A friend called recently to ask what is known about the causes of breast pain, or mastalgia, in women. She had consulted different doctors and received diagnoses varying from psychosomatic illness to possible fibrocystic disease.
Q: What is mastalgia?
A: Mastalgia is simply a medical term for breast pain. The circumstances under which the pain occurs might give us some clues as to its cause. The mastalgia sufferer should first know that breast cancer is rarely present with pain. To be safe, any women over 40 should have a mammogram.
Research indicates that mastalgia is not necessarily associated with lumpy breasts. So the absence of a lump as the source of pain does not mean the problem is more serious.
Mastalgia may occur in a cyclic pattern related to menstruation or in a non-cyclic pattern.
The cyclic pain is usually hormonal in origin; the non-cyclic pain has different causes.
Q: What are the characteristics of cyclic pain?
A: Cyclic mastalgia usually begins just before menstruation and ends at the start of the period. For most women, the discomfort is mild. For a few, however, the pain is so severe they avoid anything that might touch the breast; they may even experience pain that radiates down the arm.
Any cyclic pain, no matter how severe, is more likely due to hormonal changes, but we are not sure of the exact nature of the changes. Some investigators have found a low ratio of the hormone progesterone to the hormone estrogen in women with mastalgia.
Others have found that mastalgia patients are hypersensitive to the hormone prolactin, which is controlled by thyroid stimulating hormone. When we don't know exactly how the breast pain occurs, it is difficult to treat it.
Q: How can we treat cyclic pain?
A: Most treatments used to balance hormone ratios have side effects, so decisions regarding their use must be carefully considered by both the woman and her doctor.
Some claims have been made that the use of vitamin E or avoiding caffeine reduces breast pain; the evidence, however, is controversial. For some women, a low-fat diet and stress reduction have proven beneficial. Since all these non-hormone methods are benign, they're certainly worth considering for the woman with pain.
Q: What is the cause of non-cyclic pain?
A: This form of mastalgia is much rarer and arises from a variety of causes. Phlebitis of the vein, called Mondar's syndrome, can cause mastalgia, as can a radiation of pain from neck problems such as arthritis of the spine.
A woman with a localized point of pain should have a mammogram and see a doctor to determine whether there is any treatable cause.
Occasionally, the pain is not actually in the breast. If your pain is confined to the rib cage rather than the breast, you may actually be suffering from arthritis of those joints that lie between the ribs and breastbone.
Fractures may also occur in these bones and be mistaken for breast pain. In these conditions, the pain is increased by deep breathing and is greatest between the breasts.
Q: How can non-cyclic pain be treated?
A: Non-cyclic breast pain has varying causes and needs a doctor's evaluation to determine the treatment if pain is persistent. You can help your physician make a diagnosis by carefully noting the conditions under which the pain occurs.
The book "Dr. Susan Love's Breast Book" discusses mastalgia and fibrocystic disease of the breast and can help you conduct informed discussions with your medical practitioner.
Dr. Genevieve Matanoski is a physician and epidemiologist at the Johns Hopkins School of Hygiene and Public Health. She is a founding director of the school's Institute for Women's Health Research and Policy.