Clinical Notes : Pharmacology

202. Cyclical Breast Pain

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What is it ?

  • Cyclical breast pain is related to the menstrual cycle, with symptoms usually starting within 2 weeks of, and improving at the onset of, the menstrual period (1).

 

What causes cyclical breast pain ?

  • There is no known explanation for cyclical breast pain, but it is not associated with specific underlying breast disease (2) (3) (4) (5)

  •  Hormonal changes are thought to affect symptoms (4)

  • A number of other contributing factors have been suggested (for example caffeine, iodine deficiency, dietary fat intake), but these have not been found to definitively cause symptoms (1)

 

How common is cyclical breast pain ? 

  • Cyclical breast pain affects up to two-thirds of women, with one in ten women having moderate-to-severe pain (5)

 

What is the prognosis ?

  • In 20–30% of women, cyclical breast pain will resolve spontaneously. However, it may recur in up to 60% of women (6)

  • Breast pain is not a risk factor for developing breast cancer (7)

How should I diagnose cyclical breast pain ?

  • Consider a diagnosis of cyclical breast pain when a woman describes pain that (8) (9):

    • Usually starts during the luteal phase of the cycle (within 2 weeks before menses), increases until menstruation begins, and improves after menses.

    • Is dull, heavy, or aching in nature.

    • Is usually bilateral.

    • May be poorly localized and extend to the axilla.

  • For women with moderate-to-severe pain, consider the use of a breast pain diary to aid diagnosis. Advise the woman to use this for at least 2 months to assess the severity and timing of breast pain.

  • Exclude breast cancer.(7) (10)

    • Refer using a suspected cancer pathway (for an appointment within 2 weeks) if the woman is:

      • 30 years of age or older and has an unexplained breast lump with or without pain, or

      • 50 years of age or older and has discharge, retraction, or other concerning changes in one nipple only.

    • Consider referral using a suspected cancer pathway (for an appointment within 2 weeks) if the woman:

      • Has skin changes suggestive of breast cancer.

      • Is 30 years of age or older with an unexplained lump in the axilla.

    • Consider non-urgent referral if the woman is younger than 30 years of age and has an unexplained breast lump with or without pain.

    • Seek specialist advice if there is doubt about whether a referral is needed.

  • Exclude infection, suggested by (11) :

    • Localized breast swelling, redness, warmth, and pain.

    • Associated systemic symptoms such as fever.

  • Exclude pregnancy.

  • If the woman is experiencing additional physical and/or psychological premenstrual symptoms, consider a diagnosis of premenstrual syndrome (4)

How should I manage cyclical breast pain ?

  • Reassure the woman that there is no serious underlying pathology. Offer written information on cyclical breast pain (1) (4)

  • Consider the following treatment options:

    • A better-fitting bra during the day. A soft support bra at night. (4) (7) (8)

    • Oral paracetamol and/or ibuprofen (1) (6) (7) (8)

    • Topical nonsteroidal anti-inflammatory preparation, as required. (6) (7) 

  • Ask the woman to keep a pain diary (if she has not already done so) to evaluate the severity and timing of the pain, and its response to treatment. 

  • Consider referring to a breast specialist if the pain is severe enough to affect quality of life or sleep and does not respond to first-line treatment after 3 months. (4) (8) (12)

    • Specialist treatment options include danazol and tamoxifen.

  • If the woman is experiencing cyclical breast pain in addition to other physical and psychological premenstrual symptoms

  • Do not routinely recommend the following treatments for cyclical breast pain:

    • Stopping or changing other medication, including combined oral contraceptives (130 (14)

    • Evening primrose oil.(4) (15)

    • Progestogen-only contraceptives. (16) (17)

    • Diets low in fat or low in caffeine.(4)

    • Antibiotics.

    • Diuretics.

    • Pyridoxine.

    • Tibolone.

    • Vitamin E.

 
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1. Amin, A.L., Purdy, A.C., Mattingly, J.D. and Kong, A.L. (2103)

Benign breast disease.

Surgical clinics of North America. 93(2), 299-308

Access

2. Santen,R.J. and Mansel,R. (2005)

Benign breast disorders.

New England Journal of Medicine. 353(3), 275-285.

3. Rosolowich,V., Saettler,E. and Szuck,B. (2006)

Mastalgia.

Society of Obstetricians and Gynaecologists of Canada.

Access

4. Iddon, J. and Dixon, M.D. (2012)

ABC of breast diseases.

In: J Michael Dixon (Eds.) Mastalgia.Chichester: Wiley-Blackwell., 25-30.

5. Smith,R.L., Pruthi,S. and Fitzpatrick,L.A. (2004)

Evaluation and management of breast pain.

Mayo Clinic Proceedings. 79(3), 353-372. 

Access

6. Goyal, A. (2014)

Breast pain.

Clinical Evidence.

BMJ publishing group.

Access

7. Salzman B., Fleegle, S. and Tully, A.S. (2012)

Common breast problems.

American family physician. 86(4), 343-349.

Access

8. University of Michigan Health System (2013)

Guidelines for clinical care: common breast problems.

University of Michigan Health System.

Access

9 Chase, C., Wells, J. and Eley, S. (2011)

Caffeine and breast pain: revisiting the connection.

Nursing for women's health. 15(4), 286-294. 

Access

10. NICE (2015)

Suspected cancer: recognition and referral (NG12).

National Institute for Health and Care Excellence.

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11. Bagenal, J., Bodhinayake, J. and Williams, K.E. (2016)

Acute painful breast in a non-lactating woman.

BMJ (Clinical Research edition). 353, 1136. 

Access

12. Dixon, J.M. and Thomas, J. (2012)

ABC of breast diseases.

In: J. Michael Dixon (Eds.) Symptoms, assessment and guidelines for referral.Chichester: Wiley-Blackwell., 1-11.

13.  Bancroft,J. and Rennie,D. (1993)

The impact of oral contraceptives on the experience of perimenstrual mood, clumsiness, food craving and other symptoms.

Journal of Psychosomatic Research. 37(2), 195-202.

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14. Graham,C.A. and Sherwin,B.B. (1992)

A prospective treatment study of premenstrual symptoms using a triphasic oral contraceptive.

Journal of Psychosomatic Research. 36(3), 257-266. 

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15. Srivastava,A., Mansel,R.E., Arvind,N., et al. (2007)

Evidence-based management of mastalgia: a meta-analysis of randomised trials.

Breast. 16(5), 503-512. 

Access

16. Euhus,D.M. and Uyehara,C. (1997)

Influence of parenteral progesterones on the prevalence and severity of mastalgia in premenopausal women: a multi-instituitional cross-sectional study.

Journal of the American College of Surgeons. 184(6), 596-604. 

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17. Maddox,P.R., Harrison,B.J., Horobin,J.M., et al. (1990)

A randomised controlled trial of medroxyprogesterone acetate in mastalgia.

Annals of the Royal College of Surgeons of England. 72(2), 71-76. 

Access

Ireland notes.png

The following meds are available in Ireland :

Tramadol (Tradol, Tramadol HCL, Tramake, Tramapine, Xymel, Zydol)

Tapentadol (Palexia)

Transdermal Buprenorphine (Butrans, Transtec)

 

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