Introduction:
Mastalgia or breast pain (syn: mastodynia) is a common breast symptom experienced by females of reproductive age; the reported prevalence ranges from 41% to 79% (1-4). In the patients the severity of pain may adversely impact the routine life besides creation of fear of harboring breast cancer (4-5). Multiple studies have been published in literature on this disorder but no such study on mastalgia has been published from the Qassim region of Saudi Arabia. It was against this background, the current pilot study was conducted in general population to study the profile of females with mastalgia.
Materials and Methods:
A cross sectional study was undertaken in June 2017 in the Department of Surgery, Unaizah College of Medicine, Qassim University, Saudi Arabia ; the first two authors were deputed to present the questionnaires randomly to the women visiting the major shopping malls of Unaizah district of Qassim region of Saudi Arabia and the last two authors were deputed to analyze the data and formulate the results. The anonymous questionnaire used as investigative tool was self designed and involved questions about demographic data and breast pain. Informed consent of all subjects was obtained as per the guidelines stated in the Declaration of Helsinki. Confidentiality of data was assured and that data was used only for the stated purpose of the survey.
The demographic data of the subjects was self-reported and organized as shown in table 1. Academic qualifications were assessed in terms of the highest qualification obtained. The severity of breast pain was calculated with Visual Analog Scale (VAS). VAS is a continuous scale comprised of a horizontal line, 10 centimeters in length; 0 meant ‘No pain’ and 10 meant ‘Worst possible pain’. Mastalgia was assessed for relationship with menstrual cycle by asking direct questions: “Is the breast pain related to your menstruation cycle?” or “Does the breast pain relieve by the onset of menstrual period?”
Analyses of data were done with SPSS version 12.0 for Windows and Microsoft Excel-2010 and the data were expressed as means and numbers (with percentages). For the analyses, the significance level was set at p-value less than 0.05.
Inclusion criteria: All Saudi origin females of age above 15 years, who agreed to participate in the study.
Exclusion criteria: Females excluded from the study included the ones: (1) having history of breast surgery / specific breast disorders that can cause breast pain, (2)having non-Saudi origin and (3) pre-puberty , (4) pregnancy and (5) breast feeding.
Calculation of sample size: The subjects were chosen by using Simple Random Sampling method . The sample size was calculated by sample size equation for cross sectional studies as given below:
Sample size = [Z (1-α/2)2 p(1-p)] / d2
Where Z (1-α/2)2= Standard normal variate {at 5% Type 1 error (p <0.05), it is 1.96; p = Expected proportion in population based on data from the literature. Since the prevalence of mastalgia is reported above 40% in other studies, hence p was taken as 0.4;
d= Absolute error or precision and value selected was 0.05.
After application of values, minimal required sample to be studied was found out to be as following:
Sample size = [(1.96)2 x 0.4(1-0.4)] (0.05)2 = 369.
To improve the results, it was decided to enroll at least double the number of subjects as calculated from the formula.
Results:
The total number of females requested to participate in study was 1065 and the subjects who accepted to participate in study was 979 (92%). Out of the 979 participants, 578 (59%) gave history of experiencing mastalgia at some point of time and 401 (41%) did not suffer from mastalgia as shown in Fig 1.
 |
Fig:1 : Prevalence of mastalgia |
The demographic data is as shown in Table 1:
| Table 1: Demographic data |
Age groups (in years) |
15-24 |
25-34 |
35-44 |
45-54 |
Above 55 |
n= 212 (36.7%) |
n= 199 (34.5%) |
n= 103(17.8%) |
n= 56 (9.7%) |
n= 08 (1.4%) |
Occupation |
Housewives |
Office goers |
Students |
Teachers |
Others |
n= 308 (53.3%) |
n= 58 (10%) |
n= 101 (17.5%) |
n= 47 (8.1%) |
n= 64 (11.1%) |
Educational Level |
No school |
Primary school |
Middle/ High school |
Graduate |
Postgraduate and above |
n= 0 (0%) |
n= 37 (6.4%) |
n= 205 (35.5%) |
n= 234 (40.5%) |
n= 102 (17.7%) |
Marital Status |
Married |
Unmarried |
197 (34.1%) |
381(65.9%) |
The specific data related to character, intensity and impact of mastalgia seen in the subjects in our study is as depicted in Table 2.
Table 2: Specific characteristic of Mastalgia |
Age of Onset (years) |
Before 15 |
16-25 |
26-35 |
36-45 |
46-55 |
Above 55 |
07 (1.2%) |
236(40.8%) |
149 (25.8%) |
104 (18%) |
82 (14.2%) |
- |
Average pain score in Visual Analogue Scale (Out of 10) |
1-3 (mild) |
4-6 (moderate) |
7-10 (severe) |
107 (18.5%) |
452 (78.2%) |
19 (3.3%) |
Relation to menstruation |
Yes |
No |
492 (85.1%) |
86 (14.9%) |
Number of days/month when pain is experienced |
Up to 1 day |
2-3 days |
4-7 days |
8- 14 days |
More than 14 days |
163 (28.2%) |
238 (41.2%) |
146 (25.2%) |
24 (4.2%) |
07 (1.2%) |
Breasts affected by mastalgia |
Unilateral |
Bilateral |
76 (13.1 %) |
502 (86.9 %) |
Main concerns of the patient |
Affects the routine life |
Fear of harboring cancer |
No specific concern |
72 (12.5%) |
84 (14.5%) |
422 (73%) |
Screening for breast cancer done |
Yes |
No |
66 (11.4%) |
512 (88.6%) |
Family history of mastalgia |
Yes |
No |
356 (61.6%) |
222 (38.4%) |
Family history of breast disorders other than mastalgia |
Yes |
No |
47 (8.1%) |
531 (91.9%) |
History of other chronic disorders (Diabetes, Hypertension, Hypothyroidism, Asthma) |
Yes |
No |
111 (19.2%) |
467 (80.8%) |
|
|
The management of mastalgia in the subjects of the study is as shown in Table 3.
| Table 3: Management of Mastalgia |
Treatment sought from physicians |
Yes |
No |
174 (30%) |
404 (70%) |
Nature of the treatment in patients seeking treatment (n =174) |
Reassurance |
Non-steroidal
anti-inflammatory drugs |
Evening
primrose oil |
Danazol |
Unspecified Herbs
/ Not sure of medications |
Sports bra |
72 (41.4%) |
38 (21.8%) |
17 (9.8%) |
13 (7.5%) |
15 (8.6%) |
19 (10.9%) |
Duration over which treatment taken /medico followed up |
Up to 3 months |
3-6 months |
6-12months |
1-3 years |
3-5 years |
Above 5 years |
34 (19.5%) |
52 (30%) |
47 (27%) |
24 (13.8%) |
11 (6.3%) |
6 (3.4%) |
Impact of treatment on pain score |
Completely relieved |
Decreased but not relieved completely |
No impact |
Increased |
84 (48.3%) |
76 (43.7%) |
12 (6.9%) |
2 (1.1%) |
Total estimated lifetime duration of Mastalgia |
Up to 1 year |
1-5 years |
5-10 years |
More than 10 years |
Discussion
Mastalgia or breast pain (or mastodynia) is a common symptom experienced by women of reproductive age and the reported prevalence ranges from 41% to 79% (1-3). Mastalgia may be cyclical when it is related to menstrual cycles, non-cyclical when it bears no relation with menses or of extra-mammary origin when the breast pain arises from structures other than breast.
Many researchers have conducted and published studies in literature on this disorder. Ader and Shriver(4) in 1997 after a descriptive study involving 231 females under 55 years of age visiting a breast clinic, found that 30% of premenstrual women suffered from cyclical mastalgia lasting for 5 days or more in a month and the severity of mastalgia interfered with sexual activity for 33%, with physical activity for 29%, with social activity for 15%, and with work for 15% of the women. The study further found that young women (= 35 years old) were more than three times as likely to have had a mammogram (75%) if they regularly experienced cyclical mastalgia than if they did not (24%; p < 0.05) thereby putting pressure on the healthcare system. Scurr et al. (5) in 2014 conducted a study in general population to examine the prevalence, severity, and impact of breast pain. The study involved 1,659 females (age: 34.1 ± 13.2 years) and found that over half of the sample (51.5%) experienced breast pain with a significant severity. Of the symptomatic participants, 41% and 35% reported breast pain affecting the quality of life measures of sex and sleep, respectively. Moreover, 10% of symptomatic participants had suffered breast pain for over half their lives. The results of this study proved that mastalgia is a significant health related issue within the general population. However, some studies have found it to be less prevalent in Asian cultures (6), affecting as few as 5%.In a study from India, 12.75% of urban women had history of benign breast disorders and mastalgia (36.11%) was the most common type (7) . In another study in Hong Kong (8), the prevalence of significant mastalgia was reported to be 6.6%. It was against this background that a pilot survey was conducted by the authors to study this health disorder in general Saudi female population.
As is evident from the results, 92% (979 out 1064) of the females who were approached for voluntary participation in the study did participate and only 8% (85 out 1064) decline. These points towards the positive attitude of the Saudi population towards involvement on health related surveys as is evident from other major studies conducted from the country (9).
The study comprised of all sections of the society and age group as is evident from demographic data depicted in Table 1. Out of the 979 participants in the study, 578 (59%) had experienced mastalgia at some point of time and 401 (41%) did not suffer from mastalgia as is shown in Fig 1. This figure is comparable with the statistics from studies conducted in other parts of the world. Scurr et al. (5) found 51.5% prevalence in English population and Vaziri et al. (10) found the figures to be 33% in Iranian population living in Shiraz city. Ader and Browne after investigating 1171 American women visiting obstetrics-gynecology clinic found that 69% experienced mastalgia (11).
In our study, 385 out 578 (66.6%) of subjects has onset of mastalgia between 16-35 years with 236 (40.8%) having onset between 16-25 years and 149 (25.8%) between 26-35 years. Prevalence decreased after this age group and none of the patients had onset after 55 years. This is consistent with the pattern depicted in other populations. Davies et al (12) in their study conducted at the University Hospital of Wales, Cardiff found the median age of onset of mastalgia to be 36 years (range 12-63 years).
The severity of mastalgia was moderate in 452 (78.2%) and mild in 107(18.5%) of subjects. Only 19 (3.3%) qualified their pain as severe as shown in Table 2. Carmichael et al (13) devised a scoring system termed as breast pain questionnaire (BPQ) score for quick assessment and grading of mastalgia. In their survey, mastalgia was graded as mild in 26%, moderate in 59% and severe in 15% of patients.
Breast pain was related to menstrual cycle in 492 (85.1%) subjects and deemed as cyclic variant whereas 86 (14.9%) has no such relation and considered as non-cyclic mastalgia. The pain was bilateral in 502 (86.9%) as is expected due to predominant cyclic nature and was unilateral in 76 (13.1%). This is consistent with other studies found in literature (14-15) though some Asian studies had found predominantly unilateral mastalgia (16) in their subjects. The further reason for predominant cyclic nature of mastalgia may be the exclusion criteria where in the females with specific breast disorders (that cause cyclic mastalgia) were excluded from the study.
547 (94.6%) females in our study experience pained up to 7 days or less with 163 (28.2%) experiencing it only for a day and 238 (41.2%) for 2-3 days . Only 31 (5.4%) experience pain for more than a week per month. This is similar to the trend seen in many other studies published in literature. In the study by Vaziri et al (10), in 65% of females, duration of mastalgia was 5 days or less and in Ader’s and Brown’s study (11), 70% of the subjects experienced mastalgia less than 5 days. However, in the study by Carmichael et al (13), 93% of patients had experience breast pain lasting for more than 5 days.
In our study, 422 (73%) had no specific concern due to mastalgia and 84(14.5%) had fear about harboring cancer and 72(12.5%) had their routine life affected significantly. In contrast, Ader and Browne (11) found mastalgia to have deeper impact on life of females and found the pain to interfere with usual sexual activity in 48% of women and with physical (37%), social (12%), and work or school (8%) activity. Similarly multiple studies found higher incidence of anxiety, social dysfunction and depression in patients with mastalgia (17-18). Our results in this regards appear similar to the study of Vaziri et al from Iran where less than 14% of females report the negative impact of mastalgia on routine life. Furthermore, since 356 (61.6%) of our subject has seen one or more of females in family with mastalgia and hence this factor is likely to have decreased the percentage of subjects who felt concerned about this entity. Accordingly, only 66 (11.4%) of the females in our study had sought breast screening for cancer as compared to higher percentage found in western literature.
As far as the management of mastalgia is concerned, 404 females (70%) had not sought medical consultation and only 174 (30%) has seen the physician in this regard. This can be explained by the fact that 422 females (73%) did not consider this pain as something serious or interfering with routine life. This is in contrast to western countries where due to fear of breast cancer, the patients seek medical consultations and burden healthcare facilities. Of the 174 females seeking medical attention, reassurance, reevaluation and proper explanation of the condition was offered to 76 (43.7%) as sole management. On review of current literature, proper education and reassurance is considered an integral part of the management of mastalgia and is recommended as a first-line treatment.
Barros et al. (19) conducted a study on 121 patients of mastalgia and evaluated the results of explanation and reassurance. The subjects received reassurance and detailed information about mastalgia and were followed up with a questionnaire 2-3 months later and comparison of pain parameters of the patients before and after reassurance was made. The study showed a success rate of 70.2% (n = 85) with reassurance. On evaluation of subjects on the basis of the intensity of pain, reassurance was effective in 85.7% of the patients with a mild form of mastalgia, in 70.8% with a moderate form, and in 52.3% with a severe form. The study concluded that reassurance should be the first-line treatment for women with mastalgia and it was recommended that pharmacological management should be reserved only in the cases refractory to this form of management. Vaidyanathan et al. (20) stressed the need for updating of general practitioners so that they are able to distinguish benign breast conditions from malignant ones, and know when to reassure or else refer the patient to a specialist for evaluation.
Sports bra to support the breast had been used by 13 (7.5 %) of our subjects. Improved mechanical support externally has been found to relieve breast pain and many results of many studies have proven the therapeutic value of a supporting brassiere (21-23). Be-Lieu (22) found that an estimated 70% of women with mastalgia wear an improperly fitted brassiere and symptomatic woman may benefit from wearing a soft supportive brassiere during sleep, and use of a “sports bra” during exercise. Wilson and Sellwood (23) conducted a study enrolling 114 women in whom mastalgia lasted more than 7 days in each menstrual cycle, interfering with daily life or sleep, and severe enough to require treatment. The women were provided with 2 proper sized brassieres and counseled about the proper techniques of wearing a brassiere by a trained nurse, and monitored at 3-month intervals for up to 18 months. Out of 114 subjects, 100 completed the follow-up, and 26 of them experienced complete relief; 49 had improvement and only 21 derived no benefit, and 4 became worse. Furthermore, 11 of 15 patients who had required medication for breast pain experienced improvement or relief with this intervention.
Non-steroidal anti-inflammatory drugs (NSAIDS), orally or topically were consumed at some point of time for pain relief by 34 (19.5%) of females in our study. Many studies have found that NSAIDs to be effective in relieving breast pain and certain recent studies have recommended topical route of administration as preferred treatment, as the benefits are thought to outweigh the risk of adverse effects. Irving and Morrison (24) in their prospective pilot study demonstrated the potential for effective treatment of mastalgia using stronger types of topical NSAID- diclofenac and piroxicam and Colak et al (25) conducted a prospective randomized blinded, placebo-controlled study (n = 108) and demonstrated significant improvement with topical diclofenac diethylamonium (emulgel) in the treatment group for both cyclical and noncyclical mastalgia with minimal side effects after application for 6 months.
Use of Evening Primrose Oil (EPO) was used without any persistent benefit by 5 (2.9%) subjects in our study. The role of EPO in the management of mastalgia is controversial in literature. The breast tissue have been found to be abnormally sensitive to normal estrogen levels due to relative deficiency of gamma linoleic acid (GLA) in the cases of mastalgia . With prolonged high dose treatment (320 mg/day for 3-6 months), the GLA content of EPO has been found to thereby alleviating the pain (26). However, many other studies including certain randomized, placebo-controlled, double-blind clinical trials have shown no efficacy for EPO in the treatment of cyclic mastalgia (27-28).
Use of Danazol of uncertain dose for short periods was reported by 4 (2.3%) subjects but had not been helpful in alleviation of pain though no mention of adverse effects was made. 42(24.1%) subjects were either not sure of the kind of medications used by them or had used herbs of uncertain nature. Various herbs and plant products (29-30) have been seen to be beneficial in mastalgia which include Phytoestrogens (flaxseed, isoflavanones), topical nigella sativa seed oil and Agnus castus (Chaste tree) berry extract. Furthermore, Low Intensity Laser Therapy (LILT), Relaxation therapy (RT), diet and nutritional intervention, exercise and pharmacological agents [Progesterone, Ormeloxifene (Centchroman), Toremifene, Tamoxifen, Bromocriptine] have been found to have variable impact on mastalgia in various studies (29-30).
There was no statistically significant relationship of mastalgia in our study to the demographic differences (except) that the patients with age group of 24-25 years had higher tendency to experience cyclic mastalgia ( p less than 0.05) and sought medical intervention more than other groups (p less than 0.05). This trend is in line with the findings of series by Vaziri et al. where after logical regression, it was found that mastalgia had no relationship with marital status, level of education or job status and that subjects with age less than 25 years had higher incidence of cyclic mastalgia as compared to non-cyclic variant.
The limitations of our study are that the data was collected only from a single district and the responses to questionnaire relied upon the recall from non-clinical subjects. But since this was a pilot survey, it is hoped that this study would initiate greater studies in clinical as well as non-clinical settings and come out with recommendations based on local factors, to alleviate the sufferings of females with mastalgia.
Conclusion
The results of this study showed that mastalgia has prevalence of about 59% that is comparable with western populations though the condition has lesser negative impact on daily life. Most of the patients experienced pain for less than 7days a month. There is a suggestion for further studies on various aspects of this disease.
Acknowledgements: The authors are grateful to the subjects involved in the study.
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