BREAST PAIN

Breast pain is common - two out of three women suffer it at some time in their lives. Like any other breast problem, it can be worrying, but most breast pain can be treated and has nothing to do with cancer. There are two types of breast pain. It may be related to the menstrual cycle (cyclical breast pain), or unrelated to the cycle (non-cyclical breast pain).

Causes

Breast tissue is influenced by the hormones which control your period. From the time of ovulation, generally halfway between periods, the hormones build up and then fall rapidly once the period starts. For some, the breast tissue is more sensitive even though their hormone levels are normal, and therefore in the few days leading up to the period, many women feel discomfort in their breasts. Sometimes this can be severe enough to interfere with personal relationships, such as hugging partners and children.

Until recently the cause of breast pain was something of a mystery. Most women with breast pain have normal levels of circulating hormones. It is now accepted that the problem is abnormal sensitivity of breast tissue to normal hormone levels. This increase in sensitivity is linked with the pattern of fatty acids in the blood stream. Fatty acids are substances present in all fats and oils which can affect the way the body responds to its own hormones. Women with breast pain have low levels of a fatty acid called gamolenic acid (GLA). Low levels of GLA are not caused by dietary deficiencies, but by an inefficient conversion process in the body.

Remedies

Make sure your bra fits correctly. Go along to a specialist fitter to make sure it fits and supports you properly. Many large department stores have a specialist bra fitter who can advise you.

There is evidence that increased breast sensitivity is related to the balance between saturated and unsaturated fats, hence adjusting your diet, reducing animal fats (such as butter, cream, fatty meat) and increasing your intake of fresh fruit and vegetables can be helpful.

If you have tried both of these measures and are still getting breast pain, then go and see your doctor. Tell him/her when and where you get the pain, how severe it is, how it affects your life (i.e. work, rest and play).

In order to reassure you that your breast pain is caused by tissue sensitivity to hormones, your doctor will want to examine your breasts to make sure there are no lumps, and he/she will give you a monthly chart to fill out, to see if your pain is associated with your periods.

It is helpful to keep a pain chart over several months, marking the days you have pain, and whether it is mild or severe. Record also when your period comes, to see if there is a pattern. This is important, because treatment of pre-menstrual pain can be different to that for random breast pain.

Prescription medicines

Gamolenic acid (GLA) is the simplest and probably the best non-hormonal agent to try first. It has been shown to reduce cyclical breast pain in over 70 per cent of women. This is a special prescription version based on evening primrose oil. It needs to be taken in adequate quantities (three or four 40mg capsules twice a day) right through the cycle, and it may be up to three months before the full benefit is felt.

If three months of therapy has not helped, talk to your GP. Treatment with GLA overcomes inefficient production in the body, raises levels of the polyunsaturated fatty acids towards normal, and relieves breast pain. Fewer than 5 per cent of women will experience minor side-effects (nausea and loose motions).

There are two hormone prescriptions which work quickly but may have undesirable side-effects.

Danazol counteracts your own hormones, and generally one 100 mg tablet a day will relieve pain in the first cycle. If it does not, the dose can be doubled, though you would need to be aware of possible side-effects of weight gain, nausea, greasy skin, and deepening of the voice. After three cycles, you may be able to reduce the dose to one tablet on alternate days, or just in the second half of your cycle. Danazol should not be combined with the pill, but as it is important to avoid pregnancy during treatment, remember to use barrier methods, unless you have been sterilised or have a coil fitted.

Bromocriptine is taken in tablet form once or twice daily. Side-effects of dizziness, nausea, or constipation can occur. Bromocriptine should not be combined with the pill, but pregnancy should be avoided during treatment, using barrier methods, if necessary.

Treatment with hormones is generally continued for six months, and many women taking it will need no further treatment. Using a pain chart also helps you and your doctor to determine how well the treatment is working.

Some women gain relief by taking simple painkillers, such as paracetamol or ibuprofen, but they are generally only of value in the milder cases. Antibiotics, diuretics (water tablets), and vitamin B6 (pyridoxine), are not effective for breast pain, and there is no point using them.

Non-cyclical breast pain

Non-cyclical breast pain may come from the ribs, or the muscle of your chest wall, and simple painkillers may be all that is needed. Sometimes there is a trigger spot for the pain, and injection of this with local anaesthetic and a steroid can help.

Sometimes the joint between the front end of a rib and the breastbone can become inflamed and painful (Tietze's syndrome), and similar treatment is recommended. Attention to diet and correct bra-fitting may also help.

Cancer

If the pain affects both breasts, particularly if you are under 35 and the pain occurs before your period, or if both breasts feel the same and there is no lump, then cancer is very unlikely. If the pain is one sided, or if you are over 35, or if you have a lump, see your doctor. A painful lump could be an early cancer, but is more likely to be a cyst.

If you have a close relative, called a first degree relative (i.e. your mother, sister or daughter), who developed breast cancer before the age of 50, then you are at a moderately increased risk of developing cancer yourself. Some experts suggest that you should have regular check-ups, be examined by a specialist, and have an ultrasound of your breasts every two years, starting when you are 10 years younger than the age at which your relative developed cancer. In other words, if your mother had breast cancer at 40-years-old you should go for regular check-ups starting at the age of 30.

If your relative was more distant or more elderly when she developed breast cancer, then you are not considered to be at any greater risk than somebody whose mother or sister did not get breast cancer. In any case, you would be wise to check your own breasts each month, and when you are 50 take part in the NHS Breast Screening Programme, which offers a mammogram every three years.

If the affected relative is more distant, or if your mother or sister was elderly when she developed cancer, your risk is no greater than anyone else's.

Breast awareness

It makes sense to be aware of your breasts and to know what is normal for you. Each breast contains 15 to 20 clusters of glands designed to produce milk. Channels from each gland join together (a bit like a bunch of grapes) and each cluster has a main duct which opens at the nipple. The glands are embedded in fatty tissue which gives the breasts their individual shape. Normally women can feel the glands within their breasts. By regularly checking your own breasts, you become aware of what is normal for you throughout the month. Familiar lumps and bumps that do not change over the months are not a cause for worry. If you are thin, you will be able to feel your ribs. If in doubt about any particular area of your breast, feel the other side, and if the lumpiness is the same on both sides, all you need to do is check them again the following month. If you are still having periods, do this a few days after your period; if not, make it the first week of each month.

Firstly, with your top clothes off, stand in front of a mirror and raise your arms above your head. Notice any new difference in size or shape between the breasts, any puckering of the skin or alteration of the nipple. Lie down with your fingers flat (some women find it easiest to do this in the bath using a soapy hand), feel over the whole surface of both your breasts, feeling for anything which is different from last time. Also feel in the armpit.

If a young girl (for example, at the age of ten) develops a lump under one nipple, this is not likely to be a sign of cancer. Rather, it is simply the beginning of her breast development, which at that age is more likely to start on one side before the other.

Many women have one breast larger than the other. If this is the way it has always been, it does not matter at all. But, if there is a change in the size of one or other breast, consult your GP.

Mammograms

All women between the ages of 50 and 64 are invited to go for a screening mammogram (or breast x-ray) once every three years. This is the age when cancer is most likely to occur, and a mammogram should pick up a cancer very early, before you can feel anything wrong. Although some women feel discomfort, the earlier treatment is started, the greater the chance of success, so do go along while the screening unit is in your area.

Cancer is less common in women under 50. Also the breast tissue is more dense, and the mammograms less satisfactory, and there has been no evidence to show that screening mammograms on women under 50 reduces the death rate from the disease. Older women are welcome to continue in the screening programme after the age of 64; contact your local Breast Screening Service.

The Pill and breast cancer

No link has been proved. There was a suggestion that starting the pill early and continuing for many years could slightly increase the risk, but the pills studied contained a higher dose of hormone than those in use now. The pill continues to be recommended as a safe and convenient method of contraception.

HRT and breast cancer

Up to ten years' continuous Hormone Replacement Therapy (HRT) does not increase the risk of breast cancer. Beyond this there may be a slightly increased risk, but this needs to be balanced against the protection that HRT gives against heart attack and stroke. HRT also lessens the risk of osteoporosis, the bone thinning disease which can lead to hip fracture and spine pain in older women. Women on HRT are advised to check their own breasts each month, and if they are 50 or over, to go for three-yearly NHS mammograms.

Before you start HRT, your doctor should examine your breasts, but a mammogram is not essential.

Menopause

Breast tissue does tend to get smaller after the menopause, but usually very gradually. Much of the breast is made up of fatty tissue, and will reflect your general body contours. HRT may well help to keep your shape. It has many other benefits and some drawbacks; discuss it with your GP.