Introduction

Pain in the breast is a frequent complaint. Almost all women experience it at some stage. Importantly breast cancer only presents with pain in 10% of cases and this is a constant pain localised to an area usually associated with a mass. If there is no mass and constant pain, a mammogram or sonar should be obtained. Only 2% of these cases will be associated with a malignancy. The chances of there being no mammographically detected malignancy and still a missed cancer is only 0, 1%. All patients presenting with breast pain should have a thorough history and clinical examination. 20% of 'breast pains' are actually due to non-breast pathology such as:

• cardiac problems (heart related)

• respiratory problems (pneumonia; pleuritic chest pain)

• gastro-intestinal problems (reflux heartburn)

• rib inflammation (costochondritis)

• shingles (herpes zoster infection)

When fibroadenosis becomes excessive (severe pain with nodularity), it begins to interfere with the patient's lifestyle (they cannot wear seatbelts, sex becomes intolerable, etc). These women have what is referred to as mastalgia. All women over 40 with breast pain should have mammograms and a thorough clinical assessment and women under 40 should have an ultrasound. Breast pain can be related to hormone flux in the menstrual cycle. This is called cyclic mastalgia (67%). There is another variety of breast pain that is noncyclical (non-cyclical mastalgia). This accounts for only about 26% of breast pain. 10 % of breast pain is chest wall pain (costochondritis) or Tietze's disease.

Burning, shooting pains

This is usually as result of duct dilatation and is related to duct ectasia, smoking and pollution. The patient experiences burning discomfort in the breast and occasional shooting pain in the breast. Anti-oxidants may help for this type of pain.

Full, heavy uncomfortable breasts (feels like one needs to feed a baby)

This is caused by stress (physical, emotional, mental) which results in transient changes in the prolactin levels (a stress hormone). It is important to check thyroid function, prolactin levels and medication as well.

Isolated medial and lateral pain on pressure

This is costochondritis. Pain extending from the armpit down towards the nipple. This pain is usually worse at the end of the day and is related to breast hygiene (poor fitting bras and large breasts, with pulling on the breast ligaments).

Treatment for breast pain entails the following:

• All women with breast pain should be placed on a pain chart for four months and told to chart their pain with its variations over the menstrual cycle. The concept of breast hygiene needs to be addressed when dealing with breast pain.

• III-fitting bras or old bras, combined with large breasts, result in pain under breasts and in the axillary tail, particularly as the day progresses, and as gravity takes its toll on the breast ligaments. Vitamin B6 (pyridoxine) and gamma linolenic acid (evening primrose oil) should be tried first (gamma linolenic acid tends to stabilize breast epithelial activity via prostaglandin metabolism). The dose of evening primrose oil is 2 capsules daily. The 86 and evening primrose oil should be taken in combination. Treatment is continued for a minimum of 3 months and over 70% of patients have a good response. Some studies suggest taking up to 6 capsules per day of Danazol (antigonadotrophic hormone) may be effective. Bromocriptine (antiprolactin hormone) may be necessary, if the other drugs fail.

The problem with these 2 drugs is that the side effects often outweigh the benefit.

• Low dose anti-oestrogens (SERMS) are also used to treat breast pain (tamoxifen, fareston) although these do not have FDA approval in the USA.

• Some studies suggest crushing these SERMS and mixing them in KY jelly and applying them topically to the breast tissue.

• Finally using indol 3 carbinol (active ingredient in the cruciferous vegetables) may help, as this substance mimics the action of tamoxifen in the breast)

Chest wall pain

• Tietze's disease which is pain and tenderness over the costochondral junctions (the ribs under the breasts). This accounts for 10% of breast pain. Costochondritis may be related to excessive muscle strain (Sport) or a recent viral infection. Treatment is to abstain from doing the implicated sport for a few weeks or take NSAIDS (non steroidal anti inflammatory drugs). Some doctors recommend arnica oil for this.

• Mondor's disease is pain in the lower or lateral aspect of the breast from a thrombophlebitis of a vein crossing within the breast tissue. Anti-inflammatory drugs will give rapid relief (NSAIDS).

It should be noted that many workers prefer the name benign breast disease to fibroadenosis

Nipple discharges

The third main presentation of breast problems is a nipple discharge. Nipple discharges are classified according to colour and the number of ducts involved. Discharges from many ducts can be milky (physiological). The discharge of duct ectasia can be green, yellow or even black and this is usually from more than one duct.

The discharge from a single duct that is F/eU Incraduct fHlfIII/oma spontaneous (occurs without squeezing) is usually clear yellow or blood tinged and this is most likely from a duct papilloma.

Milky multiple duct discharge

Most importantly exclude pregnancy. Milky discharges (galactorrhoea) can be caused by a variety of hormonal imbalances such as thyroid problems, pituitary gland problems or gynecological problems. Rarely, drugs that inhibit or deplete dopamine such as certain psychiatric drugs (antidepressants in particular) and antihypertensives, can cause galactorrhoea. In fact, even the excessive stimulation of the breast mechanically can cause lactation (may be seen in marathon runners). Stress can also cause a milky nipple discharge (due to the release of an acute stress hormone prolactin).

Management should entail detailed history and physical examination followed by a pregnancy test (if indicated), a prolactin level and thyroid function tests. The patient should be told to refrain from squeezing the nipple even if tingling and pressure is felt, so as to allow the sebum plugs that normally block the ducts to dissolve and reform. It is seldom necessary to use parlodel (antiprolactin).

Of concern is a single duct discharge, which is clear, blood tinged or bloody, especially if it is spontaneous.

Intraduct papilloma (Fig 5.3)

This presents with a bloody nipple discharge, which can be localized to one duct. By "milking" the skin over the duct towards the nipple, blood or clear yellow fluid will ooze out of the relevant nipple orifice. An associated breast cancer may be detected by mammography and FNA in a small percentage of cases. lntraduct papillomas may be multiple and may be detected on ductogram. The treatment is to excise the involved duct by a michro-dochectomy; the papilloma is sent for histology to confirm that it is benign, as a percentage of duct papillomas may be ductal carcinoma or ductal carcinoma in situ.

Duct ectasia (obstructive mastopathy)

This also occurs in the twenty-five to fifty year old female and is on the increase. It is a complex disorder where there seems to be a sebaceous like thick breast secretion (like porridge or toothpaste) that blocks the ducts (causing ectasia or dilatation of the ducts). This also leaks into the breast stromal fat (periductal mastitis) causing inflammation. This periductal mastitis is a chemical inflammation, followed by a secondary bacterial infection. Smoking seems to predispose to squamous metaplasia (presents like duct ectasia). It is a condition caused by a combination of environmental factors, hormonal interaction and stress.

Duct ectasia may present with:

• nipple discharge usually when the nipple is squeezed (a pus swab must be taken of the nipple secretion for culture)

• nipple retraction or horizontal fissuring of the nipple

• mastalgia (breast pain which is usually described as a burning or shooting pain) due to a plasma cell mastitis (inflammation of the breast caused by the thick toothpaste material extruding out of the duct lumen becoming infected with anaerobic bacteria).

• non-lactating breast abscess (progression from the plasma cell mastitis to bacterial infection and abscess formation)

• mammillary duct fistula (communication between the major ducts and the preriareolar skin, at the point where the non-lactating breast abscess ruptures outwards, to drain either spontaneously or where the doctor lances the pus).

Treatment consists of giving antibiotics specific for the bacteria cultured (commonly a staphylococcus aureus or an anaerobe), such as amoxycillinlclavulinic acid or co-trimoxazole. Non-lactating breast abscess may require drainage but should initially be treated with ultrasound guided aspiration. If the condition pursues a chronic relentless course, as it often does, the major breast ducts must be excised surgically (macrodochectomy) via a subareolar incision (cone excision). This procedure should involve significant counseling of the patient as in a percentage of patients may develop complications with this procedure (recurrent fistulae; loss of the nipple areolar complex). The treatment for duct ectasia is, thus, antibiotics; except when it is intractable or complicated such as:

• recurrent discharges non responsive to antibiotics

• abscesses

• fistulae