Clinical experience of drug treatments for mastalgia

Fibrocystic Change

Fibrocystic changes are commonly seen in clinically symptomatic patients and during imaging workup of screening-detected findings. The term "fibrocystic changes" encompasses a broad spectrum of specific benign pathologic entities. Recognition of classically benign findings of fibrocystic changes, including cysts and layering calcifications, can prevent unnecessary follow-ups and biopsies. Imaging findings such as solid masses, nonlayering calcifications, and architectural distortion may require core needle biopsy for diagnosis. In these cases, understanding the varied appearances of fibrocystic change aids determination of radiologic-pathologic concordance. Management of fibrocystic change is typically conservative.

The effect of Oenothera biennis (Evening primrose) oil on inflammatory diseases: a systematic review of clinical trials

BACKGROUND

Evening primrose oil (EPO), extracted from the seeds of Oenothera biennis, has gained attention for its therapeutic effects in various inflammatory conditions.

METHOD

We performed a systematic search in multiple databases and defined the inclusion criteria based on the following PICOs: P: Patients with a form of inflammatory condition, I: EPO, C: Placebo or other therapeutic interventions, O: changes in inflammatory markers or patients' symptoms; S: randomized controlled trials. The quality of the RCTs was evaluated using Cochrane's RoB tool.

RESULTS

Several conditions were investigated in the literature. In rheumatoid arthritis, mixed results were observed, with some studies reporting significant improvements in symptoms while others found no significant impact. EPO showed some results in diabetes mellitus, atopic eczema, menopausal hot flashes, and mastalgia. However, it did not demonstrate effectiveness in chronic hand dermatitis, tardive dyskinesia, psoriatic arthritis, cystic fibrosis, hepatitis B, premenstrual syndrome, contact lens-associated dry eyes, acne vulgaris, breast cyst, pre-eclampsia, psoriasis, or primary Sjogren's syndrome. Some results were reported from multiple sclerosis after EPO consumption. Studies in healthy volunteers indicated no significant effect of EPO on epidermal atrophy, nevertheless, positive effects on the skin regarding hydration and barrier function were achieved.

CONCLUSION

Some evidence regarding the potential benefits of EPO in inflammatory disorders were reported however caution is due to the limitations of the current survey. Overall, contemporary literature is highly heterogeneous and fails to provide strong recommendations regarding the efficacy of EPO on inflammatory disorders. Further high-quality studies are necessitated to draw more definite conclusions and establish O. biennis oil effectiveness as an assuring treatment option in alleviating inflammatory conditions.

Herbal Products Used in Menopause and for Gynecological Disorders

Herbal products are often used as an alternative to pharmacological therapy. Menopausal symptoms and gynecological disorders (such as premenstrual syndrome and dysmenorrhea) are the indications where pharmacological therapy may have serious adverse events, hence many women prefer to use herbal products to help with these symptoms. Here, we reviewed plants and derived products, which are commonly used for the abovementioned indications, focusing on clinical data, safely profile and whether or not their use is justified. We noted that limited data are available on the use of some plants for alleviating the symptoms of menopause and gynecological disorders. While black cohosh (Cimicifuga racemose) and red clover (Trifolium pretense) were consistently shown to help reduce menopausal symptoms in clinical studies, currently available data do not fully support the use of fenugreek (Trigonella foenum-graecum), hops (Humulus lupulus), valerian (Valeriana officinalis), and soybean (Glycine max and Glycine soja) for this indication. For premenstrual syndrome and premenstrual dysphoric disorder, chaste tree (Vitex agnus-castus) shows effectiveness, but more clinical studies are needed to confirm such effect upon the use of evening primrose (Oenothera biennis).

A Systematic Review and Meta-Analysis of the Efficacy of Evening Primrose Oil for Mastalgia Treatment

Mastalgia, or breast pain, is common among women which can lead to significant impairment in daily living. Hence, finding an effective treatment that can alleviate the symptom is very important. Thus, we carry out this study to determine the efficacy of evening primrose oil (EPO) for mastalgia treatment in women. The review included published randomised clinical trials that evaluated EPO used for treating mastalgia against a placebo or other treatments, irrespective of the blinding procedure, publication status, or sample size. Two independent authors screened the titles and abstracts of the identified trials; full texts of relevant trials were evaluated for eligibility. Two reviewers independently extracted data on the methods, interventions, outcomes, and risk of bias. The random-effects model was used for estimating the risk ratios and mean differences with 95% confidence intervals. Thirteen trials with 1752 randomised patients were included. The results showed that EPO has no difference to reduce breast pain compared to topical NSAIDS, danazol, or vitamin E. The number of patients who achieved pain relief was no different compared to the placebo or other treatments. The EPO does not increase adverse events, such as nausea, abdominal bloating, headache or giddiness, increase weight gain, and altered taste compared to a placebo or other treatments. EPO is a safe medication with similar efficacy for pain control in women with mastalgia compared to a placebo, topical NSAIDS, danazol, or vitamin E.

Current Management and Treatment Options for Breast Pain

Breast pain is a commonly experienced symptom in women of all ages and can significantly impact quality of life. Fear of cancer prompts many patients to report their pain, although risk for malignancy is low in the absence of a palpable mass or other abnormal finding on breast examination. All patients with breast pain should have a thorough history and physical examination to determine if diagnostic imaging is indicated. Management of breast pain without anatomic or radiographic abnormalities depends on pain type and severity. Often, no intervention is required. However, for women with pain that adversely impacts daily living, short-term therapies may be considered. For mild to moderate pain, a trial of conservative, nonpharmacologic strategies should be tried first. For those with severe symptoms impacting quality of life, a trial of pharmacologic therapy can be considered after appropriate counseling for medication-related adverse effects. Herein, we have provided a concise summary of a generalized approach to classification, assessment, and management of breast pain.

Triacylglycerol structure of plant and fungal oils containing ψ-linolenic acid

The triacylglycerol stereospecific structure was determined for the major plant oils containing ψ-linolenic acid (GLA): evening primrose oil (EPO), black currant oil (BCO), borage oil (BO), andMucor javanicus fungal oil (MJO). It was found that GLA, although not α-linolenic acid, resisted pancreatic lipase hydrolysis. Therefore, the 2-position analysis was determined using phospholipase C-generated 1,2-diacylglycerol and phospholipase A2-generated lysophosphatidylcholine. GLA was found to be concentrated in the 3-position of EPO and BCO, the 2-position of BO, and the 2- and 3-positions of MJO. In BCO, octadecatetraenoic acid (n-3), also a †-6 fatty acid, was distributed similarly to GLA, but α-linolenic acid was found predominantly in the 1-position. Linoleic acid was nearly evenly distributed in all positions of EPO and BCO but was concentrated in the 1-position of BO and the 2-position of MJO. Both palmitic and stearic acids were found predominantly in the 1-position of all of the oils. The results demonstrate similarities and differences in the positional distribution of fatty acids in GLA-containing oils.

Clinical effectiveness of vitamin E and vitamin B6 for improving pain severity in cyclic mastalgia

Background:

Recent attempts have been focused on employing chemical and natural supplemental agents for treatment of cyclic mastalgia. Among various agents, the potential effects of vitamins remain questionable. In the present study, we examined the efficacy of two types of these vitamin supplements (vitamin E and vitamin B6) in improving pain severity in cyclic mastalgia.

Materials and Methods:

In a randomized double-blinded clinical trial, 80 patients suffering from cyclic mastalgia were randomly assigned to receive 200 IU of vitamin E daily or 40 mg/day of vitamin B6 for 2 months. Written informed consent was obtained from all participants. Severity of breast pain was detected by the Cardiff breast pain score during one menstrual cycle before and two menstrual cycles after the intervention. Data were analyzed using t-test, Chi-squared test, analysis of variance (ANOVA), and regression with SPSS version 19 and P < 0.05 was considered significant.

Results:

There was no significant difference in the mean of severity of cyclic mastalgia during one menstrual cycle before the intervention between the vitamin E and B6 groups (9.1 ± 2.1 and 8.4 ± 3.1, respectively), but the difference was significant during the first cycle (5.1 ± 1.6 and 5.2 ± 2.5, respectively) and the second menstrual cycle (2.3 ± 1.0 and 2.6 ± 2.0, respectively) in the two groups after the intervention. The trend of changes in pain severity score showed significant downward trend of pain severity score within the study period in both the treatment groups (P < 0.001), while these trends were similar in both groups when examined by the repeated-measure ANOVA test. By multivariable linear regression analysis adjusted for baseline variables, we found that both the treatment regimens resulted in similar reduction in breast pain severity (P = 0.067).

Conclusions:

Both regimens containing vitamin E and vitamin B6 are similar in reducing breast pain severity in cyclic mastalgia.

Comparison of naproxen with placebo for the management of noncyclical breast pain: a randomized, double-blind, controlled trial

BACKGROUND

Breast pain is a common symptom in patients attending breast clinics. Although most patients experience mastalgia of mild to moderate severity, approximately 15% of patients suffer from severe pain that causes significant distress and some disturbance in their daily life that lead them to seek treatment. Despite a considerable number of drugs suggested for decreasing the severity of mastalgia, there is no standard treatment for the complaint. In this study, we investigated the effect of naproxen on reducing the complaint of breast pain compared with placebo.

METHODS

Eighty-one women suffering from noncyclic breast pain were recruited to a randomized, double-blind, clinical trial between January 2002 and September 2004. All patients were suffering from this complaint for at least 3 months before the study. Patients were randomly assigned to two groups. Patients in the case group received naproxen 250 mg BD. Patients in the placebo group took placebo in a similar manner. The intensity of mastalgia was assessed before and twice after intervention by using a Visual Analogue Scale.

RESULTS

Forty-two of 81 patients were recruited randomly as cases and the remaining 39 were assigned placebo. Of these 24 and 22 patients fulfilled the study protocol respectively. The mean age of patients was 35 (SD = 7.5; range, 19-55) years. The mean pain severity at the beginning of the study was 5.8 and 6.1 in naproxen and placebo groups, respectively. The severity of pain was decreased significantly at the end of the study in both groups (3.9 in patients and 3.7 in controls (P = 0.005 and 0.0001)). Although the decrease in pain severity in each individual group was statistically significant, it was not significant compared with one another (P = 0.64).

CONCLUSIONS

Breast pain is a complex symptom that can be relieved significantly with reassurance. According to the result of this study, naproxen has no superiority over placebo in reducing noncyclic breast pain.

Might DHEA be considered a beneficial replacement therapy in the elderly?

Dehydroepiandrosterone (DHEA) [prasterone] is typically secreted by the adrenal glands and its secretory rate changes throughout the human lifespan. When human development is completed and adulthood is reached, DHEA and DHEA sulphate (DHEAS) [PB-008] levels start to decline so that at 70-80 years of age, peak DHEAS concentrations are only 10-20% of those in young adults. This age-associated decrease has been termed 'adrenopause', and since many age-related disturbances have been reported to begin with the decline of DHEA/DHEAS levels, this provides a potential opportunity for use of DHEA as replacement therapy. For these reasons, use of DHEA as a replacement therapy in aging men and women has been proposed and this paper outlines the reported beneficial effects of such treatment in humans. Many interesting results have been obtained in experimental animals suggesting that DHEA positively modulates most age-related disturbances. However, renewed interest in DHEA has arisen as a result of recent studies suggesting that DHEA appears to be beneficial in hypoandrogenic men as well as in postmenopausal and aging women. Menopause is the event in a woman's life that induces a dramatic change in the steroid milieu, and use of DHEA as 'replacement treatment' has been reported to restore both the androgenic and estrogenic environment and reduce most of the symptoms of this change. As menopause is the beginning of the biological transition of women towards senescence, it is of great interest to better understand how DHEA might help to solve and/or overcome the problems of this complex stage of life. In men with adrenal insufficiency and hypogonadism without androgen replacement, DHEA administration results in a significant increase in circulating androgens. Though most data are suggestive for use of DHEA as hormonal replacement treatment, more defined and specific clinical trials are needed to uncover all of the 'secrets' and features of this steroid before it can be used as a standard treatment. Furthermore, DHEA is perceived differently around the world, being considered only a 'dietary supplement' in the US, while in many European countries it is considered a 'true hormone' that has not been approved for use as a hormonal treatment by the European health authorities. This overview offers some points of view on use of DHEA as an experimental hormonal replacement therapy.

Objective analyses of mastalgia in breast clinics: Is breast pain questionaire a useful tool in a busy breast clinic?

The aim of this study was to investigate the feasibility of use of breast pain questionnaire (BPQ), a short, focussed and robustly designed tool to assess severity of mastalgia and its impact on quality of life, in a busy breast clinic. Seventy-four consecutive women completed BPQ prior to their consultation with a Breast Surgeon. Based on the BPQ score, mastalgia was graded as mild (score 0-100) in 26%, moderate (score 101-200) in 59% and severe (score >200) in 15% of patients. In 93% of patients breast pain lasted for more than 5 days and visual analogue score (VAS) was more than 3.5 in 82% of patients. The breast pain was described as mild (12%) discomforting (55%), distressing (22%) excruciating (3%) or horrible (8%). All results are presented as median (interquartile ranges). Out of maximum possible 100, overall pain rating was 17(9-31), percent sensory component was 21(12-33) and percent affective component was 0(0-17). The percent VAS was 60(40-80), percent pain index was 40(40-60) and quality of life score (maximum possible 60) was 20(0-40). Of maximum possible score of 360, total breast pain was 137(99-180). In conclusion BPQ can be used routinely in a busy breast clinic as a quick, user-friendly and reliable tool to assess the degree and severity of breast pain in order to provide an organised approach to the management of mastalgia.

Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction?

BACKGROUND

Mastodynia is among the most frequently reported symptoms in women with breast complaints; it is usually classified as cyclic, noncyclic, or nonbreast in origin. A useful response with medical or conservative therapy is obtained in the majority of these patients. There is a subset of patients, however, who have exhausted every medical effort and psychiatric counseling and will desire mastectomy with breast reconstruction in the hope of alleviating their chronic pain.

METHODS

Three patients with noncyclical, bilateral mastodynia referred for breast reconstruction options from December of 2000 to March of 2004 are presented in this article. Daily breast pain charts with a visual analogue scale for pain assessment were analyzed and recorded for all patients throughout the study period.

RESULTS

Two patients underwent delayed reconstruction and had complete resolution of pain 6 to 8 weeks after bilateral mastectomy, with no recurrence of mastalgia after reconstruction. One patient underwent bilateral mastectomy with immediate reconstruction and achieved complete resolution of her pain 3 months postoperatively. Histopathologic findings of all breast specimens revealed benign breast tissue with proliferative breast disease consistent with mastodynia.

CONCLUSIONS

This modality, which includes mastectomy with or without reconstruction, is a viable alternative after exhaustion of all other nonsurgical options and when quality of life is significantly affected. Although mastectomy for the treatment of mastodynia refractory to medical therapy does not guarantee alleviation of chronic breast pain, it should be considered in these often desperate patients.

Topical nonsteroidal anti-inflammatory drugs versus oil of evening primrose in the treatment of mastalgia

OBJECTIVE

To compare oil of evening primrose (OEP) and topical nonsteroidal anti-inflammatory (NSAIDs) with respect to safety, effectiveness, rapidity of response, cost effectiveness and acceptability in the treatment of breast pain.

STUDY DESIGN

An open, non-randomised, comparative study of topical (NSAI) gel versus OEP was carried out, over a period of one year.

PATIENTS AND METHODS

Fifty female patients attending the outpatient department with moderate to severe breast pain were given one of the two agents alternatively, after selection.

RESULTS

Results showed that out of 25 patients treated with OEP, 64% had a clinically significant response after three months of treatment, compared with 92% with topical NSAIDs. Only one patient (4%) had side effects with OEP, while no patient had side effects with topical NSAIDs. Twenty per cent and seventy per cent showed acceptability as far as costs were concerned and mode of administration respectively, with OEP. The acceptability rate was 68% and 96% respectively, with topical NSAIDs.

CONCLUSION

This study has shown topical NSAIDs to be safe, effective, rapid and acceptable mode of treatment for cyclical and non-cyclical mastalgia.

A Randomized Multicenter Study of Gamolenic Acid (Efamast) with and without Antioxidant Vitamins and Minerals in the Management of Mastalgia

In a double-blind, placebo-controlled, parallel group, multicenter study, 555 women with moderate to severe mastalgia were randomized to one of the four treatment groups to receive (a) gamolenic acid (GLA) and antioxidants, (b) placebo fatty acids and antioxidants, (c) GLA and placebo antioxidants, or (d) placebo fatty acids and placebo antioxidants, for four menstrual cycles. This was followed by a further eight menstrual cycles of open treatment in which all patients received GLA, but continued to be randomized to active or placebo antioxidants as in the preceding parallel phase. Diary pain cards and linear analog charts were used for assessment of response. A reduction in breast pain was seen in all four treatment groups during the blinded treatment phase. There was a substantial improvement in the placebo fatty acids groups (response rate of 40%), and there were no significant differences among the four treatment groups. During the open treatment phase, a further reduction in breast pain was seen in all groups, with no statistically significant differences between groups. This study showed that GLA (Efamast) efficacy did not differ from that of placebo fatty acids, regardless of whether or not antioxidant vitamins were present.

Local anaesthetic and steroid combined injection therapy in the management of non-cyclical mastalgia

AIMS

We aimed to assess the effectiveness of a local anaesthetic and steroid combination injection therapy in the management of non-cyclical mastalgia.

METHODS

Patients with non-cyclical mastalgia were assessed for rib tenderness (lateral chest wall tenderness-LCWT). The tenderest spot was injected with a combined preparation of 1 ml 2% lignocaine and 1 ml 40 mg depomedrone. Those who declined injection therapy were advised on topical or oral NSAIDs or reassurance. All patients were reassessed 6 weeks later. A successful outcome was taken as either a complete response (CR) or partial response (PR), i.e. pain although present is tolerated.

RESULTS

One hundred and thirty eight women were diagnosed with LCWT. One hundred and four women were injected. Thirty-four women declined and were managed appropriately. At assessment 83 injected cases were successful (83%; CR n = 61, PR n = 22) compared to 13 non-injected cases (44.8%; CR n = 5, PR n = 8, P < 0.0001). No side effects were recorded. Sixteen cases recurred and were successfully re-injected.

CONCLUSIONS

A steroid and local anaesthetic injection is an effective and safe treatment for LCWT.

Evaluation and management of breast pain

Pain is one of the most common breast symptoms experienced by women. It can be severe enough to interfere with usual daily activities, but the etiology and optimal treatment remain undefined. Breast pain is typically approached according to its classification as cyclic mastalgia, noncyclic mastalgia, and extramammary (nonbreast) pain. Cyclic mastalgia is breast pain that has a clear relationship to the menstrual cycle. Noncyclic mastalgia may be constant or intermittent but is not associated with the menstrual cycle and often occurs after menopause. Extramammary pain arises from the chest wall or other sources and is interpreted as having a cause within the breast. The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low. After appropriate clinical evaluation, most patients with breast pain respond favorably to a combination of reassurance and nonpharmacological measures. The medications danazol, tamoxifen, and bromocriptine are effective; however, the potentially serious adverse effects of these medications limit their use to selected patients with severe, sustained breast pain. The status of other therapeutic strategies and directions for future research are discussed.

Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment

BACKGROUND

The aim of the study was to investigate the effects of topical nonsteroidal antiinflammatory drugs (NSAIDs) on mastalgia.

STUDY DESIGN

A prospective, randomized, blinded, placebo-controlled study was performed to evaluate the effects of topical NSAIDs on cyclic and noncyclic mastalgia. A total of 108 patients, 60 with cyclic (group I) and 48 with noncyclic (group II) breast pain were enrolled. Patients within each group were randomly assigned to receive either topical NSAIDs or placebo three times daily for at least 6 months. Severity of pain was measured before and after 6 months of treatment.

RESULTS

The pain score decreased significantly when the mean initial breast pain score was compared with the sixth-month breast pain score of the treatment or the placebo group of cyclic (p = 0.0001 and p = 0.0001, respectively) or noncyclic mastalgia (p = 0.0001 and p = 0.0001, respectively). Significant differences were found when the mean within-person change in pain values in each treatment group were compared with the change in the respective placebo group for either cyclic or noncyclic mastalgia (p = 0.0001 and p = 0.0001, respectively). Changes in pain within treatment groups or placebo groups for cyclic versus noncyclic mastalgia were not found to be statistically different (p = 0.53 and p = 0.96, respectively). No side effect was seen in any group.

CONCLUSIONS

Topical application of NSAIDs was effective in both cyclic and noncyclic mastalgia with minimal side effects.

Endocrine and intracrine sources of androgens in women: inhibition of breast cancer and other roles of androgens and their precursor dehydroepiandrosterone

Serum androgens as well as their precursors and metabolites decrease from the age of 30-40 yr in women, thus suggesting that a more physiological hormone replacement therapy at menopause should contain an androgenic compound. It is important to consider, however, that most of the androgens in women, especially after menopause, are synthesized in peripheral intracrine tissues from the inactive precursors dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S) of adrenal origin. Much progress in this new area of endocrine physiology called intracrinology has followed the cloning and characterization of most of the enzymes responsible for the transformation of DHEA and DHEA-S into androgens and estrogens in peripheral target tissues, where the locally produced sex steroids are exerting their action in the same cells in which their synthesis takes place without significant diffusion into the circulation, thus seriously limiting the interpretation of serum levels of active sex steroids. The sex steroids made in peripheral tissues are then inactivated locally into more water-soluble compounds that diffuse into the general circulation where they can be measured. In a series of animal models, androgens and DHEA have been found to inhibit breast cancer development and growth and to stimulate bone formation. In clinical studies, DHEA has been found to increase bone mineral density and to stimulate vaginal maturation without affecting the endometrium, while improving well-being and libido with no significant side effects. The advantage of DHEA over other androgenic compounds is that DHEA, at physiological doses, is converted into androgens and/or estrogens only in the specific intracrine target tissues that possess the appropriate physiological enzymatic machinery, thus limiting the action of the sex steroids to those tissues possessing the tissue-specific profile of expression of the genes responsible for their formation, while leaving the other tissues unaffected and thus minimizing the potential side effects observed with androgens or estrogens administered systemically.

Evening primrose oil and fish oil for severe chronic mastalgia: a randomized, double-blind, controlled trial

OBJECTIVE

The purpose of this study was to evaluate the effect of evening primrose oil and fish oil on breast pain in premenopausal women with severe chronic mastalgia, in a randomized double-blind factorial clinical trial.

STUDY DESIGN

One hundred twenty women were placed randomly into four groups: (1) fish oil and control oil, (2) evening primrose oil and control oil, (3) fish and evening primrose oils, or (4) both control oils during 6 months. Corn oil and corn oil with wheat germ oil were used as control oils. The change in the percentage of days with breast pain after 6 months of treatment was analyzed on an intention-to-treat basis.

RESULTS

The decrease in days with pain was 12.3 % for evening primrose oil and 13.8% for its control oil (P =.73); the decrease in days with pain was 15.5% for fish oil and 10.6% for its control oil (P =.28).

CONCLUSION

All groups showed a decrease in pain. Neither evening primrose oil nor fish oil offered clear benefit over control oils in the treatment of mastalgia.

Clinical management of breast pain: a review

Breast pain (mastalgia) is a common cause of anxiety among women and frequently leads to a primary care clinic for consultation. Fortunately, mild premenstrual breast discomfort lasting for 1 to 4 days can be considered "normal." However, moderate-to-severe breast pain lasting over 5 days can interfere with usual activities, lead to unnecessary medical tests, and potentially invite the use of ineffective, occasionally harmful medications. Despite the severity of some patients' symptoms, mastalgia is still considered a trivial complaint by many physicians; often it is felt to be psychological in nature. Careful evaluation to rule out breast cancer and reassure the patient is enough to make the pain resolve in most cases. In a few patients, however, mastalgia is severe enough to deserve further evaluation and treatment. Overall, 92% of patients with cyclical mastalgia (CM) and 64% with noncyclical mastalgia (NCM) can obtain relief of their pain with the judicious use of several available therapies.

Gynecology: select topics

Menopause, premenstrual syndrome, dysmenorrhea, female fertility, and mastalgia are common problems not easily treated by conventional medicine. Women often seek alternative therapies to help address these conditions. Some evidence points to the efficacy of black cohosh, exercise, and possibly Kava and St. John's wort, in the treatment of menopausal symptoms. Clinical trials indicate that symptoms of premenstrual syndrome may be alleviated with calcium, magnesium, vitamin E. Thiamine, omega-3 fatty acids, the Japanese herbal concoction, TSS, and calcium have proved useful in treating women with dysmenorrhea. Symptoms of mastalgia may be attenuated by evening primrose oil, chaste tree and flaxseed oil may be helpful.

Herbs, menopause, and dialysis

Women with chronic kidney disease (CKD) are at increased risk for menstrual disorders, early menopause, and osteoporosis, and rarely discuss gynecologic and reproductive issues with their nephrologist. Various complementary and alternative medicine (CAM) products are of interest to women with end-stage renal disease (ESRD) who have these disorders. However, very little is known about the specifics of using herbal medicines in patients on chronic dialysis, resulting in numerous problems when patients and providers try to ascertain the safety and efficacy of these products. This article reviews evidence regarding the safety and efficacy of black cohosh, ginseng, chastetree, dong quai, evening primrose oil, soy products, and the so-called natural hormones. Pharmacologic parameters important to evaluating the quality of botanical products are discussed, along with recommendations and information resources.

Flavonoids--a new direction for the treatment of fluid retention?

Flavonoid extracts are important for the health of the micro-blood vessel network and are clinically exploited in this way by medical herbalists and physicians in mainland Europe. In the present review, we provide preliminary evidence that suggests that plant flavonoid extracts from dietary sources facilitate the repair of vessel damage responsible for 'small blood vessel permeability'. Correction of this pathophysiological abnormality is known to lead to a reduction in symptoms of diffuse benign fluid retention including swollen limbs, fingers, breasts and the tissue surrounding the eye area. There is currently little orthodox treatment for this type of fluid retention except diuretics which are not without side effects and fail to address the underlying cause of the disorder. This paper marshals available data including some preliminary studies that suggest that detailed scientific study of this clinical area and its treatment through flavonoid intervention is warranted.

A randomized double blind-cross over trial of soya protein for the treatment of cyclical breast pain

Twenty patients with cyclical breast pain were enrolled in a double-blind cross-over trial in which either a soy protein drink or a flavoured cow's milk was taken orally each day for 3 months before crossing over to the alternate drink for a further 3 months. Records of pain scores were taken throughout the study. Blood was also taken before and after 3 and 6 months for the measurement of phytoestrogents to assess compliance. Two women withdrew from the study at the outset leaving 18 evaluable patients who completed the study. Of these 10 (56%) felt that soy protein improved breast pain (two of whom received soy as first treatment) and two (11%) felt that cow's milk alleviated symptoms (one receiving this as first preparation) and the remaining six (33%) experienced no relief of pain with either dietary preparation. Blood levels of diadzein and genistein were elevated after the ingestion of soy protein in only 13 patients (seven of whom felt that soy improved their breast pain); in the remaining five patients (three of whom suggested that soy protein improved breast pain) phytoestrogen levels were no higher than pretreatment values. Although the ingestion of soy protein may be associated with relief of breast pain, these results illustrate the problem of non-specific effects in studies of mastalgia in that 1) cow's milk also relieved breast pain in some patients and 2) that the benefits of soy protein were not always associated with evidence of elevated circulating levels of phyto-estrogens, indicating the difficulty of compliance in dietary intervention studies using soy foods.

Herbs of special interest to women

OBJECTIVE

To review the efficacy and safety of specific herbal medications that have been used traditionally to treat common conditions in women.

DATA SOURCES

Current literature, with emphasis on more rigorously controlled studies.

DATA SYNTHESIS

Herbal medicines have long been used in traditional healing systems to treat conditions of particular interest to women, such as premenstrual syndrome (PMS) and menopausal symptoms. For a select number of phytomedicines, including evening primrose oil, black cohosh root extract, dong quai, and chaste tree berry, scientific investigation is elucidating the pharmacologically active constituents, mechanism of action, and clinical value.

CONCLUSION

Based on the available evidence, evening primrose oil and chaste tree berry may be reasonable treatment alternatives for some patients with PMS. Dong quai may have some efficacy for PMS when used in traditional Chinese multiple-herb formulas. For relief of menopausal symptoms, black cohosh root extract and dong quai have good safety profiles, but only black cohosh has demonstrated efficacy for this indication. Safety data, especially during pregnancy and lactation, are still largely lacking for many herbal medications, and recommendations for usage and dosage vary. Pharmacists who wish to recommend herbal products for women's health conditions need to evaluate the scientific literature in order to form their own opinions about appropriate use and safety.

Expression of sex steroid receptors and IGF-1 mRNA in breast tissue--effects of hormonal treatment

The mechanisms behind increased breast tissue proliferation and a possibly increased breast cancer risk in women using hormonal contraception (HC) and hormonal replacement therapy (HRT) are incompletely understood. We analyzed breast tissue from 20 premenopausal and seven postmenopausal women undergoing reduction mammoplasties for estrogen receptor (ER) and progesterone receptor (PR) content as well as mRNA levels for ER, PR and insulin-like growth factor-1 (IGF-1). The receptor values were correlated to IGF-1 mRNA concentrations and levels of steroid and peptide hormones and SHBG. In women using HC, we found significantly lower ER values (p = 0.02) but non-significantly lower ER mRNA levels compared to those in naturally cycling women. PR and PR mRNA were no different. Women on HC displayed a higher breast tissue proliferation (p = 0.05) expressed as Ki-67, MIB-1 positivity, which was correlated with IGF-1 mRNA (r(s) = 0.82, p = 0.04). Since the concentration of sex steroid receptors in breast tissue is comparatively low and steroid receptors are down-regulated during hormonal treatment, mechanisms other than direct sex steroid receptor action are likely to be present. Our results suggest a role for IGF-1 in the proliferative response of breast tissue during exogenous hormonal treatment.

Breast disease in adolescents and young women

Breast lesions, including mastalgia; benign proliferative changes; and benign masses, including fibroadenomas, are common in adolescents and young adult women. Breast cancer is rare in women less than 20 years old and uncommon in women less than 30 years old. Discrete masses in women less than 30 years old that do not feel suspicious on examination can be observed for 1 or 2 months. If they persist, than an FNA can differentiate those that are benign and can be observed versus those that need either an excisional biopsy or definitive surgery. Mammography has little role in the diagnosis of women less than 30 years old except in those individuals with highly suspicious lesions on examination.

The long-term course of mastalgia

Mastalgia is a common condition in women of reproductive years. We have assessed the long-term course in patients with severe mastalgia by distributing a postal questionnaire to 212 patients previously studied in 1983 who had attended the mastalgia clinic at the University Hospital of Wales, Cardiff. 175 patients (83%) responded, with an original diagnosis of cyclical mastalgia (CM) in 120 and non-cyclical mastalgia (NCM) in 55. The median age of onset of breast pain was 36 years (range 12-63 years). The average duration of pain was long (median 12 years), especially if it started in the second or third decade of life. Pain persisted in 68 (57%) of CM and 35 (64%) of NCM patients. In CM patients resolution was commonly associated with a 'hormonal' event, notably the menopause; in NCM patients it more often seemed to be spontaneous. Severe mastalgia ran a chronic relapsing course often requiring repeated drug treatments.

Comparison of tamoxifen with danazol for treatment of cyclical mastalgia

This study evaluates the benefits and side-effects of two drugs (tamoxifen or danazol) used randomly in women with severe cyclical mastalgia. Ninety-three patients with severe cyclical mastalgia of more than 6 months duration were randomly selected for treatment with tamoxifen (32 women), danazol (32 women) or placebo (29 women) for six consecutive cycles. A standard protocol was used, which included pain relief as measured by linear analog, side-effects and cost. Statistical analysis was performed using the non-parametric Mann-Whitney U or Kruskall-Wallis tests and Student's t-test. As measured by linear analog scoring, pain relief was achieved in 23/32 (72%) of those receiving tamoxifen, 21/32 (65%) of those taking danazol (p < or = 0.001) and 11/29 (38%) of those taking placebo. Twelve months after the end of treatment, 17 (53%) women who received tamoxifen were still free of symptoms, as compared with 12 (37%) of the danazol-treated patients (p < 0.001) and none of the placebo-treated patients. These results suggest that tamoxifen is highly efficaceous and cost effective for the management of severe cyclical mastalgia.

Effect of evening primrose oil on gastric ulceration and secretion induced by various ulcerogenic and necrotizing agents in rats

The evening primrose oil (EPO) commercially known as Callanish evening primrose oil (omega-6 polyunsaturated fatty acid) is linoleic acid (LA) and gamma-linolenic acid (GLA)-enriched oil obtained from the seeds of Oenothera biennis L. (Fam. Onagraceae). EPO was investigated for its ability to protect the gastric mucosa against injuries caused by pylorus ligation, non-steroidal anti-inflammatory drugs (NSAIDs; aspirin, indomethacin and phenylbutazone), hypothermic restraint stress and necrotizing agents [0.6 M HCl, 0.2 M NaOH, 25% NaCl or 80% (v/v) aqueous ethanol]. It was administered by gastric intubation at doses of 5 and 10 ml/kg body weight to rats fed standard chow diet. An additional group of animals was given the same amount of corn oil in each experimental model studied. The results showed that EPO at the doses of 5 and 10 ml/kg body weight provided significant protection in various experimental models used. It produced a significant inhibition of gastric mucosal damage induced by pylorus ligation, NSAIDs, or hypothermic restraint ulcers. EPO also had a marked cytoprotective effective effect against all necrotizing agents used in this study. The results suggest that EPO rich in LA and GLA possesses both antisecretory and anti-ulcerogenic effects.

Comparison of the grignard deacylation TLC and HPLC methods and high resolution 13C-NMR for the sn-2 positional analysis of triacylglycerols containing gamma-linolenic acid

There is increasing evidence that the fatty acid, gamma-linolenic acid (GLA) is the effective component found in evening primrose oil (EPO) which has been shown to bring about clinical improvement in a number of disease conditions. The two major triacylglycerols (TAGs) in EPO are trilinolein (LLL) and a TAG species containing one GLA and two linoleic (LA) fatty acid chains. This latter TAG, called dilinoleoyl-mono-gamma-linolenin (DLMG or Oenotheral), makes up about 15% by weight of EPO and accounts for over one-half of the total amount of GLA present in EPO. Although DLMG is comprised of three possible isomers, the abbreviation is used to represent the naturally occurring mixture of these isomers. We have isolated DLMG from EPO and also prepared its three possible isomers, sn-GLL, sn-LGL and sn-LLG, and carried out the sn-2 positional analysis using three different approaches, namely, Grignard deacylation TLC and HPLC methods and high resolution 13C-NMR spectroscopy. The results of the sn-2 positional analysis for both the natural and synthetic TAGs containing LA and GLA in this study using the three approaches are all in very good agreement. This indicates that the three positional analysis methods are valid within their acceptable error margin and can be used with confidence in determining the fatty acid composition of the sn-2 position. Given the increased availability of NMR spectrometers this method might prove to be the easiest and most convenient in determining the sn-2 position for oil or TAG samples that contain a small number of different fatty acids providing all the 13C-NMR carbonyl resonances are well resolved.

The effects of gamma-linolenic acid on breast pain and diabetic neuropathy: possible non-eicosanoid mechanisms

Gamma-linolenic acid (GLA) has recently been found to be beneficial in the management of breast pain and of diabetic neuropathy. GLA is a precursor of unsaturated fatty acids which are important in membrane structures, as second messengers in their own right and as precursors of eicosanoids. While the mechanisms of GLA action are likely to be complex, non-eicosanoid effects are probably of substantial importance. These effects include modification of membrane fluidity and of the functions of lipid-associated receptors and changes in the inositol cycle.

Progesterone receptor induction by danazol in cultured cancer cells and the rat uterus

We have previously reported that clinical trials relating to the use of danazol in the management of benign breast disease show a positive correlation between favourable clinical response and an induction of progesterone receptors in the affected tissue which is maintained for a period of at least 6 months subsequent to the cessation of treatment. Further studies designed at elucidating more clearly the actions of danazol at the cellular and molecular levels have confirmed that progesterone receptors are down-regulated by short-term progestin action at the level of the mRNA transcript, but that danazol is subsequently able to produce an enhanced cellular response, inducing progesterone receptors in the presence of oestrogenic agents. Uteri from danazol-treated rats showed a doubling of progesterone receptor concentrations compared with the control uteri. In the mammary cancer cell line T-47D, cells treated with danazol had increased progesterone receptor concentrations of 558.4 +/- 32.0 compared with 152.6 +/- 7.0 fmol/mg protein in the control cells. In both cases, these inductions were observed following a period of progesterone receptor suppression. Short-term molecular studies on T-47D cells indicated that progesterone and danazol initially inhibit mRNA transcription, but that 24 h after treatment an induction is observed. This is especially marked in the danazol-treated cells.

Plasma fatty acid profiles in benign breast disorders

Breast pain (mastalgia) and macroscopic breast cysts present commonly. Mastalgia may be improved by dietary manipulation to reduce saturated fat or supplement essential fatty acid intake. Fatty acid profiles were measured in women with mastalgia and breast cysts, before and during treatment with evening primrose oil, a rich source of essential fatty acids. The fatty acid profiles of both groups of patients were abnormal, with increased proportions of saturated fatty acids and reduced proportions of essential fatty acids. Treatment with evening primrose oil improved the fatty acid profiles towards normal, but this was not necessarily associated with a clinical response.