Cyclical mastalgia: premenstrual syndrome or recurrent pain disorder?

Clinicopathological profile of mastalgia in females: incidence, types, and pathological correlations. a cross-Sectional study

Introduction

Mastalgia was the most common symptom in patients attending a breast clinic. The two most common types of mastalgia were (cyclical and non-cyclical). The common cause of cyclical was Physiological changes due to premenstrual tension syndrome fibrocystic changes or fibroadenosis and (Aberrations in the Normal Development and Involution of the breast ). Non-cyclical diseases are mainly benign rather than malignant. Solid masses (fibroadenomas), cysts, infections, abscesses, trauma, and nipple discharge (hormones) are rare diseases associated with breast cancer. The aim of this study is to study the incidence of mastalgia, types (cyclical and non-cyclical) and pathological types of mastalgia (benign and malignant pathologies).

Material and methods

A cross-sectional descriptive study of mastalgia was carried out at the Breast Center Department of Maternity Teaching Hospital located in Erbil, from January 2014 to September 2015. A total of 150 breast pain cases (available clinical data) were studied in detail.

Results

There are two types of mastalgia based on triple assessments, these are as follows, cyclical 90 cases (60%) and non-cyclical 60 cases (40%). Fibrocystic breast changes or fibroadenosis 35 cases (23.3%) and thirdly nipple discharges as part of fibrocystic (fibroadenosis) five cases (3.3%). Non-cyclical mastalgia was subdivided into benign breast pathologies, fibroadenoma 30 cases (20%), breast cyst 10 cases (6.7%), nipple discharge (hormonal) five cases (3.3%), mastitis three cases (2%) abscess two cases (1.3%), fat necrosis one case (0.7%), and malignant breast pathologies, cancer three cases (2%). Clinicopathological correlations in the current study were highly significant (P<0.005).

Conclusion

Not all discomfort or pain can be diagnosed as mastalgia; occasionally, chest wall, referral pain, and systemic causes can mimic mastalgia. These results highlight the importance of differentiating between cyclical and non-cyclical mastalgia using clinical assessment, sonography, mammography, and blood investigations. Most mastalgia cases are benign, with cyclical mastalgia primarily related to hormonal changes during the menstrual cycle.

The Assessment of Nipple Areola Complex Sensation with Semmes-Weinstein Monofilaments-Normative Values and Its Covariates

Objective: To establish normative data for nipple-areola complex (NAC) sensibility examined with Semmes-Weinstein monofilament test (SWMT) and two-point discrimination (TPD) in women with varying breast sizes, including women with gigantomastia. We also aimed to identify clinical variables influencing NAC sensation. Methods: A total of 320 breasts in 160 Caucasian women (mean age 33.6 years, SD 11 years) were examined (including 50 hypertrophic breasts). NACs sensation was examined using Semmes-Weinstein monofilaments (SWM) and the Weber Two-Point Discrimination Test. Results: The nipple appeared to be the most sensitive part of NAC. In normal-sized breasts, sensation thresholds (SWM) correlated with: age, BMI, history of births, breast size and ptosis (for all locations), breastfeeding history (for nipple and upper areola) and areola diameter (for all locations apart from the nipple). Regression analysis showed that age, cup size and suprasternal notch-to-nipple distance are risk factors for diminished NAC sensation. Sensation thresholds in all NAC locations of hypertrophic breasts were significantly higher compared to normal-sized breasts, while TPD tests did not differ between the groups. Conclusions: We provided normative values of NAC sensation (tactile threshold and TPD) for different NAC areas. Our investigation indicated that SWM are useful diagnostic tools when the following factors are considered while examining NAC sensation: location (nipple vs. areola), age, breast size, suprasternal notch-to-nipple distance, history of births and breastfeeding. Hypertrophic breasts presented significantly higher sensation thresholds for all NAC locations. The report may serve as a reference data for further investigations regarding NAC sensation after different breast surgeries.

Evaluation of Treatment Methods and Clinical Characteristics of Patients Applying to the Outpatient Clinic with Complaint of Mastalgia

Objective: Mastalgia or breast pain is one of the most vital complaints among women patients. This study aims to determine the prevalence of mastalgia and the properties of pain, elucidate the associated factors, particularly modifiable ones, and establish a treatment of standard. Methods: The study evaluated 685 female patients admitted to our outpatient clinic with a complaint of mastalgia in the period between 2017 and 2019. Results: Mean age of the patients was 35.20 ±10.28 (13–86). The pain was experienced in the right breast of 123 (17.9%) patients, in the left breast of 141 (20.6%) patients, and in both breasts of 422 (61.5%) patients. The mean pain value was found to be 5.29. The study population comprised 61 (8.9%) patients in the menopause state, whereas 624 (91.1%) patients were not in menopause. The pain was noncyclic in 519 (75.8%) patients, while cyclic for 166 (24.2%) patients. For treatment, a restricted diet in terms of coffee, salt, and fat as well as wearing supportive bra were recommended for 456 (66.5%) patients, while 181 patients with pain VAS (Visual Analog Scale) score of 8 and above was initiated with vitex agnus-castus. No patient was initiated with local or systemic analgesics and LHRH (luteinizing hormone-releasing hormone) analogs. Conclusion: The prevention and management of mastalgia reflected that restricted salt intake, regulated diet, and the use of properly fitted bras could significantly improve the quality of life. Appropriate radiological imaging could eliminate patients’ concerns regarding developing cancer. Keywords: Breast cancer, Diet, Mastalgia, Risk factor

The Association of Breast Pain with Malignancy

OBJECTIVE

Breast pain is a common reason for imaging evaluation; however, the limited literature available suggests a low incidence of malignancy with isolated pain. The goal of this study is to calculate the risk of cancer in patients with breast pain, and to compare to the screening mammography cancer detection rates.

METHODS

This retrospective, institutional review board-approved study included all patients for whom a breast pain history sheet was filled out between November 3, 2013, and July 28, 2016. Those without at least two years of follow-up were excluded. From the medical record, any malignancy found at the site of pain at presentation or within two years was noted. Screening cancer detection rate was calculated from the mammography tracking software, and the Chi-square test was used to evaluate the significance of the difference between the cancer detection rates in patients with pain versus that detected by screening.

RESULTS

Of 421 patients who met the inclusion criteria, 4 (1.0%) had cancer at the site of pain, with a rate of malignancy of 9.5/1000 (95% CI: 3.5/1000 to 25.2/1000). The screening cancer detection rate was 7.3/1000 (P = 0.403), which was not significantly different. All cancers occurred in patients with coexisting palpable abnormalities; none was found when pain was the only symptom.

CONCLUSION

The rate of malignancy in patients with breast pain did not differ significantly from that detected by screening mammography. In patients with isolated breast pain without a palpable abnormality, there were no cases of malignancy. Imaging patients for the sole purpose of evaluating breast pain may not be necessary.

Existence of Cervical Discopathy in Non-Cyclic Mastodynia

Background

Mastodynia is a subjective symptom that impairs the quality of life. It may be directly related with breast disorders. Moreover, a substantial rate is caused of reflective pain.

Objectives

Non-cyclic mastodynia is multifactorial, and treatment should be planned according to the underlying cause. In this study, we aim to evaluate the existence of cervical discopathy via cervical magnetic resonance imaging (MRI) in the etiology of non-cyclic mastodynia.

Methods

The study included 60 patients with normal physical examination results and imaging findings. Management was determined individually in patients. Patients with pathological MRI findings were evaluated by physical therapy, rehabilitation, and neurosurgery specialists, and appropriate treatment was planned. Patients were evaluated with the visual analogue scale (VAS) scoring system at initial presentation and after 1 and 3 months of treatment.

Results

The majority of patients had positive findings on MRI (53 [88.4%] vs. 7 [11.6%]). The mean VAS scores at the time of presentation, after 1, and after 3 months of treatment were 7.41, 6.39, and 3.35, respectively. The decrease in the scores was statistically significant (p ≤ 0,01).

Conclusions

We suggest that cervical discopathy should be kept in mind in cases of idiopathic non-cyclic mastodynia. Furthermore, cervical discopathy-related mastodynia seems to have a good response to appropriate treatment.

Evaluation of 1294 Female Patients with Breast Pain: A Retrospective Study

INTRODUCTION

Mastalgia, or breast pain, is one of the most important complaints referred to outpatient clinics. The objective of this study was to evaluate the factors causing mastalgia. All patients who presented to our clinic with complaints of mastalgia were assessed along with their type of mastalgia symptoms, menopausal status, and radiology results.

METHODS

A total of 3157 patients with mastalgia complaints visited our clinic between January 2015 and February 2018. Only 1294 of them were retrospectively screened. Age, sex, menopausal (premenopausal, postmenopausal) status, mastalgia type (cyclic, non-cyclic), and imaging findings of the patients were examined.

RESULTS

The mean age was 43.8 ± 11.8 (13-86) years, with 453 (35%) patients younger than 40 years and 841 (65%) older than 40. Cyclic mastalgia was found in 207 (16%) patients, and non-cyclic mastalgia was seen in 1087 (84%) patients. A total of 786 (60.7%) patients were premenopausal, and 508 (39.3%) were postmenopausal. Mammography was used in 545 (42.1%) patients; 1190 (92.0%) women had breast ultrasonography.

CONCLUSION

Although breast pain is a common symptom in women who are referred to breast outpatient clinics, we concluded that patients who complain of mastalgia should not be afraid of cancer. Despite this and for reassurance, clinical imaging may be necessary to alleviate these patients' suspicions.

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.

[Breast pain: Recommendations]

OBJECTIVES

To evaluate the diagnostic value of clinical examination and additional tests in the exploration of breast pain, to evaluate the strategy of their care and to provide recommendations.

METHODS

A literature search in English and French carried out by consulting the databases PubMed, Cochrane Library and international recommendations.

RESULTS

Clinical examination and interrogation, with the use of visual analog scale used to differentiate non-cyclical breast pain from mastodynia (LE2). A calendar can be used to characterize the cyclical breast pain (LE3). Using a questionnaire can help to characterize the pain (LE3). In the absence of palpable abnormality, it is not recommended to modify systematic or individual screening modalities (LE2). MRI is not recommended in case of normal mammography and sonography. Explorations biopsy is guided by imaging. The therapeutic management includes reassurance after a normal clinical evaluation and/or normal radiological findings (LE2), and precise fitting of a brassière. In case of failure of this first approach, NSAIDs gel can be proposed (LE1-2).

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.

Mastalgia

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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.

The characteristics of cyclical and non-cyclical mastalgia: a prospective study using a modified McGill Pain Questionnaire

Breast pain (mastalgia) is a common condition (usually classified as cyclical or non-cyclical) the characteristics of which have never been studied using a standardized pain instrument. We have modified the short form of the McGill Pain Questionnaire (SF-MPQ) for the measurement of mastalgia, and have administered it to 271 women with breast pain and without breast cancer. The mean pain-rating index (sum of 15 descriptors of SF-MPQ) was similar between cyclical and non-cyclical pain, and was 12.0 (of 45) for the entire group. When compared to similar studies of pain at other sites, this falls in the same range as chronic cancer pain, and just below the pain of rheumatoid arthritis. Mean %VAS (visual analog scale) was 45.12 and mean %PPI (present pain index) was 39.9. Most women described their pain as 'heavy, aching and tender,' and these descriptors were given significantly higher ratings by women with cyclical pain. In women with non-cyclical mastalgia, the overall pain severity was related to the size of the painful area, and the steadiness of the pain, and the affective components were more prominent than in women with cyclical mastalgia. Thus, cyclical and non-cyclical mastalgia show some differences in their characteristics with substantial overlap. The total breast pain score was most efficiently estimated by a combination of the VAS, the PPI, and the quality of life questions (R2 = 0.96). Studies of breast pain should include both groups to better understand and characterize these differences, particularly with regard to a possible connection with breast cancer risk.

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.