MASTODYNIA

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Effects of age and body mass index on breast characteristics: a cluster analysis

Limited research has quantified variation in the characteristics of the breasts among women and determined how these breast characteristics are influenced by age and body mass. The aim of this study was to classify the breasts of women in the community into different categories based on comprehensive and objective measurements of the characteristics of their breasts and torsos, and to determine the effect of age and body mass index on the prevalence of these breast categories. Four breast characteristic clusters were identified (X-Large, Very-ptotic & Splayed; Large, Ptotic & Splayed; Medium & Mildly-ptotic; and Small & Non-ptotic), with age and BMI shown to significantly affect the breast characteristic clusters. These results highlight the difference in breast characteristics exhibited among women and how these clusters are affected by age and BMI. The breast characteristic clusters identified in this study could be used as a basis for future bra designs and sizing systems in order to improve bra fit for women. Practitioner summary: This original research provides evidence for bra designers and manufacturers on the diverse breast characteristics exhibited by women within the population and the significant effect that both body mass index and age have on the breast characteristic clusters. Future bra designs should consider the variation in breast characteristics among women.

ABBREVIATIONS

BMI: Body Mass Index; UBCC: Under-bust chest circumference.

Can breast characteristics predict upper torso musculoskeletal pain?

BACKGROUND

Several studies have associated a large breast size with an increased prevalence and severity of musculoskeletal pain, particularly pain in the upper torso. Despite this evidence, no research has explored whether breast size or related characteristics are risk factors for upper torso musculoskeletal pain.

METHODS

A backward multiple regression analysis was performed to identify whether characteristics of the breasts and upper torso, as well as physical factors known to be associated with musculoskeletal pain, could predict musculoskeletal pain among a cohort of 378 Australian women aged 18 years and over who had a wide range of breast sizes.

FINDINGS

The model identified that breast volume, age and nipple-to-nipple distance predicted 23% of the variance in upper torso musculoskeletal pain reported by the participants.

INTERPRETATION

Women with a larger breast volume, lower age and a greater nipple-to-nipple distance were predicted to report a higher upper torso musculoskeletal pain score.

Cyclic and non-cyclic breast-pain: A systematic review on pain reduction, side effects, and quality of life for various treatments

CYCLIC AND NON-CYCLIC BREAST-PAIN

A systematic review on pain reduction, side effects, and quality of life for various treatments.

BACKGROUND

No clear systematic-review on all the various treatment regimen for (Non-) cyclical-breast-pain currently exists.

OBJECTIVES

The aim of this study was to assess the various forms of therapy for treatment of breast-pain and the evidence for their effectiveness.

SEARCH STRATEGY

Search-terms included 'mastalgia' and 'therapy' or 'hormones' or 'nsaid' or 'psychotherapy' or 'analgesia' or 'surgery', and synonyms.

SELECTION CRITERIA

The review was conducted according to the Preferred Reporting Items for Systematic-reviews and Meta-Analysis guidelines. RCT's and pro-/retrospective studies reporting on treatment of breast-pain were considered eligible. Minimal follow-up and sample-size criteria were 6 months and 10 patients respectively.

DATA COLLECTION AND ANALYSIS

Data was extracted using standardized tables and encompassed number of subjects, type of breast-pain and treatment, efficacy of treatment and clinical complications/side-effects. No pooling of data could be achieved due to heterogeneity amongst studies.

MAIN RESULTS

Twenty-three studies were included, that reported on 2100 patients in total. Topical-Diclofenac was found to reduce pain by 58.7 and 63.3 on a Visual-Analogue-Scale (VAS) in cyclical and non-cyclical-breast-pain respectively. Persistent cyclical-breast-pain can be treated with short courses (2-6 months) of either Bromocryptine (VAS↓=25.4) or Danazol (VAS↓=33.6) as long as benefits outweigh the side-effects. Last-resort options for unresponsive and severe debilitating breast-pain include surgery in the form of bilateral mastectomy with reconstruction.

CONCLUSIONS

Pain reduction in patients with breast-pain can be achieved with analgesics, hormonal-regimen and possibly surgery as a last resort. Additional studies are needed with well-described patient-characteristics, robust study set-up, and longer follow-up times.

Breast volume is affected by body mass index but not age

BACKGROUND

This study aimed to establish normative breast volume data for women of varying ages, body masses and breast sizes, and to determine the effect of age and body mass index (BMI) on breast volume.

METHODS

The breast volume of 356 women (age range: 18.1-83.7 years; BMI range: 18.4-54.5 kg/m²) was measured using three-dimensional scanning in a prone position.

RESULTS

Breast volumes ranged from 48 to 3100 mL. Although breast volume was not significantly affected by age, it was significantly affected by BMI, with the breast volume of overweight and obese women being two-to-three times greater than women with normal BMI's.

CONCLUSION

It is recommended that bra cups must be designed to support the wide range and increasing magnitude of breast volumes exhibited by women. Practitioner summary: This original research provides evidence for bra designers and manufacturers on the range of breast volumes of women and the significant effect of BMI on breast volume. Bra cups need to be designed to support the wide range and increasing magnitude of breast volumes exhibited by women.

Can breast ultrasound reduce patient's level of anxiety and pain?

BACKGROUND

Breast pain is one of the most common complaints of women attending a gynecology clinic and general practitioners. This pain can cause anxiety and, consequently, reduce the woman's quality of life. The objective of this study was to assess the severity of pain and anxiety in patients with breast pain and normal examination, before and after breast sonography.

MATERIALS AND METHODS

Among the patients with breast pain and normal examination who came for breast sonography in three centers in Shiraz during 2011-2012, 51 patients agreed to cooperate in this project. These patients filled out the questionnaire for evaluation of pain and anxiety before and after breast sonography.

RESULTS

Sonography findings indicated that 88% of patients have normal sonography without any finding. The average amounts of pain severity before and after sonography were 3.3 and 2.4, respectively (p < 0.005). The average amounts of anxiety severity in patients before and after sonography were 51.9 and 37.9, respectively (p < 0.005).

CONCLUSION

This study shows the severity of pain and anxiety after ultrasonography decreased significantly. It can be concluded that ultrasound findings, which reassure the patients that they do not have specific pathology, can reduce the pain and anxiety by its impact on psychological status of the patient.

A Randomized Pilot Study of Inositol in Association with Betaine and Boswellia in the Management of Mastalgia and Benign Breast Lump in Premenopausal Women

Benign mammary lumps and mastalgia are the most common breast disorders; yet, there is no clear-cut consensus about the best strategy for their treatment. We hypothesized that a combination, including boswellic acid, betaine, and myoinositol, would be beneficial in breast disorders by exerting a pleiotropic effect on multiple pathways. Indeed, myoinositol has already been proven to modulate some factors involved in the genesis of breast diseases, such as fibrosis and metabolic and endocrine cues. In our study, 76 women were randomly assigned to either the experimental or the placebo arm. After six months of treatment, statistically significant differences between the two groups were recorded for pain relief (56% vs 17%) and breast density reduction (60% vs 9%). Furthermore, benign breast mass dimension showed a reduction in the experimental group (40% vs 16%). The combination of boswellic acid, betaine, and myoinositol has been demonstrated to be effective in the treatment of breast pain and radiologically and histologically confirmed benign breast mass and in the reduction of breast density, one of the pivotal risk factors for the development of breast cancer, without any side effects.

Bra strap orientations and designs to minimise bra strap discomfort and pressure during sport and exercise in women with large breasts

Background

Bra straps are a primary source of discomfort during sport and exercise, particularly for women with large breasts. This study aimed to investigate the effects of altering bra strap orientation and design on bra strap comfort, pressure and breast support in women with large breasts. This is a descriptive laboratory study.

Methods

Bra strap discomfort (visual analogue scale, 0 to 10), pressure (custom-designed 10 mm² calibrated pressure sensor, 0.5 to 24 kPa range, 50 Hz, S2011, Novel GmbH, Munich, Germany, placed under the right bra strap at the crest of each participant’s shoulder), preference ranking and vertical breast displacement (VBD; Optotrak Certus® motion capture system, 200 Hz, Northern Digital, Ontario, Canada) data during dynamic treadmill running and static upright standing (pressure only) were collected for 23 active women with large breasts (D+ cup size) while they wore an encapsulation sports bra with six different bra strap conditions (two bra strap orientations: vertical and cross-back; three bra strap designs: standard width, wide and gel).

Results

Bra strap discomfort was significantly less (p ≤ 0.001) in the vertical compared to the cross-back strap orientation, which was the most preferred orientation despite no significant difference in strap pressure. The wide strap design had the lowest discomfort scores, significantly lower strap pressure compared to the standard width and gel strap designs (p < 0.001), and was equally the most preferred design with the gel straps. There was no significant difference in VBD among the six strap conditions.

Conclusions

Bra straps that are vertically orientated and wide (approximately 4.5 cm in width) are preferable for women with large breasts during sport and exercise to minimise bra strap pressure and discomfort. The addition of gel pads under bra straps may also decrease discomfort and prevent straps slipping off the shoulders, although this notion warrants further investigation.

The effect of imaging on the clinical management of breast pain

BACKGROUND

Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described.

OBJECTIVE

To determine if initial imaging for breast pain reduces subsequent utilization.

DESIGN

Retrospective cohort study at a hospital-based breast health practice.

PATIENTS

Women referred for breast pain from 2006-2009.

MAIN MEASURES

Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit.

KEY RESULTS

Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification.

CONCLUSIONS

Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.

Evaluation of professional bra fitting criteria for bra selection and fitting in the UK

A correctly fitting bra is essential for good health; this study investigates the use of professional bra fitting criteria to establish best-fit in an underwire bra commonly sold in the UK. A comparison was made between women's bra size as measured by the traditional bra fitting method with their recommended bra size based on professional bra fitting criteria. Forty-five female participants were recruited; their mode self-reported bra size was 34DD. Participants were measured in their own bra using the traditional bra-fitting method to establish their 'traditional size'. A 'best-fit' bra size was recorded for participants based on professional bra fitting criteria. Significant differences were found between traditional and best-fit cup and band sizes (p < 0.001); the traditional method of bra fitting overestimated band size and underestimated cup size. As band size increased the traditional method also became more inaccurate (p < 0.001). It is recommended that women are educated in assessing their own bra fit using professional bra fitting criteria and less emphasis placed on determining absolute bra size. Practitioner Summary: This is the first study to investigate using professional bra fitting criteria to establish best-fit in an underwired bra commonly sold in the UK. The traditional method of bra fitting was found to be inadequate, especially for larger-breasted women; the use of professional bra fitting criteria should be encouraged.

Deciphering the mechanism(s) of action of natural products: analgesic peroxide oil as example

BACKGROUND

There are multiple reports of natural products having therapeutic effect. In an era of evidence-based medicine, clinical trials inform clinical decisions regarding use of the product, but prevailing preference is to identify and use a single 'active ingredient'. Yet, the clinical benefit of a natural product might derive from the fortuitous combination of its multiple components. Therefore, the elucidation of the mechanism(s) of action of natural products is important, but presents significant challenges. This article examines this issue using peroxide oil (essential oxygen oil) as an illustrative example.

OBJECTIVE

To review the published literature of a natural product in an effort to elucidate postulated mechanism(s) of action of a complex mixture.

METHODS

The clinical and preclinical literature was reviewed from the perspective of its contribution to elucidating a mechanism of analgesic action of a natural product.

RESULTS

Peroxide oil contains ingredients that are associated with analgesic mechanisms, such inhibition of lipid peroxidation and arachidonic acid metabolism and non-opioid, glibenclamide-sensitive receptor-mediated and K(ATP) -NO-cGMP channel pathways.

CONCLUSION

Although its exact mechanism remains unknown, peroxide oil provides an example of how a natural product can be evaluated for plausible mechanistic explanation of its purported therapeutic efficacy. Such an approach seems valuable, since, as in this case, the constituents appear to contribute in an additive or synergistic manner, something not possible with a single substance.

Education improves bra knowledge and fit, and level of breast support in adolescent female athletes: a cluster-randomised trial

QUESTIONS

Can an education booklet handed out by a physiotherapist improve bra knowledge and fit, and level of breast support, of bras worn by adolescent female athletes?

DESIGN

Cluster-randomised trial with intention-to-treat analysis.

PARTICIPANTS

115 adolescent females from four regional sporting academies aged 16 yr (SD 1) and with an average Australian bra size of 12B.

INTERVENTION

The experimental group received an education booklet on bra fit and breast support from a sports physiotherapist. The control group received no intervention.

OUTCOME MEASURES

The primary outcome was bra knowledge measured by a questionnaire. Secondary outcomes were a pass on the Bra Fit Assessment and the Level of Breast Support tests, and breast discomfort during exercise rated on a 10-cm visual analogue scale.

RESULTS

Four months after receiving the education booklet, the experimental group had improved their bra knowledge 19% (95% CI 14 to 25) more than the control group. In addition, 39% (95% CI 19 to 54) more of the experimental group passed the Bra Fit Assessment test and 30% (95% CI 11 to 47) more passed the Level of Breast Support test than the control group at 4 months. There was no difference in the level of breast discomfort during exercise.

CONCLUSION

Bra knowledge, bra fit, and level of breast support in adolescent female athletes were all poor but improved significantly after receiving an education booklet about breast support designed specifically for them.

TRIAL REGISTRATION

ACTRN12609000607279.

Toremifene use does not alter serum inhibin A and B levels during mid-luteal phase in women with premenstrual mastalgia

AIMS

To find out if there is any link between the therapeutic effect of toremifene on premenstrual mastalgia and luteal phase serum inhibin A and/or B levels.

METHODS

Forty-eight patients participating in a randomized cross-over trial on toremifene vs. placebo for premenstrual mastalgia gave three blood samples during the luteal phase of the menstrual cycle: the first at baseline, the second during the third toremifene/placebo cycle, and the third during the third placebo/toremifene cycle, respectively. The blood samples were analyzed for inhibin A and B with respective specific two-site enzyme-linked immunosorbent assays. Toremifene (20 mg/d) and placebo were administered during the luteal phase only.

RESULTS

When all the toremifene-treated cycles were compared with all the placebo cycles and with the baseline, the median inhibin A levels were 42, 38, and 40 pg/ml, respectively (baseline versus toremifene, p = 0.638; baseline versus placebo, p = 0.468; and toremifene versus placebo, p = 0.365). The median inhibin B levels were at baseline 19 ng/l, during placebo 20 ng/l, and during toremifene 17 ng/l (baseline versus toremifene, p = 0.983; baseline versus placebo, p = 0.519; and toremifene versus placebo, p = 0.880).

CONCLUSION

A luteal administration of toremifene does not seem to result in any changes in mid-luteal concentrations of inhibin A or B in serum.

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.

Toremifene for premenstrual mastalgia: a randomised, placebo-controlled crossover study

OBJECTIVE

To investigate the efficacy of toremifene in the treatment of premenstrual mastalgia.

DESIGN

Double-blind, placebo-controlled crossover study.

SETTING

Three Finnish general practices from the districts of Satakunta Central Hospital and Tampere University Hospital. POPULATION A total of 62 women aged 25-45 years with premenstrual mastalgia during at least three previous menstrual cycles.

METHODS

Women were randomised to receive toremifene 20 mg daily or placebo from day 15 of the menstrual cycle until menstruation for three consecutive cycles. After a wash-out cycle, the women were crossed over to receive placebo or toremifene for three additional cycles.

MAIN OUTCOME MEASURES

Cyclic breast pain relief assessed by visual analogue scale (VAS) score. Quality-of-life scores assessed by a modified 36-item Finnish Depression Scale, with a score ranging from 0 to 108. Acceptability of treatment.

RESULTS

About 32 women were randomised to receive toremifene first and 30 to receive placebo first. Twenty-nine and 27 participants in the groups treated with toremifene first or placebo first completed the treatment, respectively. There were significant reductions in VAS scores in both groups after three treatment cycles. This was significantly greater in the toremifene-treated group (VAS: 1.8 in the toremifene group and 3.7 in the placebo group, P= 0.004). Treatment effect between treatment cycles was significant (P= 0.001). Quality of life was similar during the toremifene and placebo cycles. CONCLUSION This study demonstrates that the antiestrogenic compound, toremifene, is able to relieve premenstrual breast pain without major adverse effects. There was a 64% reduction in median pain scores in the toremifene-treated cycles compared with a 26% reduction in placebo-treated cycles.

Frequency of mastalgia among women veterans. Association with psychiatric conditions and unexplained pain syndromes

OBJECTIVE

To determine the prevalence and frequency of mastalgia and its association with psychiatric conditions and unexplained pain syndromes.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional mailed survey completed by 1,219 female veterans enrolled at the VA Puget Sound Health Care System in 1998.

MEASUREMENTS

Breast pain in the past year, unrelated to pregnancy, was categorized as infrequent (< or =monthly) or frequent (> or =weekly) mastalgia. Surveys assessed posttraumatic stress disorder (PTSD), depression, panic disorder, and alcohol misuse with validated screening tests, as well as self-reported past-year chronic pelvic pain, fibromyalgia, and irritable bowel syndrome.

RESULTS

The response rate was 63%. Fifty-five percent of the respondents reported past-year mastalgia. Of these, 15% reported frequent mastalgia. Compared to women without mastalgia, women reporting frequent mastalgia were more likely to screen positive for PTSD (odds ratio [OR] 5.2, 95% confidence interval [CI] 3.2 to 8.4), major depression (OR 4.2, 2.6 to 6.9), panic disorder (OR 7.1, 3.9 to 12.8), eating disorder (OR 2.6, 1.5 to 4.7), alcohol misuse (OR 1.8, 1.1 to 2.8), or domestic violence (OR 3.1, 1.9 to 5.0), and to report fibromyalgia (OR 3.9, 2.1 to 7.4), chronic pelvic pain (OR 5.4, 2.7 to 10.5), or irritable bowel syndrome (OR 2.8, 1.6 to 4.8). Women with infrequent mastalgia were also more likely than women without mastalgia to screen positive for PTSD, depression, or panic disorder, or report pelvic pain or irritable bowel syndrome, although associations were weaker than with frequent mastalgia.

CONCLUSIONS

Like other unexplained pain syndromes, frequent mastalgia is strongly associated with PTSD and other psychiatric conditions. Clinicians seeing patients with frequent mastalgia should inquire about anxiety, depression, alcohol misuse, and trauma history.

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.

Mastalgia

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

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.

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.

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.

Utility of targeted sonography in the evaluation of focal breast pain

OBJECTIVE

To determine the utility of targeted sonography in the evaluation of patients with focal breast pain.

METHODS

From January 1995 through December 1999, 110 targeted sonographic examinations were performed in 99 patients for evaluation of focal breast pain in the absence of an associated palpable mass. The sonographic, mammographic, and clinical findings were reviewed. The hospital pathology database was searched to identify any interval cancers and false-negative interpretations.

RESULTS

No cancer was identified in any of the 110 examinations. Eighty-five (77.3%) of the examinations had negative findings. Cysts were identified in 15 cases (13.6%), and 3 solid masses (2.7%) were identified. Two of these 3 solid masses had biopsies and were shown to be benign, whereas the third mass was followed for 29 months without change. Most patients were premenopausal, had no family or personal history of breast cancer, and were not taking exogenous hormones. Eighty-five patients (77%) were referred by primary care physicians.

CONCLUSIONS

In patients with focal breast pain without an associated palpable mass, sonography may be more useful for patient reassurance than for cancer detection.

Cyclical mastalgia: prevalence and associated health and behavioral factors

Perimenstrual breast pain (cyclical mastalgia) is a common problem that can be sufficiently severe to interfere with usual activities, and has been associated with elevated mammography usage in young women. This study was undertaken to replicate clinic-based research on cyclical mastalgia, and to examine the association between this disorder and health-related behaviors and perceived stress. Using random digit dialing throughout Virginia, 874 women aged 18-44 were interviewed. Sixty-eight per cent of women experienced cyclical breast symptoms; 22% experienced moderate to extreme discomfort (classified as cyclical mastalgia). Hormonal contraceptive usage was associated with significantly less mastalgia and premenstrual syndrome (PMS). Smoking, caffeine consumption and perceived stress were associated with mastalgia (odds ratios = 1.52, 1.53 and 1.7, respectively). Young women (under 35 years) with mastalgia were more likely to have had a mammogram (20.2%) than those without mastalgia (9.9%). Most women with this disorder (77.5%) did not have PMS. The prevalence of cyclical mastalgia and its association with mammography replicate clinic-based findings. Associations with smoking and stress had not previously been reported. Prospective research is needed to determine the biopsychosocial factors contributing to this disorder.

Treatment of mastalgia with tamoxifen in male patients with liver cirrhosis: a randomized crossover study

OBJECTIVE

Mastalgia is occasionally found in patients with liver cirrhosis, especially in those receiving spironolactone for treatment of ascites. The pathogenesis is still unclear. Estrogen excess in cirrhotic patients and estrogenic effects of the spironolactone are possible leading causes. Treatment directed against the preponderance of estrogenic stimulation in these patients has never been investigated. This study was designed to investigate the efficacy and safety of tamoxifen, an estrogen antagonist, on mastalgia in patients with liver cirrhosis.

METHODS

A total of 16 male cirrhotic patients with mastalgia were randomly assigned to two groups. One group was treated with tamoxifen (20 mg p.o., b.i.d.) for 1 month, followed by placebo for the next month. The other group was treated in the reverse order. All patients received spironolactone for ascites and/or peripheral edema, and the drug was continued during the study period. The size of the breasts and the degree of breast pain and tenderness were recorded in all subjects before and after the treatment periods. Serum levels of estradiol and testosterone were measured using the radioimmunoassay method.

RESULTS

Of the 16 patients, 14 experienced a decrease or disappearance of the breast pain and/or tenderness during the tamoxifen treatment period, whereas only two of the 16 patients felt an improvement during the placebo period (p < 0.05). There were significant improvements in the breast pain and tenderness scores and decreases in the breast sizes during the tamoxifen treatment period (before vs after: 1.4+/-0.3 vs 0.4+/-0.2, p = 0.002; 1.9+/-0.2 vs 0.5+/-0.2, p < 0.001; and 6.8+/-0.6 vs 5.5+/-0.6 cm, p = 0.02, respectively), whereas no obvious change was seen during the placebo period. Serum levels of estradiol and testosterone did not change significantly after the tamoxifen or placebo treatments (p > 0.05). No major side effects were noted during the therapeutic periods.

CONCLUSIONS

Tamoxifen is effective and safe in the management of mastalgia in male cirrhotic patients taking spironolactone.

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.

Cyclical mastalgia: premenstrual syndrome or recurrent pain disorder?

Approximately 8-10% of premenopausal women experience moderate to severe perimenstrual breast pain or cyclical mastalgia, monthly. This mastalgia can occur regularly for years until menopause, can interfere with usual activities, and is associated with elevated utilization of mammography among young women. Although mastalgia is a well documented symptom in premenstrual syndrome (PMS), it is unknown whether PMS is necessarily present in women with cyclical mastalgia. The present study prospectively examined mastalgia and its relationship to PMS. Thirty-two premenopausal women reporting recent mastalgia completed breast pain and menstrual symptom scales daily for 3-6 months. Eleven women (34.4%) met criteria for clinically significant cyclical mastalgia, reporting an average of 10.2 days of moderate-severe mastalgia monthly. Five women (15.6%) met criteria for PMS. Mastalgia was not significantly associated with PMS: 82% of women with clinical cyclical mastalgia did not have PMS. Cyclical mastalgia, although by definition associated with the menstrual cycle, is not simply premenstrual syndrome, and merits further investigation as a recurrent pain disorder whose presentation, etiology, and effective treatment are likely to differ from those of PMS.

Randomized controlled trial of the management of premenstrual syndrome and premenstrual mastalgia using luteal phase-only danazol

OBJECTIVE

Our goal was to evaluate the efficacy and side effects of danazol 200 mg daily given only in the luteal phase of the menstrual cycle to treat premenstrual syndrome and premenstrual mastalgia.

STUDY DESIGN

We conducted a randomized, double-blind, placebo-controlled study of 3 menstrual cycles in a postgraduate medical school and National Health Service hospital. The subjects of the study were 100 women who had been referred to the premenstrual syndrome clinic at the North Staffordshire Hospital for the management of premenstrual syndrome and premenstrual breast pain. Outcome measures for the study included assessment of improvement in symptoms measured by specific daily visual analogue scales for 4 principal symptoms of premenstrual syndrome and for premenstrual mastalgia and assessment of side effects and adverse events.

RESULTS

Significant improvement in symptoms was seen in visual analog scores for mastalgia in months 1 (P =.03), 2 (P =.004), and 3 (P =.01) of the study during active therapy compared with placebo. No improvement was seen for any other symptom or for the global premenstrual syndrome score. Side effects on danazol and on placebo were equal and minimal.

CONCLUSIONS

Luteal phase-only danazol is not effective for the treatment of the general symptoms of premenstrual syndrome but appears highly effective for the relief of premenstrual mastalgia. This approach to therapy is associated with few side effects. Studies of cyclic mastalgia using strict diagnostic criteria are required to see whether the freedom from symptomatic side effects is found in longer-term studies and to determine whether such a regimen avoids potentially detrimental effects on the lipid status.