Clinical:Case Study: Normal Breasts

Original materials created in February 2000 by JoDean Nicolette, M.D.

History

GL is a 37 yo White woman who came to my office to discuss “breast problems.” She described a several year history of pain in both breasts, occurring just before her periods. The pain is “pulling and aching,” accompanied by a feeling of fullness. It doesn’t interfere with her daily activities, but she is always aware of it. Sometimes she can’t sleep on her stomach, and feels slight discomfort when she holds her partner tightly. She denied feeling any lumps, change in breast size, rash, or nipple discharge. She said she sometimes examines her breasts, but “wouldn’t know cancer if she felt it.GL said suddenly, “Do I have cancer? I think I might. I heard you can get your breasts removed to avoid it. I might do that, what do I need them for anyway?

GL denied past medical or surgical history.

Two Normal Breasts

Fam Hx: No history of cancer, including breast and ovarian cancer

Social Hx: GL lives with her longtime partner and works for the County. She denies tobacco, alcohol, or street drugs. No vitamins or herbal medications. She does not have children, but thinks she may want to eventually.

ROS: Positive for premenstrual irritability and occasional weight gain.

Exam

She is a well developed, well nourished woman, appearing slightly anxious. After discussing her concerns, symptoms and history, I stepped out, asking GL to gown, with the opening in the front. She knew very little about her breasts, and had never discussed them with her MD, so on my return, we did the exam together. In front of a mirror, we observed her normal breasts. I pointed out the few hairs on her areolas as normal. Her right breast was slightly larger than her left. I asked her to raise her hands above her head. No skin changes, asymmetry, or dimpling were evident. She placed her hands on her hips and pressed down to contract her pectoralis muscles and put stress on her suspensory ligaments, again with no abnormalities seen. No lymph nodes were identified on axillary or supraclavicular palpation.

I continued the exam with GL supine, palpating her breasts in a pattern of vertical lines, using my three middle finger pads in a rectangular area bounded by her clavicle superiorly, her mid-sternum medially, bra-line inferiorly, and mid-axillary line laterally. At each location I performed three circles, each with slightly increasing level of pressure. In order to flatten and better examine the medial aspects of her breasts, I asked GL to lie flat and raise her elbow to her shoulder; for the lateral segments I asked to place her hand over her head and keep her shoulders flat while rotating onto the contralateral hip.

After reassuring GL that she had a normal exam and normal breasts, I stepped out, and returned after she had dressed, to continue our discussion.

Discussion

Mastodynia (Greek) and mastalgia (Latin) translate literally into “breast pain.” The large majority of women experience breast pain in their lifetimes, usually occurring between the ages of 30 and 50. It is most often cyclic, occurring during the luteal phase of the menstrual cycle, as is the case with GL. For some women, it is a component of premenstrual syndrome. As with other poorly understood conditions unique to women, breast pain has been pathologized in the male model of medicine. Breast pain may be more accurately characterized, however, as manifestation of a normally functioning breast, given its prevalence, and it’s hormonal component in a hormonally sensitive organ. As with many physiologic functions, hormonal response in breast tissue is experienced on a continuum, ranging from unnoticed to interfering with daily activities. It is not known why some women are more sensitive to cyclic changes in their breasts than others. Some studies suggest that women who experience breast pain have a lower progesterone to estrogen ratio during the second half of the menstrual cycle, or that they have increased sensitivity to prolactin. No studies have shown that cyclical breast pain is related in any way to subsequent development of breast cancer.

The approach to breast pain consists of a careful history and physical exam to establish cyclic vs. noncyclic symptoms, and to exclude other causes of pain in the breast area (i.e. costochondritis, angina, or musculoskeletal conditions). Breast imaging with mammogram and/or ultrasound may be appropriate depending on the circumstances. Patients can use a daily breast pain chart or calendar if they have not noted any pattern. The importance of a thorough clinical breast exam (CBE) can not be over-emphasized, both from the perspective of ruling out breast masses, and reassuring the patient. The most sensitive exams can take 5-10 minutes (total) for both breasts. Several recent publications address up-to-date, complete techniques, and warrant review.1,2 After practitioner evaluation, most women don’t require treatment of their pain, but rather re-assurance that they do not have cancer.

For women who desire intervention to reduce symptoms, we can offer mostly anecdotal evidence. The non-hormonal therapies listed below have been reported to help some women

• Vitamins E, A, B-complex, or beta-carotene
• Avoidance of caffeine (coffee, tea, chocolate,colas)
• Evening Primrose Oil
• Diuretics
• Low fat, high carbohydrate diet
• Athletic support bra

Given that cyclic breast pain is hormone responsive, hormonal therapies are a logical choice to investigate for treatment of women who have severe pain that affects their quality of life. Those which may be useful, some having data supporting their effectiveness include oral contraceptive pills, progesterone, bromocryptine, danazol, and tamoxifen. Use of these agents is often limited due to adverse effects, cost, and lack of long term safety profile. Several good discussions of breast pain therapies are referenced below.

Non-cyclic breast pain, often called “triggerpoint pain,” is also rarely related to breast cancer. This may have an anatomic cause – like a breast cyst or “fibrocystic changes” or musculoskeletal etiologies, and is not hormonally related. Treatment for non-cyclic pain differs from that of cyclic pain, and is not addressed here.

Plan

I explained mastalgia to GL in the context of normal breast physiology and function, discussing what we know and don’t know. I emphasized that she had normal, functioning breasts, and certainly had no indication of cancer. We discussed a reasonable screening program for her. She seemed reassured, and said that she now realized the anxiety surrounding her breast discomfort had been far more troublesome than her breasts. She declined any specific therapy for her symptoms, but would consider the dietary change in the future, since “that seemed good for her all-around health.”

After addressing GL’s breast symptoms, I asked GL about her perceptions of her breasts as pathologically-prone appendages. Our discussion of normal anatomy and physiology had already made an impact on her ideas, but she agreed that she viewed her breasts as foreign, and potential invaders, rather than parts of herself. We agreed that the ubiquity of information about breast cancer is essential for public awareness and prevention, but that it also creates alarm and anxiety in some women because it is not balanced with information about healthy breasts. GL felt that women are encouraged to examine their breasts, rather than know and enjoy them. I referred her to parts of Dr. Susan Love’s Breast Book, and one chapter in particular, called, “Getting Acquainted with Your Breasts.” 4 She said she would take a look, and call me with any questions.

References

1. Wallis, LA. Breast and Pelvic Examinations: A Handbook for Professionals (fourth edition). The ational Council on Women’s Health, Inc: New York, 1996.
2. Barton, MB, Harris, R, Fletcher, SW. Does this patient have breast cancer? The screening clinical breast exam: Should it be done? How? JAMA, 1999; 282(13): 1270-80.
3. Miller, JE. “Benign Breast Disorders,” in Primary Care of Women (eds. Lemcke, DP, Pattison,J,Marshall, LA, and Cowley, DS). Appleton & Lange: Norwalk, CN,1995.
4. Love, SM. “Breast Pain,” in Dr. Susan Love’s Breast Book. Addison-Wesley Publishing Company: New York, 1995.
5. Burns, RB. “Evaluation and Management of a Palpable Breast Mass,” in The Medical Care of Women (eds. Carr, PL, Freund, KM, and Somani, S). WB Saunders Company: hiladelphia, 1995.

For Your Patients

Love, SM. Dr. Susan Love’s Breast Book. Addison-Wesley Publishing Company: New York, 1995

The Boston Women’s Health Collective. Our Bodies, Ourselves: For the New Century. Simon & Schuster, New York, NY: 1998