Breast problems - Painful breasts

Painful breasts

Almost all women have tender, painful breasts at some time during their life. If you suffer from regular pain, ask yourself these two important questions:

is the pain related to the menstrual cycle (is it worse before your period)?
are both breasts affected, or just one?

You can check these points by keeping a daily diary over 2 or 3 months. Every day, record whether or not you have any breast pain, whether it is mild or severe and which breast is affected. Also make a note of the days of your period.

Breast pain and breast cancer
If you have breast pain, you are probably worrying that it might be breast cancer. This is very unlikely. Breast pain is very common – about 70% of women have it at some time. Doctors at the Edinburgh Breast Unit have looked at the medical records of more than 8500 women who attended the Unit simply because of breast pain. They found that less than 3% of these women – whose breast pain was probably quite severe – had breast cancer. And breast cancer is very, very unlikely if your only symptom is pain that varies with the menstrual cycle and both breasts are affected.

Breast pain related to the menstrual cycle (cyclical breast pain)
It is common to have painful, heavy, bloated breasts before a period. Both breasts are affected at the same time and you may also feel the discomfort in the armpit or upper arm. The breasts may feel generally lumpy but there is not one particular lump. If you are particularly unlucky, it may be so bad you cannot bear to be touched, are pain-free for only a few days each month and have to wear a bra at night because it is so tender when you lie on your side in bed. The problem usually starts in the 20s and 30s, and ends about the time of the menopause. It may go away for long periods and then return.

Causes. Cyclical breast pain affecting both breasts is not a symptom of breast cancer. It occurs because some women’s breasts are particularly sensitive to hormone changes. Each breast is made up of a collection of glands for producing milk; these look rather like bunches of silky white grapes. The ‘stalks’ of the bunches are small milk ducts, which lead into larger and larger ducts for the milk to reach the surface of the nipple. The glands are supported and padded in ‘packing tissue’, which is mostly fat. Each month, the glands respond to the rise and fall of hormones. It used to be thought that the problem was caused by fluid retained in the packing tissue, but this has been disproved.

What you can do. There are a number of things that you can try to ease the pain.

Wear a soft bra at night.
Avoid jogging, aerobics or other high-impact exercises.
Make sure your bra fits correctly – get properly measured by a specialist fitter (most department stores have one).
If you are taking any hormones, such as the oral contraceptive pill or hormone replacement therapy (HRT), consider stopping them for a while to see if the breast pain lessens. Breast pain seems to be common in women who have recently started HRT.
Try a low-fat diet. There is some evidence that high levels of saturated fats in the blood make the breasts more sensitive to hormone levels, so it may be worth changing your diet. Avoid fatty meat, cheese, full-fat milk, cream, butter and anything made of pastry. Instead eat oily fish, such as herring and mackerel, twice a week. Fill up with carbohydrates (bread, potatoes, rice, pasta), fresh fruit and vegetables.
Try avoiding coffee and cola drinks for a few weeks to see if this makes any difference.
Consider Vitus agnus castus (Chasteberry), which is available from health-food stores. It affects various hormones, such as progesterone, and may help cyclical breast pain, though the scientific evidence is scanty (American Family Physician 2005; 72:821–4).

What your doctor can do. Most treatments for cyclical breast pain take several months to work, so you will have to be patient. Continue your diary when starting any treatment; this will help you decide whether it is having any effect. If any treatment works, it is best to continue it for about 6 months and then stop. In 50% of women, the pain will not recur; if it does, further treatment can be given.

Gamolenic acid. Try gamolenic acid, the active ingredient of evening primrose and starflower oils. You can buy this at a health store; in the past, UK doctors could prescribe this on the National Health Service, but this has been stopped. Three to four capsules are usually taken twice a day for 8–12 weeks; it may take this long to have any effect and the improvement is usually gradual. If it works, the dose is then reduced. It can sometimes cause nausea and indigestion, but has no other side effects. Of women who take this treatment, 30–40% find their condition improves.

NSAIDs. A cream or gel containing an NSAID (non-steroidal anti-inflammatory drug) may help. NSAIDs are painkillers and also reduce inflammation. A research study found that gently massaging the cream into the breasts three times a day for 6 months totally relieved breast pain in almost half of the women in the study (Journal of the American College of Surgeons 2003;196:525–30). If this does not work, the next step is hormone treatment, such as danazol or bromocriptine.

Danazol has several different effects on the hormone system. In the breast, it may block the effects of hormones such as progesterone. It works in about 70% of women with breast pain, and works more quickly than the other treatments. It has some side effects such as irregular periods, weight gain, headache, nausea, acne, oily skin and sometimes deepening of the voice. These effects can be minimized by taking the drug for only the 7 days before a period. It interferes with the effectiveness of the contraceptive pill, so you will have to use a different method of contraception.

Bromocriptine reduces the level of the hormone prolactin, which stimulates breast tissue to grow. It works in about half of women, but is seldom used now because of its side effects – a third of those taking it develop nausea, headache, constipation or dizziness when they stand up suddenly.

Clinic treatments. If no treatments seem to help after 4 months, ask for a referral to a specialist breast clinic.

Testosterone. Some clinics prescribe drugs related to testosterone (the male hormone), such as Restandol. These can have some masculinizing side effects and would usually be prescribed for only a short period (for example, 3 months).

Tamoxifen is another possibility. This drug counteracts oestrogen and is often used for breast cancer, but sometimes a low dose is used for breast pain not caused by cancer (though it is not officially licensed for this purpose at present). If the specialist suggests that you take tamoxifen, do not assume that you have cancer. It must not be taken during pregnancy, so effective contraception is essential. About 30–40% of those taking it experience side effects such as flushing, vaginal discharge and vaginal dryness.

Goserelin. If the pain is very severe, the specialist might suggest goserelin. This is a drug that works on the hormone system, and is effective in 80% of women with bad breast pain. However, it has to be given by an injection once a month and does have side effects.

Treatments to avoid. A few treatments do not really work.

Diuretics do not work, because the pain is not caused by fluid retention.
Vitamin B6 is sometimes prescribed if gamolenic acid does not help, before moving on to hormone treatment. Studies have shown that about 30% of women find that vitamin B6 helps; however, the same number reported an improvement with a placebo (dummy tablet), so its effect is probably psychological. Taking a dose of vitamin B6 of more than 10 mg a day over a long period may cause nerve damage.
Antibiotics are pointless; there is no infection.
Progesterone hormone has been tried in tablet form and as a breast cream, but there is no evidence that it does any good (apart from having a psychological effect).

Pain unrelated to the menstrual cycle (non-cyclical breast pain)
If your breast pain has no monthly pattern and occurs in just one breast, it is known as ‘non-cyclical breast pain’ and should not be ignored. Rather than a heavy, bloated, tender feeling, this pain tends to be sharp or burning. There is usually a very simple cause such as bruising from an injury, a sports strain, an infection such as shingles or a breast abscess, a viral infection of the muscles between the ribs (Bornholm disease), inflammation of the joint between the front of a rib and the breastbone (Tietze’s syndrome), a lung problem such as pleurisy or even gallstones. However, there is a very faint chance that it could be related to early breast cancer, so you should check it out with your doctor. If no cause can be dealt with, it is usually treated with NSAIDs such as ibuprofen, or in the same way as cyclical breast pain, such as with gamolenic acid.