as a dopamine agonist (in the body dopamine inhibits prolactin secretion). Bromocriptine requires a prescription and is gradually increased to 2.5 mg twice daily for three to six months. The medication should be taken with meals.

Side effects of danazol include acne, oily hair, hot flushes, increased body hair growth, deepening of the voice, fluid retention, headaches and an increase in sex drive.

The side effects of bromocriptine are nausea, dizziness, headache, vomiting, and constipation.

Danazol and/or bromocriptine are used because it is thought that prolactin and related hormonal disorders may be responsible for breast pain, although abnormal hormone levels often cannot be shown in an individual person.

Severe mastalgia that is refractory to danazol or bromocriptine can be treated by tamoxifen. The most common use of tamoxifen is as an adjuvant (additional) treatment of breast cancer. In breast pain, it is thought to work by inhibiting the action of oestrogen on the breast. Tamoxifen is very effective in treating breast pain at doses of 20 mg per day, for three to six months. The side effects of tamoxifen include flushing, sweating, vaginal discharge, and altering or stopping periods. Long-term dangerous side effects are unlikely as it is used for a short period of time only.

Other treatments

Vitamin B6 at 50 mg to 100 mg a day for three months is unlikely to be helpful for breast pain per se but might be useful if breast pain is associated with pre menstrual syndrome. Other vitamins and diuretics are not usually used for treating breast pain. Some women find complementary approaches, including homeopathy, helpful.

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