Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample

Cyclical Mastalgia: Prevalence and Impact in an Outpatient Breast Clinic Sample Deborah N. Ader, PhD* and Craig D. Shriver, MD, FACSt Background: A descriptive study was conducted to ex-

Cyclical mastalgia (CM) is breast pain a n d / o r tenderness, often accompanied by swelling, which occurs regularly in some w o m e n during the luteal phase of the menstrual cycle. Benign breast pain is a c o m m o n problem, with reported prevalences ranging from 45% to 70% (1-4). Although swelling and m i n o r discomfort lasting 1-4 days premenstrually is considered "normal," many w o m e n experience significant swelling a n d m o d e r a t e to severe discomfort lasting 5-14 days or m o r e each m o n t h . Spontaneous remission often occurs, but many w o m e n experience CM for years, often with increasing severity until m e n o p a u s e (5). In some women, this pain interferes with activity, relationships, and quality of life (4, 6 - 8 ) . Cyclical mastalgia may be associated with excessive use of mammograms and with unnecessary, ineffective, or undesirable self-medication (4). Possible costs in terms of inefficient health care utilization and attempting alternative medical interventions have n o t been investigated. Mastalgia is a c o m m o n complaint of w o m e n seen in breast clinics and outpatient surgery, but no US studies have d o c u m e n t e d the prevalence or impact of this complaint a m o n g w o m e n in these settings. The present descriptive study was undertaken to (1) estimate the prevalence of CM in a breast clinic population and compare it with that previously obtained in a primary care sample, (2) investigate the association between d e m o g r a p h i c variables (age, race, marital status, parity, a n d education) and CM, (3) characterize the impact of this p r o b l e m on normal activities, health care utilization, and self-medication, (4) d e t e r m i n e whether participation in m a m m o g r a p h y or regular breast self-examination (BSE) is associated with CM, and (5) identify a group of w o m e n for further prospective study of the pattern and severity of cyclical breast pain.

amine prevalence of premenstrual breast symptoms, impact o f cyclical mastalgia on various activities, and associated patterns of health care utilization among breast clinic outpatients.

Study Design: Patients (n = 231, age < 55 years) completed a questionnaire about lifetime and current premenstrual breast discomfort (cyclical mastalgia). Results: Seventy-nine percent reported having regularly experienced cyclical breast symptoms; 48% have asked a health care provider about their mastalgia. Young women ( ~ 35 years) 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). Current moderate to severe mastalgia lasting 5 days or more monthly was reported by 30% of women. This "clinical" level of mastalgia interferes with usual sexual activity for 33%, with physical activity for 29%, with social activity for 15%, and with work for 15% of these women.

Conclusions: Reported prevalences of mastalgia obtained in this sample are higher than those reported in British studies; possible reasons for these differences are discussed. Cyclical mastalgia is a common problem sometimes severe enough to interfere with normal activity levels, and it is related to excessive use o f mammography among young women. Although largely ignored both scientifically and clinically in the United States, this condition merits further biopsychosocial investigation. (J Am Coll Surg 1997;185:466-470. © 1997 by the American College of Surgeons)

Received April 18, 1997; Revised July 21, 1997; Accepted July 28, 1997. From the *Uniformed Services University of the Health Sciences, and *Walter Reed Army Medical Center, Bethesda, Maryland. This research was supported in part by an intramural grant from the Uniformed Services University of the Health Sciences. Correspondence address: Deborah N. Ader, PhD, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799. This article represents the personal viewpoints of the authors and is not to be construed as a statement of official policy of the Department of Defense, Walter Reed Army Medical Center, or the Uniformed Smwices University of the Health Sciences. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.

Methods

Subjects. Institutional approval for the study was obtained from the D e p a r t m e n t of Clinical Investi466

ISSN 1072-7515/97/.$17.00 PII S1072-7515(97)00095-1

Ader and Shriver gation at Walter Reed Army Medical Center (WRAMC). W o m e n presenting to the WRAMC D e p a r t m e n t of Surgery Breast Clinic were recruited by clinic staff to participate i n ' t h e study. To minimize potential recall difficulties, only w o m e n less than 55 years old (n -- 231) were included in analyses. Procedure. While waiting for their a p p o i n t m e n t , participants c o m p l e t e d a three-page questionnaire about premenstrual breast discomfort. T h e questionnaire, developed by the authors a n d used in a previous study (4), requested d e m o g r a p h i c inform a t i o n and menstrual and obstetric history and included questions about participation in breast screening (whether the patient had ever had a m a m m o g r a m and frequency of BSE); premenstrual breast discomfort; and health-care seeking, self-treatment, and interference with usual daily activities related to mastalgia. If participants had experienced premenstrual symptoms d u r i n g the past 6 months, they were asked to check any of the following symptoms that applied to them: swelling, tenderness, pain, other (list any other breast symptom). They were also asked to indicate duration and frequency of symptoms and to rate severity on a 10-cm visual analogue scale (VAS) a n c h o r e d at the left by "no p a i n / t e n d e r n e s s " and a t the right by "worst possible pain/tenderness." Visual analogue scales c o m m o n l y are used in rating cyclical breast pain and have been shown to have good reliability and validity for rating pain (9-12). To m e e t inclusion criteria for analysis of possible c u r r e n t CM, respondents had to be p r e m e n o pausal, n o n p r e g n a n t , n o t lactating, and n o t using oral contraceptives or other h o r m o n e s or steroids. To be considered positive for "clinical" CM, w o m e n reporting recent symptoms must have indicated severity above 4.0 cm o n the VAS and duration of 5 days or m o r e monthly. These criteria were adapted from the British literature, which typically uses at least 7 days of any level of mastalgia (our criteria are comparable in terms of rated severity, but allow fewer days; ie, 5 days of severe mastalgia may be as distressing to some w o m e n as are 7 days of moderate mastalgia). Statistical analyses were primarily descriptive, but logistic regressions were used to examine the association between d e m o g r a p h i c variables and CM and the •relationship between these variables and participation in breast screening. Inferential tests were twotailed, with ~ set at 0.05. Data were analyzed using SPSS 6.1 (SPSS Inc., 1994, Chicago, IL) on an Apple Macintosh computer.

CYCLICALMASTALGIA 467

T a b l e 1. R e p o r t e d P r o v i d e r R e s p o n s e s to P a t i e n t I n q u i r i e s About Mastalgia Provider responses (n = 117) Normal or c o m m o n Fibrocystic disease or cysts H o r m o n a l or PMS O r d e r e d test, referred, told to do BSE Suggested or prescribed treatment* Suggested patient reduce or eliminate caffeine Suggested nothing; was n o t helpful, advised patient to "live with it" Water retention; suggested patient reduce salt intake

n

%

65 17 7 6 5 5

55.7 14.5 6.0 5.1 4.3 4.3

3

2.6

3

2.6

*Vitamins, medroxyprogesterone acetate. PMS, premenstrual syndrome; BSE, breast self examination.

Results

Sample demographics. Participants ranged in age from 19 to 54 years; m e a n age was 41.1 years (median 43, SD = 9.3). Sixty-six percent were white, 25% African-American. The majority (79.7%) were married. Fifty-one percent h a d college or graduate degrees; 6% did not finish high school. Seventy-seven percent were civilian; 8%, active duty army; and 10%; retired military. Lifetime prevalence of premenstrual breast symptoms. O n e h u n d r e d seventy-three w o m e n (79% of nonmissing responses for this item) reported having regularly experienced breast changes prior to onset of their menstrual period. Of these women, 87 (51.2%) indicated having asked a health care provider about premenstrual breast changes. Type of provider consulted was listed by 83 women, and 16 (19.3%) had asked m o r e than one health care provider. Most c o m m o n l y consulted were gynecologists (59.4%) and family physicians or general practitioners (19.8%). T h e responses w o m e n rep o r t e d receiving f r o m providers are listed in Table 1. Thirty-five w o m e n (20.2%) indicated trying some form of self-medication or dietary change for their breast symptoms; 18 of t h e m tried m o r e than one treatment. Most c o m m o n l y tried were decreasing or eliminating caffeine; taking vitamin or mineral supplements, taking nonprescription pain or premenstrual syndrome medications, and making dietary changes. Seventeen (48.6%) believed at least one thing they tried was successful. Recent premenstrual breast symptoms. O n e h u n d r e d twenty w o m e n m e t criteria for analysis of possible current CM; m e a n age was 39.6 years (median 41.5, SD 7.9). Ninety of these w o m e n (75%) indicated experiencing premenstrual breast discomfort during the past 6 months. Frequency of mas-

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T a b l e 2. P r o p o r t i o n o f S y m p t o m a t i c W o m e n M e e t i n g a n d n o t M e e t i n g Diagnostic Criteria for Cyclical Mastalgia W h o Have E n g a g e d i n Specific H e a l t h - R e l a t e d Behaviors

Diagnostic category Positive Negative Chi-square

Had a mammogram (< 36 y)

Perform BSE Monthly

Asked provider

Tried self-treatment

n

%

n

%

n

%

n

%

6/ 8 4/17

75 24

14/35 26/54

40 48

26/35 21/54

74 39

13/34 11/53

38 21

§*

.57

10.7*

3.2

*p < 0.05. *p < 0.001. ~Fisher's exact test. BSE, breast serf-examination.

talgia was r e p o r t e d by 87 women: 49 (56.3%) tive for CM were 3.2 times as likely to have h a d a r e p o r t e d e x p e r i e n c i n g symptoms every m o n t h , m a m m o g r a m as were symptomatic y o u n g w o m e n a n d an additional 28.4% r e p o r t e d experiencing n o t m e e t i n g criteria for clinical CM. symptoms most months. Duration of mastalgia was W o m e n with CM were 1.9 times as likely to have r e p o r t e d by 88 w o m e n : 44 (50%) indicated expeasked a health care provider about their symptoms riencing 5 or m o r e days of discomfort each as were symptomatic w o m e n negative for CM. m o n t h ; 30 (35.2%), 7 or m o r e days; a n d 20 Twenty-six (55%) of the 47 w o m e n who r e p o r t e d (22.7%), 9 or m o r e days. T e n d e r n e s s was r e p o r t e d asking a provider m e t criteria for CM. W o m e n by 78 w o m e n (86.7%), swelling by 59 (65..6%), and with CM who asked a provider were six times as pain by 43 (48.3%). Twenty-five (27.8%) w o m e n likely to have asked m o r e t h a n o n e provider than r e p o r t e d only o n e o f these symptoms; 39 (43.3%) were symptomatic w o m e n without clinical CM; r e p o r t e d two; a n d 26 (28.9%) r e p o r t e d all three. 89% of w o m e n who asked m o r e t h a n o n e provider Mean severity was 4.63 cm on the 10-cm VAS m e t criteria for CM. E l e v e n (45.8%) o f 24 w o m e n (SD = 2.3). W o m e n r e p o r t i n g r e c e n t symptoms with CM who asked a health care provider about did n o t differ in age, race, m e n a r c h e , parity, or their mastalgia r e p o r t e d being told their p r e m e n e d u c a t i o n level f r o m those r e p o r t i n g no r e c e n t strual pain or tenderness was n o r m a l or c o m m o n . symptoms. o m e n with CM were 1.8 times as likely to have Cyclical mastalgia. A d e q u a t e data for assessment W tried self-treatment as were symptomatic w o m e n of "clinical" CM were available for 88 of the 90 n o t m e e t i n g criteria. w o m e n r e p o r t i n g r e c e n t symptoms. Thirty-five Table 3 shows the p r o p o r t i o n or p e r c e n t o f w o m e n (39.8% of w o m e n with r e c e n t symptoms, w o m e n for w h o m mastalgia interferes with usual 29.9% o f all p r e m e n o p a u s a l w o m e n ) m e t criteria sexual, physical, social, or work activity. W o m e n for clinical CM. W o m e n with CM did n o t differ in m e e t i n g criteria for CM were significantly m o r e d e m o g r a p h i c characteristics from asymptomatic likely to r e p o r t i n t e r f e r e n c e with physical, social, w o m e n or f r o m symptomatic w o m e n negative for a n d work activity than were symptomatic w o m e n criteria. Twenty-five (71.4%) of those with the din o t m e e t i n g criteria. Although w o m e n with cliniagnosis listed pain as a symptom; 9 (25.7%) listed cal CM were 1.7 times as likely as w o m e n not swelling a n d tenderness, but not pain; a n d 1 m e e t i n g criteria to r e p o r t that mastalgia inter(2.9%) listed tenderness only. No one listing only f e r e d with usual sexual activity, this finding was swelling m e t the criteria. Mean severity of tendern o t statistically significant. Mastalgia interferes ness or pain was 6.5 cm (SD = 1.8). with sexual activity even in w o m e n with "subcliniData r e g a r d i n g participation in breast screencal" symptom levels. ing, asking a health care provider about symptoms, a n d attempting self-treatment are summarized in Table 2. T h e sample i n c l u d e d 35 y o u n g Discussion w o m e n (<_ 35) eligible to be evaluated for CM; 12 (34%) of the 35 h a d h a d a m a m m o g r a m . Logistic In this breast clinic sample, overall r e p o r t e d liferegression controlling for age and education time prevalence of CM was 79%; 75% o f p r e m e n o f o u n d that m e e t i n g diagnostic criteria for CM was pausal w o m e n r e p o r t e d e x p e r i e n c i n g mastalgia significantly associated with having h a d a m a m m o regularly d u r i n g the past 6 months; a n d 30% reg r a m ( i m p r o v e m e n t X2 = 11.19, d f = 1, p = 0.001). As shown in Table 2, y o u n g w o m e n posip o r t e d 5 days or m o r e of m o d e r a t e to severe mas-

Ader and Shriver

CYCLICALMASTALGIA 469

Table 3. Proportion of Symptomatic Women Who Report Interference of Cyclical Mastalgia With Usual Activities, by Diagnostic Criteria Status Activity Diagnostic category Positive Negative Chi-square

Sexual

Physical

Social

Work

n

%

n

%

n

%

n

%

11 / 33 10/52

33 19

9/33 5/52

29 10

5/33 0/52

15 0

5/33 0/52

15 0

2.4

4.6*

*;

1-*

*p < 0.05. +p < 0.01. *Fisher's exact test.

talgia. This prevalence of CM is h i g h e r than that r e p o r t e d in British breast clinic samples a n d h i g h e r t h a n the 67% prevalence f o u n d in o u r obstetrics a n d gynecology ( o b / g y n ) clinic (4); a n u m b e r o f possible factors could a c c o u n t for these differences. As military health care beneficiaries, the w o m e n in our sample have relatively g o o d access to health care, so w o m e n c o n c e r n e d about their mastalgia may be m o r e likely to persist in seeking care h e r e t h a n in some o t h e r settings, a n d primary care providers may be m o r e likely to refer these patients to surgery for f u r t h e r evaluation. In addition, m e a s u r e m e n t m e t h o d o l o g y in this study differed f r o m that often used in E u r o p e a n reports. A l t h o u g h retrospective reporting frequently is used in Britain as well, the d e t e r m i n a t i o n that 11-15% o f w o m e n have mastalgia sufficiently severe to warrant t r e a t m e n t is generally based on prospective pain charting for 2 or m o r e months. Allowing for the possibility of s p o n t a n e o u s remission of symptoms a n d elevated retrospective reporting in some w o m e n , the true prevalence o f severe CM in o u r sample is likely to be somewhat lower than 30%. In an A m e r i c a n hospital setting, however, it is n o t surprising to find a h i g h e r prevalence of CM a m o n g outpatients in a surgery dep a r t m e n t ' s breast care clinic than in a general o b / g y n clinic. W o m e n e x p e r i e n c i n g p r e m e n s t r u a l breast disc o m f o r t often do n o t bring their symptoms to the attention o f a health care provider. By far, the most c o m m o n provider response to w o m e n who did complain o f discomfort was that p r e m e n s t r u a l t e n d e r n e s s or pain is a c o m m o n or n o r m a l symptom o f the menstrual cycle. In m a n y cases, this response is p r o b a b l y accurate; but even Women e x p e r i e n c i n g 5 days or m o r e o f m o d e r a t e to severe pain m o n t h l y e n c o u n t e r e d this provider response frequently. These w o m e n ' s providers may n o t have assessed w h e t h e r the duration or severity of the symptoms truly were "normal." W o m e n with clinical CM are significantly m o r e likely t h a n those

with lower s y m p t o m levels to ask a provider about their mastalgia. T h e pattern o f r e p o r t e d provider responses points to a n e e d for better education o f providers r e g a r d i n g assessment of CM a n d treatm e n t options. Although the n u m b e r of w o m e n who r e p o r t e d asking m o r e than o n e provider is small, the fact that all but one m e t CM criteria is striking. O u r results suggest that a simple m e t h o d of identifying patients warranting f u r t h e r evaluation and, possibly, t r e a t m e n t m i g h t consist o f (1) d e t e r m i n i n g the duration a n d severity of the patient's m o n t h l y p r e m e n s t r u a l mastalgia and (2) querying the patient about previous health care seeking related to this problem. If the patient reports 5 days or m o r e o f m o d e r a t e to severe pain or tenderness monthly, f u r t h e r prospective assessment is indicated, especially if she has b r o u g h t this p r o b l e m to the attention o f a previous h e a l t h care provider. Currently, the efficacy o f screening m a m m o g r a phy in w o m e n in their forties is being debated, a n d obtaining even a baseline m a m m o g r a m has never b e e n r e c o m m e n d e d in w o m e n y o u n g e r than 35 years old. O u r data suggest relatively high utilization o f m a m m o g r a p h y a m o n g y o u n g breast clinic patients in general, a n d m a m m o g r a p h y utilization is significantly h i g h e r in y o u n g w o m e n with CM than in those without CM. A l t h o u g h the n u m b e r of w o m e n 35 years or y o u n g e r in this clinic was small, the effect size is large a n d this finding replicates that f o u n d in our o b / g y n sample (4). T h e reason for o r d e r i n g m a m m o g r a m s for these w o m e n is n o t known; thus, the n a t u r e o f the relationship b e t w e e n having CM and having h a d a m a m m o g r a m c a n n o t be d e t e r m i n e d , a n d interpretation o f this result should be m a d e with caution. These data suggest that there may be some excessive utilization o f m a m m o g r a p h y a m o n g y o u n g w o m e n with CM. Better awareness a m o n g health care providers about CM could improve differential diagnosis o f breast disorders a n d help avoid unnecessary costs a n d risks.

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Limitations of the present study include a relatively small sample size and use of a one-time retrospective self-report measure to assess CM. The extent to which this particular sample is representative of the population of surgery breast clinic patients is unclear. Nevertheless, the sample provided sufficient power to obtain significant effects, and the pattern of obtained effects replicates those f o u n d in o u r large o b / g y n sample. The accuracy of r e p o r t e d duration, frequency, a n d severity of breast symptoms is also unclear. Statistical comparisons a m o n g responses to the questions assessing mastalgia ( c o n d u c t e d on the larger data set collected from the o b / g y n clinic) indicate strong convergent and discriminant validity. One purpose of this study was to identify patients to include in a prospective study with daily breast pain charting; such prospective data are likely to be m o r e reliable a n d valid than the retrospective reports obtained in this initial study. The relationship of CM to breast cancer and other breast disease has n o t b e e n established, and very little research on treatment or prevention has been c o n d u c t e d in the U n i t e d States. Longitudinal research is n e e d e d to d o c u m e n t t h e pattern and severity of CM, to test treatment options systematically, and to investigate the biopsychosocial mechanisms involved in the disorder. Prospective daily charting of pain is necessary for t h o r o u g h clinical assessment a n d to m o n i t o r treatment. We are currently researching breast histology and

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