Mastalgia: It's not normal
DR. UMA KRISHNASWAMY
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Women need not feel embarrassed about seeking medical help for this common problem.
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MOST women experience painful breasts at some point in their lives, particularly prior to the menstrual periods. So common is this experience in urban societies that mild degrees of breast discomfort in the peri menstrual phase are deemed "normal".
Indeed, most women assume this to be part of the constellation of symptoms that plague a woman during periods and hence do not even voice it as a specific complaint.
There is, however, more intense pain that affects a significant proportion of women. This is termed "mastalgia" (painful breasts). Technically, mastalgia is defined as pain severe enough to interfere with a woman's lifestyle. The cause of mastalgia is largely unknown.
Many theories are postulated as the cause — nutritional, endocrine, psychological or a combination of these.
Cyclical pattern
In the majority, mastalgia is mild and is felt maximally in the week prior to the period and disappears after the onset of the menstrual flow. In others, the pain may be more intense and also prolonged in duration. Such a cyclical pattern of pain may be present for varying durations lasting months or even years.
Significantly, the pain often disappears spontaneously with a hormone-related event such as pregnancy, abortion or menopause. In some the pain may recur after a respite. In some women, particularly in the older, postmenopausal age group, the pain may not have a cyclical pattern. Such non-cyclical pain often disappears spontaneously, but may tend to recur with frequency.
Mastalgia may be accompanied by other symptoms, particularly nodularity of the breasts which is often cyclical in nature, waxing prior to periods and waning after. In some, premenstrual syndrome, a constellation of physical and emotional symptoms, may coexist. It is imperative to remember that mastalgia is seldom associated with any serious abnormality in the breast.
Most women mistake the pain to be a symptom of serious disease and approach a healthcare provider assuming the worst. Only rarely is the pain an indicator of a problem such as an inflammatory pathology or a breast cancer and in these instances, the pain tends to be localised and persistent. A skilful clinician can differentiate this with ease.
Evaluation
On approaching one's healthcare provider, an evaluation of the breast is undertaken, usually by a thorough physical examination. If an underlying abnormality is suspected an imaging modality such as an ultrasound scan in women less than 35 years and a mammogram in women over 35 years may be suggested.
It is important to emphasise that tests are of little value in the management of this condition. The current fashion of pushing all women through unnecessary mammograms is to be frowned upon.
Contrary to popular belief, diagnostic mammograms are not easy to interpret nor are the interpretations entirely accurate. Often normal variants are mistaken to be abnormalities enhancing the anxiety of both the patient and her healthcare giver.
The vast majority of patients, nearly 80 per cent, need little but reassurance that mastalgia is a benign symptom of little medical significance.
This had given rise to an unfortunate tradition within the male-dominated medical profession until recently to dismiss the woman as "neurotic".
It is true that in some instances, the woman might have certain emotional overlay to the problem.
This is often related to the fact that she views mastalgia as an indicator of serious underlying disease. And once reassured that this is not so, her attitude to the pain and her perception of the same changes. But in a small group of patients, counselling or medication from a psychiatrist may be necessary to address underlying psychiatric disorder or disease.
With the strong possibility of the pain disappearing spontaneously, no medication is required in most women.
Treatment
It is a sad fact that in urban India, many women are needlessly medicated with a vast array of drugs. Many have no or little value in mastalgia, while having the potential for causing side effects.
In those limited instances, where the pain is unresponsive to such simple measures of support and lifestyle alteration, an array of medication is available. As a general rule, these are not drugs that can be used with impunity by the primary care providers, but are best prescribed by the breast specialist in a rigidly graded and supervised fashion.
In all but the rarest of cases, it is to be noted that the patient responds to the treatment extremely well.
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Self-help measures
Use a well-fitting and supportive brassiere always, particularly during exercise.
Eat a healthy, low-fat diet.
Minimise intake of coffee, tea, cola and chocolate
Exercise regularly
Reduce stress levels
Provide comfort through warm water fomentation, gentle massage
Abstain from medication known to precipitate or aggravate mastalgia such as the oral contraceptive pill orHRT.
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