Breast Health Education Series: eBook Edition

Judy C. Kneece, RN, OCN

3rd Edition

Solving The Mystery Of

Breast Pain

Judy C. Kneece, RN, OCN

Solving The Mystery Of

Breast Pain

Copyright © 2014 Judy C. Kneece, RN, OCN

All rights reserved. Reproduction or use of editorial or pictorial content in any manner is prohibited without written permission, except in the case of brief quotations embodied in articles or reviews. Readers accessing an on-line version of this work in an authorized manner are permitted to download or print one copy for personal viewing. Other reproduction, distribution or use of copyrightable content without the express written consent of the copyright owner is prohibited. Permission can be requested by contacting the author at: 8420 Dorchester Road, Suite 203, North Charleston, SC 29420.

No patent liability is assumed with respect to the use of the information contained herein. While every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information contained herein. This book has been written to enlighten women and motivate them to discuss the issues with their healthcare team. Patients should determine the best treatment protocol based on physicians’ recommendations and their own needs, assessments and desires.

All trademarks used in this book are the property of their respective owners.

Illustrations: Debra Strange, Setsuko Lawson, Jeremy Darby

3rd Edition 2014; 2nd Edition 2003; 1st Edition 1996.

Library of Congress Card Number: 2014936517 Printed in the United States of America | Published by EduCare Publishing Inc.

To Order a Print Copy of This Book:EduCare 8420 Dorchester Road, Suite 203 North Charleston, SC 29420 1-800-849-9271 or Fax: 843-760-6988 www.educareinc.com

ISBN 13: 978-1-8866652-6-2 (Paperback edition)

ISBN 13: 978-1-886665-28-6 (eBook edition)

DedicationThis book is dedicated to Dr. Patrick Henry Leis, Jr., who served as one of my first mentors in the area of breast disease. It was through his gracious sharing of his clinical expertise that I gained much insight into breast pain and breast discharge.

As a young physician, Dr. Leis completed a fellowship in breast surgery following World War II and spent the remainder of his distinguished career as a dedicated breast surgeon. As Professor Emeritus of Surgery, Emeritus Chief of the Breast Service and Emeritus Co-Director of the Institute of Breast Diseases at New York Medical College in Valhalla, New York, Dr. Leis made contributions to breast care that still stand as hallmarks of excellence.

His vision of care extended beyond the surgical removal of breast tumors to improving the quality of life for patients. He was the first physician to write instructions and exercises distributed to women by the American Cancer Society on postsurgical arm care. He worked closely with the founder of the Reach to Recovery program, Terese Lasser, to make physical and psychosocial support available to patients. As a result of his work, thousands of women have enjoyed an increased degree of physical and psychological survivorship after breast cancer.

He was the author of numerous surgical textbooks and articles on breast cancer, but his outstanding accomplishment was his

personal campaign to promote a multi-disciplinary approach to breast disease. His patient-centered philosophy makes him one of the leading heroes in changing the way breast care is delivered today.

Dr. Leis died on March 7, 2003. During his life, he heeded the words of Ralph Waldo Emerson: “Do not go where the path may lead, go instead where there is no path and leave a trail.” Dr. Leis indeed charted a new path for patient-focused breast care and blazed a trail that has impacted, and will continue to impact, millions of women with breast disease.

About the AuthorJudy C. Kneece, RN, OCN, is a certified oncology nurse with a specialty in breast cancer. She began her career in 1991 as a Breast Health Navigator, where she developed her concept of patient navigation. In 1994, she started EduCare Inc. to train other nurses as Breast Health Navigators and to write educational information for breast cancer patients.

During the past nineteen years, EduCare Inc. has been a leader in developing educational materials and in training nurses to support breast cancer patients. Judy has trained over 2,300 registered nurses to fill the Breast Health Navigator role in hospitals, breast centers and physicians’ offices. Over 500 hospitals and breast centers have used her Comprehensive Strategic Planning principles to start breast care programs that emphasize the importance of implementing a Nurse Navigator and pre-treatment interdisciplinary care conferences.

Judy is the author of the Breast Cancer Treatment Handbook and the Breast Cancer Support Partner Handbook. She has also created the COPE Library: Breast Health Edition, a collection of over 430 patient education topics.

Her background as a Breast Health Navigator has allowed her to train thousands of women in breast self-exam skills. It was through this experience that she recognized the need women have for information

about normal and abnormal changes in their breasts, as well as the importance of a woman working as a partner with her healthcare provider to monitor her breast health between clinical exams. She also recognized the need women have for information about suspicious breast findings and abnormalities, especially while they are waiting for an evaluation. To fill this need, she wrote the first edition of this book in 1996.

Judy currently serves as a national consultant for breast centers and hospitals. She serves as a member of the American College of Surgeons’ Education Committee for the National Accreditation Program for Breast Centers (NAPBC) and on the advisory board for the Clinical Breast Care Project. She has served as a contributing editor for numerous national women’s magazines on the issues of breast health and cancer and has over 40 nationally published articles on breast care topics. Judy speaks widely to patients on triumphant survivorship.

Table of ContentsDedicationAbout the AuthorTable of ContentsIntroductionChapter 1: Breast Pain (Breast Mastalgia or Mastodynia)

■ What Should I Do If I Have Breast Pain? ■ Healthcare Provider’s Evaluation of Breast Pain ■ Internal Structure of the Breast

Chapter 2: Cyclic Pain ■ Understanding the Role of Reproductive Hormones ■ Correlations Between Uterine and Breast Changes ■ Reproductive Hormones Impact on the Breast ■ How Common Is Cyclic Breast Pain? ■ Clinical Description of Cyclic Breast Pain ■ How to Determine If Your Pain Is Cyclic ■ Factors Contributing to Cyclic Pain ■ Management of Cyclic Pain ■ Mechanical Interventions for Cyclic Pain ■ Prescription Medications ■ Medication Effectiveness

Chapter 3: Noncyclic Pain ■ Noncyclic Causes of Breast Pain ■ Chest Wall Conditions Mimicking Breast Pain ■ Musculoskeletal Conditions Causing Pain ■ Additional Causes of Noncyclic Breast Pain ■ Physiological Conditions Promoting Breast Pain

■ Breast Pain Caused by Cancer ■ NSAIDs Commonly Used

Chapter 4: The Caffeine Connection ■ Reducing Caffeine in Your Diet ■ Caffeine Consumption Sources ■ Caffeine Content: Beverages ■ Caffeine Content: Non-Prescription Drugs ■ Caffeine Content: Prescription Drugs ■ Herbal Products Similar to Caffeine ■ Synonyms for Caffeine-Like Ingredients

Chapter 5: The Drug Connection ■ Over-the-Counter Herbal Products and Breast Pain ■ Identifying Drugs That May Cause Breast Changes ■ General Breast Changes ■ Breast Size Changes ■ Breast Lumpiness ■ Breast Pain or Tenderness ■ Breast Discharge

Chapter 6: Identifying Your Pain ■ Chart: Cyclic Breast Pain ■ Chart: Non-Cyclic Breast Pain ■ Chart: Comparison of Cyclic, Noncyclic, Musculoskeletal and Chest Wall Pain

■ Chart: Breast Pain Treatments ■ Chart: Benign Conditions Causing Breast Pain ■ Chart: Conditions Mistaken for Noncyclic Breast Pain

ReferencesGlossary

Introduction“At the present, most physicians are ill-trained for the treatment of mastalgia. Ninety percent of patients with cyclic pain and 64 percent with noncyclic pain can obtain relief with proper assessment and a combination of nonprescription and prescription drugs.”

—Suzanne Klimberg, M.D., The Breast, 2009

Breast pain is the most common of all breast problems experienced by premenopausal women. Because it is so common, it would be reasonable to think that the evaluation and treatment would be clearly defined for healthcare providers. Yet, until recently, this was not the case. Information on breast pain for breast clinicians had very few guidelines for evaluation and treatment. Patients complaining of breast pain would often receive a clinical exam followed by an ultrasound or mammogram and then offered only reassurance when told, “You do not have breast cancer.” These patients were left to continue dealing with their breast pain. Knowing that cancer was not the cause of the pain made it much easier to bear, but still the discomfort remained.

As a woman and a nurse, I had the privilege to meet and be tutored by a true pioneer in breast disease, Dr. Henry Leis. Beginning his work in the late 1940s, Dr. Leis dedicated his career to women as a dedicated breast surgeon at New York University. His goal was to improve the quality of care for women who were diagnosed with

breast cancer. One of his areas of interest was breast pain and its relationship to breast cancer. He carefully documented patients’ complaints of pain and then compared their complaints to future disease, while documenting causes and promoters of different types of pain. Dr. Leis became a popular lecturer on the little-researched topic of breast pain. It was through his sharing of information that I have had the privilege to continue carrying the message of understanding breast pain to women and nurses—a subject that affects them equally. My goal is to make this common problem understandable and to offer observations for management and treatment.

Good breast health to you!

Chapter 1

Breast Pain (Breast Mastalgia or Mastodynia)

“Why are my breasts so painful?” “What can I do about the pain?” “I’m scared! Could the pain possibly mean I have breast cancer?” ... You may be experiencing some of these same fears and asking the same questions about your breasts if you have breast pain. Pain is the most common complaint women have about their breasts. It is estimated that 70 to 80 percent of women will experience some degree of breast pain at some time in their lives. Breast pain is also the most feared of any breast change because most women associate breast pain with breast cancer.

Pain in one or both breasts can cause you much anxiety. The pain may be uncomfortable and annoying, but for the majority of women the pain is usually not unbearable. What seems unbearable is the fear that the pain could possibly be a symptom of cancer. For this reason, you need to work with your healthcare provider in ruling out breast disease as the cause. Studies show that a very small percentage of breast pain is associated with breast cancer. Almost all breast pain is due to other causes. Only 7 to 10 percent of diagnosed breast cancer patients have any type of pain or discomfort as a symptom.

If your healthcare provider does not appear overly alarmed when you report you have breast pain, understand that it is because breast pain is usually not caused by problems that are life-threatening. However, this does not mean the cause of your pain should not be identified. During the process of identifying the reason for your breast pain,

remember that cancer is usually not the cause, but it always needs to be ruled out.

Breast pain is one of the most difficult breast problems to diagnose because it has a wide variety of causes that often require intensive investigation to determine the origin. Because breast pain often eludes traditional screening evaluations such as clinical exams, mammography exams and ultrasounds, determining the cause can require more time for physicians to pinpoint than most breast diseases. Breast pain often requires an intensive look into many problems outside of the breast as the cause.

Because of the difficulty in determining the cause, many women continue to live with breast pain after being told that there were no abnormalities in their screening exams.

The purpose of this book is to help you understand breast pain and its identified causes and treatments. And most importantly, to identify what you and your healthcare provider can do as partners to solve the mystery of your breast pain.

What Should I Do If I Have Breast Pain?Breast tenderness, a feeling of fullness and mild pain in both breasts, occurring several days before the onset of the menstrual period is normal for many premenopausal women. So the question is, what pain do you need to report to a healthcare provider for evaluation?

Breast Pain to Report to a Healthcare Provider: ■ Pain that is persistent (lasting longer than several weeks) ■ Pain that is sudden and severe ■ Pain that occurs in only one breast ■ Pain with a lump in the same breast ■ Pain with redness and warmth of breast tissues ■ Pain in one breast that also has a change in skin texture

■ Pain with discharge from one breast ■ Pain that has a large amount of discharge from both breasts, not associated with pregnancy or nursing

If you have any of the above symptoms, contact your healthcare provider for an appointment for evaluation of your pain.

Note: Bilateral (both breasts) pain is a common early warning symptom of pregnancy. If your pain began recently and it is possible that you may be pregnant, a pregnancy test is your first step in evaluation.

Healthcare Provider’s Evaluation of Breast PainWhen a woman complains of breast pain, the first goal of a healthcare provider is to rule out breast cancer. This consists of a thorough clinical evaluation by the healthcare provider.

A Healthcare Provider’s Clinical Evaluation Will Include: ■ Personal history of any previous illnesses or diseases ■ Personal hormonal history: age at onset of menstrual period ■ Present hormonal status: premenopausal, perimenopausal, post-menopausal or have undergone surgical menopause by removal of the ovaries

■ Medication history: birth control pills, estrogen or progesterone replacement, over-the-counter medications, herbal supplements or prescription medications

■ Personal and family cancer history: particularly breast, ovarian, prostate or pancreatic cancer found in either the mother’s family or the father’s family for two generations

■ Clinical breast exam of both breasts by healthcare provider ■ Mammogram or ultrasound to further evaluate any abnormality found during breast exam; possibly a breast MRI (magnetic resonance imaging)

■ Biopsy of any abnormality identified from ultrasound, mammogram or MRI

The clinical evaluation by a healthcare professional helps rule out breast cancer as the cause of your pain and, in the process, often identifies the cause of your pain. Many benign (noncancerous) breast diseases or conditions have pain as a symptom and are discussed in this book. The search for the cause of pain may be difficult and may require more than one exam by a healthcare provider to investigate all of the possible causes. During this search, your healthcare provider will offer interventions and a plan for pain management.

After a clinical evaluation has ruled out a benign breast disease or breast cancer, the next step is to determine if your pain is cyclic (occurs at regular intervals) or noncyclic (does not occur in cycles). Because these two types of pain are completely different in origin, each type of pain will be discussed separately. This book will help you work in partnership with your healthcare provider by understanding of the different types, characteristics and causes of breast pain.

As you can see, the breast is a complex glandular organ that sits on the chest wall over the pectoralis muscles and ribs. It is an organ that changes daily because of the influence of hormones. Becoming familiar with your own breasts will help you work as a partner with your healthcare provider.

Internal Structure of the Breast

Nipple Areola Complex

Lobe

Lobule

Duct

Clavicle (Collarbone)

Acini (Milk-Producing)

Ribs

Axillary NodeSupraclavicular Node

Internal Mammary Node Chain

Lymph Vessels

Pectoralis Muscle

Infraclavicular Node

Remember: ■ Breast pain is most often related to noncancerous causes. ■ Pain is not a common symptom of breast cancer; only 7 ‒ 10 percent of documented breast cancers have breast pain as a presenting symptom.

■ A thorough clinical exam by a healthcare provider is the first step to rule out any type of breast disease.

■ Breast pain is often difficult to diagnose quickly because of its many causes.

www.EduCareInc.com 8420 Dorchester Road, Suite 203

North Charleston, SC 29420 • 843.760.6064

This is one of the most structured and complete resources on breast pain that I have ever come across. Pain and tenderness is seen more often than breast cancer in physician’s offices. It is often approached without an appreciation for the anxiety and dynamics that surround it. This book will become a staple for our breast practice and will certainly improve the level of care at our Breast Center!

—Edward P Dalton, MD FACS Elliot Breast Health Center, Manchester, NH

Solving The Mystery Of Breast Pain

HEALTH / PSYCHOLOGY

“Solving the Mystery of Breast Pain” Describes:• Breast pain caused by normal hormonal functioning, benign breast disease, breast cancer

and other medical conditions.• Breast pain characteristics that should be reported to a healthcare provider immediately.

“Solving the Mystery of Breast Pain” Provides:• List of over 400 prescription and over-the-counter medications that may cause breast

changes and promote breast pain.• List of common herbal and weight-reduction products that cause breast pain.• List of benign conditions that may cause breast pain.• Insight into the possible connection between caffeine and breast pain.• Charts, additional resources, recommended reading and a full glossary.

“Solving the Mystery of Breast Pain” Patient Benefits:• Provides cost-free remedies that may reduce or alleviate breast pain caused by normal

hormonal functioning.• Helps a woman prevent expensive and unnecessary diagnostic tests.• Empowers a woman to work as an educated partner with her healthcare provider.

Judy C. Kneece, RN, OCN, has authored five books on breast cancer and benign breast disease, including Solving the Mystery of Breast Discharge, Breast Cancer Treatment Handbook, Breast Cancer Support Partner Handbook and Breast Cancer Survivorship Handbook. She has also trained over 2,300 nurses to serve as Breast Health Navigators to coordinate the clinical, educational and support needs of patients.

Breast Health Education Series: eBook Edition