As with premenstrual syndrome (PMS), the cyclic nature of mastalgia suggests variations in ovarian hormones as the cause of the symptoms. Adding weight to this theory, women taking hormone preparations that contain oestrogens or progestogens also suffer from breast pain, and stopping these medications can result in markedly reduced symptoms. It is also possible that elevated prolactin is responsible for structural changes in the breast and breast discomfort. Despite these theories, no hormonal changes have been consistently identified that can explain the existence of premenstrual breast pain.”
There is also a strong possibility that an oestrogen-induced increase in the pro-inflammatory (series 2) prostaglandins may increase bloodvessel dilation and give rise to breast pain. Diets high in omega-6 polyunsaturated vegetable oils and animal fats, but low in essential fatty acids, may also be responsible for, or exacerbate, the increase in pro-inflammatory prostaglandins. On the other hand, women with cyclic breast disorders may have low serum levels of the (anti-inflammatory) series 1 prostaglandins, which may in turn increase sensitivity to prolactin and contribute to pain. Coffee consumption, which also triggers pro-inflammatory changes, has been linked to breast pain and breast changes.
Cyclic breast pain also seems to be affected by lifestyle factors. One Australian study found that women who developed mastalgia exercised less than other women, and had either not breastfed or had done so for less than two months.
When pain is severe enough to warrant treatment, it is wise to wait and monitor the symptoms with a menstrual chart for two cycles first. This not only provides a record of the frequency and severity of the symptoms, it can also help to monitor the effectiveness of subsequent treatment. As many cases of mastalgia are short-lived, expensive or unnecessary treatments may also be avoided.
The medical approach
Bromocriptine reduces prolactin levels and breast soreness; Danazol also has a high success rate (around 70 per cent), but both drugs are accompanied by many unwanted side effects. GnRH agonists improve mastalgia by inducing a menopausal state, but also have side-effects. Tamoxifen is an anti-oestrogen and can lower prolactin levels. It is effective in reducing cyclical breast pain, although long-term safety in pre-menopausal women has not been proven. It is usually only recommended when all other drugs fail.
Between 70-90 per cent of women on the Pill have a much lower incidence of cyclical breast complaints, especially when the oestrogen level in the Pill is low. However, some women on these medications experience more breast pain. Women who are 40 and older, or who have abnormal HDL:LDL cholesterol ratios should take between 400-1200 IU vitamin E while on this regime to prevent the progestogen-induced reduction in HDL and increase in LDL.
Progestogens such as Provera have been shown to reduce symptoms. Various trials on progesterone (‘natural’ progesterone) found no difference in response rates between progesterone and placebo. Controversially, antibiotics are sometimes suggested, despite a lack of rationale in the treatment of cyclic breast pain. These drugs are discussed in ‘Drugs and surgery’.
The natural therapist’s approach
Natural therapists believe that cyclical breast disorders are caused by a number of inter-related hormonal factors which culminate in pain, swelling and tissue changes. Principal among these are the changes caused when oestrogen levels increase in the luteal phase of the cycle without adequate levels of progesterone, and a prostaglandins-induced sensitivity to prolactin.
Improving oestrogen-progesterone balance is achieved by restricting fats and increasing fibre; using herbs such as Paeonia lactiflora and Vitex agnus-castus to improve progesterone levels (discussed in ‘Herbs’); increasing phyto-oestrogens to compete with the more active endogenous oestrogens, especially linseeds (which additionally improve the oestrogen-progesterone ratio); and using bitter foods and herbs for oestrogen clearance.
Vitex agnus castus is one of the most reliable herbal treatments for the control of premenstrual mastalgia and also seems to reduce the incidence of premenstrual breast lumps. Positive effects can be expected within the first two cycles, although very occasionally some women experience a temporary increase in breast discomfort and fullness when first started on Vitex that usually settles in one to two cycles.
The Chinese herbal formula Cinnamon and Hoelen Combination (Gui Zhi Fu Ling Tang) is also effective. A clinical trial assessing the efficacy of this formula in the treatment of premenstrual breast complaints found it to be effective for pain in 88 per cent of women, and to reduce the size of breast lumps in 40 per cent of the women treated. Positive effects were seen in the majority of cases within the first cycle. The formula is believed to act as a weak GnRH antagonist, reducing levels of LH, FSH and oestrogen, and may also act as a weak anti-oestrogen by actively competing with oestrogen in breast tissue.
A variety of supplements are regularly suggested for breast pain, including the omega-6 essential fatty acids which are found in high quantities in evening primrose, star flower, black currant and borage seed oils. Enthusiasm for their use has continued even though studies have found that there is a substantial delay between commencing treatment and a reduction in symptoms — up to three months in one study — and that less than half of all women who take these supplements respond favourably. The recommended dose of evening primrose oil for breast pain is 3000-4000 mg per day.
Vitamin B6 is also commonly recommended; however, the only controlled study for cyclic mastalgia compared 100 mg B6 daily and placebo for two months, and found no difference between the two treatments. Thiamine or vitamin B1 has also been used for breast pain since World War II, when prisoners of war who developed gynaecomas-tia (excessive development of the breast in males) responded to treatment with vitamin B1. Vitamin B1 is necessary for the hepatic metabolism of oestrogens, and since relative oestrogen excess may be responsible for cyclic breast disorders, the use of B1 has continued. Doses of between 60-100 mg per day are usually recommended, and although improvement is occasionally reported, no double-blind studies have been published.
Better results can be expected with vitamin E. A study of vitamin E, 600 IU per day, reduced breast pain in 85 per cent of women; in another, vitamin E improved the oestrogen to progesterone ratio in favour of progesterone. Combining vitamin E with 25-50 mcgm of selenium is also beneficial.
A French trial showed that a standardised extract of Gingko biloba (containing 24 per cent Gingko flavone glycosides and 6 per cent terpenoids) was an effective treatment for breast pain. The double-blind study monitored 165 women over two menstrual cycles who took 160 mg per day of the standardised extract or placebo from day 16 of the menstrual cycle through to day 5 of the following cycle. Gingko biloba decreases abnormal capillary permeability, increases capillary resistance and reduces oedema. The terpenoids also counter the effects of the pro-inflammatory platelet-activating factor (PAF) which may also contribute to tissue swelling.
Some women may develop breast lumps because of an underactive thyroid gland. This may be sub-clinical (not detected with blood tests) and manifest as a low basal body temperature, increased sensitivity to cold and erratic menstrual cycles. Hypothyroidism causes levels of SHBG to fall, which may contribute to a greater availability of oestrogen. These women often respond to iodine-containing herbs such as Fucus vesiculo-sis, or the addition of seaweeds to the diet.
Additional benefits are also seen when herbs which improve lymphatic drainage are prescribed. These include Calendula officinalis, Viola odorata, Pbytolacca decandra, Galium aparine, Stillingia sylvatica and Trifolium pratense (which has the additional benefit of containing phyto-oestrogens). These herbs are believed to improve the removal of cellular debris during normal involution of breast tissue in the menstrual phase of the cycle.
Topical applications of creams containing Zingiber officinale 15 per cent and Pbytolacca decandra 10 per cent (as tinctures), applied twice daily, also improves pain and breast lumpiness.