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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, St. Hildegardis Hospital, Academic Teaching Hospital, Mainz; and Bioscientia Institute of Laboratory Chemistry, Ingelheim, Germany.
Address reprint requests to: Friedolf Peters, PhD, St. Hildegardis Hospital, Academic Teaching Hospital, Department of Obstetrics and Gynecology, D-55131 Mainz, Germany; E-mail: friedolf.peters{at}main-rheiner.de.
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ABSTRACT |
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METHODS: A total of 335 premenopausal women participated in a genital and breast cancer screening program. Of these, 123 women were asymptomatic and 212 complained of breast pain (136 had cyclical mastalgia; 76 reported the noncyclical type). The width of milk ducts was measured by ultrasonography and correlated with the intensity of breast pain. The site of the pain was correlated with duct dilatation. Statistical analysis was performed using the t test, the 
2 test, analysis of variance, and Pearson correlation.
RESULTS: In asymptomatic women, the maximum mean width of the milk ducts was 1.8 ± 0.84 mm, in cyclical mastalgia 2.34 ± 1.10 mm, and 3.89 ± 1.26 mm in noncyclical mastalgia (P < .001). The intensity of pain showed a significant, positive correlation with the width of the milk ducts (r = .5008, P < .001). Noncyclical mastalgia patients located the pain at the site where dilated ducts were detected ultrasonographically (P < .001).
CONCLUSION: The results of this study demonstrate that duct ectasia is a major factor in mastalgia. The degree of duct dilatation correlates positively with the intensity of breast pain. In the noncyclical type of pain, there is a positive correlation between the site of duct dilatation and the site of pain.
Public awareness of breast cancer causes concern in every patient with breast symptoms. The most common complaints are a lump, nipple discharge, inflammatory signs, and breast pain. The nature of the tumor can be established by an image-guided biopsy,1 and guidelines for evaluating nipple discharge have been published.2 We have recently described the coincidence of nonpuerperal mastitis and breast cancer and the procedure to investigate this condition.3 Breast pain is of considerable importance within the health care system. About 8–10% of all women seek medical advice for breast pain at least once during their life after menarche. Pain may be a presenting symptom of a small breast cancer.4 Therefore, breast cancer has to be ruled out using the established procedures in this most common breast symptom; however, knowledge of the etiology of breast pain is incomplete, and medical means of resolving the disorder are rather unsatisfactory.
The cause of cyclical mastalgia is unknown. Histopathology also cannot detect any distinctive characteristics.5,6 From a clinical point of view, mastalgia patients are divided into subgroups of which the cyclically pronounced, the noncyclical pattern, and the Tietze syndrome are the most frequent types.7 It is believed that cyclical mastalgia is hormonally based7,8 or mediated by fat intake, especially of saturated fatty acids.9 We characterized mastalgia endocrinologically in terms of prolactin secretion8 and thyroid hormones.10 Moreover, mastalgia responds to hormone treatment 11,12 and fat restriction13 or administration of essential fatty acids.12
Noncyclical mastalgia has been associated with duct ectasia on the basis of histological findings or mammograms7; however, milk ducts can be visualized by mammography only in cases of tissue reaction, such as periductal mastitis, fibrosis, or intraductal calcification or fibrosis.14 Moreover, the feasibility of identifying any consistent relationship between mammographic patterns and histology seems questionable.15 Furthermore, mammography cannot exactly localize milk ducts without further equipment, such as stereotaxy or wires. Technological advances of ultrasonography, such as color Doppler imaging, high-frequency ultrasound, and contrast media, are increasing the specificity in evaluating benign conditions of the breast. Ultrasound has been deemed appropriate to obtain further insights into breast structures with apparently benign conditions. First attempts to apply ultrasonography to patients with mastalgia used low-frequency probes and could only detect cysts.16
The milk ducts of the breast have been neglected by clinicians in the evaluation of breast symptoms and disorders for a long time. It was believed that the milk ducts remained asymptomatic unless they had been distended during lactation or inflammation (duct ectasia with periductal mastitis and breast infection).7 In most women, it is possible to image the milk ducts with modern sonographic techniques even if they are not distended. This study therefore investigated the ultrasonographic appearance of the milk ducts in otherwise healthy women to obtain further insights into the nature of mastalgia and to correlate the width of the ducts with the severity of mastalgia.
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MATERIALS AND METHODS |
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Patients with breast pain were given another ultrasound scan during the period of the worst pain to correlate the site of the pain with the site of the dilated ducts. The sonographic picture was analyzed for a putative tissue edema. Homogeneous echogenicity of the parenchyma differing from fibrous structures in conjunction with the patient’s report of breast swelling was interpreted as tissue edema. Tissue edema could not be quantified. For these ultrasonographic scans, an AI 3200 (Dornier Instruments, Munich, Germany) was used with a linear array 7.5-MHz probe. This instrument can focus on different depths of the breast. Large breasts and small breasts could be examined with the same precision. The method successfully imaged the milk ducts in different parts of the breast. In some cases, a special maneuver or conformational change to the breast was necessary, as described by Harper and Kelly-Fry,18 to enable the ducts to be visualized. To clearly distinguish the milk ducts from the blood vessels, color Doppler sonography was applied. The lower threshold of this ultrasound technique in detecting a milk duct was a dilatation of more than 0.4 mm. In each patient, the milk ducts were identified, and their maximum width was evaluated. The ultrasound scans were exclusively done by one person (PD). The intraobserver variability of the width of the milk ducts was (mean ± SD) 4.8% ± 1.8% (n = 40). A prior study investigated whether there was any significant difference in the diameter of the milk ducts in the course of the menstrual cycle. Forty patients of the three groups with measurable milk ducts were randomly selected and given two separate ultrasound scans on days 7–10 and on days 24–26 of the cycle. Statistical analysis was performed with the t test, the 2 test, correlation coefficient according to Pearson, and an analysis of variance.
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RESULTS |
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). The mean age of the three groups (asymptomatic: 33.5 ± 6.00 years, cyclically pronounced: 32.85 ± 8.70 years, noncyclical: 34.32 ± 6.69 years) did not vary statistically (analysis of variance). Details regarding clinical symptoms and nicotine addiction are listed in Table 2.
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). In the 40 patients of the three groups with measurable milk ducts who were investigated during the first and the second part of the cycle, the width of the milk ducts did not vary significantly: follicular phase: 2.15 ± 1.8 mm, luteal phase: 2.34 ± 1.6 mm, P > .05 (t test for paired data). Therefore, the day of the cycle was not mentioned in this study.
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), 2.34 ± 1.10 mm in cyclically pronounced (range 0.5–5.2 mm), and 3.89 ± 1.26 mm (range 1.3–8.0 mm) in noncyclical mastalgia (t210 = 9.30, P < .001). A tissue edema was diagnosed in 1.6% of asymptomatic women, in 46.3% of cyclical, and in 3.9% of noncyclical mastalgia patients (Table 2). Representative depictions of the asymptomatic breast, premenstrual mastalgia, and noncyclical mastalgia with the corresponding milk ducts are presented in Figure 2. The severity of the pain (visual linear analogue scale) in noncyclical mastalgia (53.0 ± 19.3 mm) significantly exceeded that of cyclically pronounced mastalgia (34.7 ± 17.2 mm, t210 = 7.12, P < .001). The intensity of pain showed a significant, positive correlation with the width of the milk ducts (Figure 3, r = .5008, P < .001). Sixty-three (82.9%) of the noncyclical and 24 (17.7%) of the cyclically pronounced mastalgia patients pinpointed the pain at the site where the dilated ducts had been detected ultrasonographically (2 = 740.69, P <.001).
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DISCUSSION |
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). A more correct analysis might be made by dividing the cases into breast pain groups; however, the aim of this study was to investigate a relationship between breast pain and the degree of dilatation of the ducts. The numerical distribution of women in the three groups neither reflects the actual incidence of mastalgia within the population nor the ratio between the two types of breast pain. The women were recruited from a cancer screening program, therefore patients with breast pain who were worried about having breast cancer are over-represented. Furthermore, the asymptomatic group does not represent the normal population as control subjects. Therefore, bias is possible. There is a good correlation between the maximum width of the milk ducts and the degree of the pain documented. Patients with wider milk ducts have more pain than those with narrower ducts. The majority of our cases involved the terminal ducts and the subareolar region, sometimes only over a short distance. Moreover, the localized pain can be attributed to an ultrasonographically identified dilated duct at this site. In a noncyclical mastalgia group of patients, clinical examination by Griffith and colleagues found a palpable ectatic duct behind the nipple, with green- or yellow-stained nipple discharge or with a trigger zone pain (persistent and well localized).19 This correlates with our finding that ultrasonography reveals a dilated duct at the site of pain.
Until now, the cause of mastalgia has not been clarified conclusively. In cyclical mastalgia, elevated prolactin response to thyrotropin-releasing hormone (TRH), and thus a higher daily prolactin production, has been documented.8 Bromocriptine as a potent prolactin-lowering drug is established in the treatment of cyclical mastalgia.12 A possible mechanism of action of prolactin may be fluid and electrolyte absorption. Although the effects of prolactin on osmoregulation in mammals are less clear, it has been shown that prolactin stimulates the retention of fluid and electrolytes in the intestine and kidney in rats.20,21 Moreover, prolactin may also play a role in osmoregulation in amniotic fluid by decreasing the diffusion of water from the fetal side to the maternal side of the membrane.22 Prolactin-related fluid retention within the breast may provide a possible explanation for premenstrual mastalgia. The increase of the breast volume during the premenstrual period is a well-known phenomenon.23 The tissue edema could be inferred from ultrasonography in some cases in our study, although it is difficult to quantify this phenomenon. Tissue edema may be responsible for a tension-mediated pain7,12,23 and may result in a compression of the milk ducts that are narrower than those in noncyclical mastalgia.
Because breast secretion is thought to be controlled by prolactin,24 one would expect the wider milk ducts in patients with noncyclical mastalgia to be correlated with elevated prolactin levels. However, an earlier study by Kumar and colleagues,25 as well as a conjoined study by our group, could detect only normal basal and TRH-stimulated prolactin values (manuscript in preparation). The response rate to prolactin-lowering treatment with bromocriptine is also less in patients with noncyclical mastalgia compared with patients with the cyclical type.12 Thus, cyclical and noncyclical mastalgia are probably two distinct entities. The reason why milk ducts are more distended in noncyclical mastalgia than in the cyclical type may at least be related to the tissue edema in the latter group. Because milk ducts also regress in width in postmenopausal women, attention should also be focused on estrogens. Further studies are needed to elucidate possible connections. Whatever the cause of distended milk ducts is, their manifestation is correlated with pain, as documented in our study. Milk ducts are known to be sensitive to pain. Every breast-feeding mother describes discomfort or pain of the filled breast before letting the child suckle. Breast engorgement during lactation can also be extremely painful. Therefore, the dilated milk ducts described by this study are most likely to be the origin of the pain, which is mediated by sensory nerve endings accompanying the blood vessels.26
Normal measurements for the diameter of a milk duct are not clearly defined. Regarding the histological criteria of duct ectasia with periductal mastitis, most authors describe milk ducts with a diameter of roughly 3 mm as fulfilling the definition.27 Based on our data, a cutoff value of 3 mm (eg, as a criterion for defining a dilated duct) is not clinically feasible in the same way. Most asymptomatic women have duct widths below this value, and most symptomatic patients have widths above it. Statistically, a threshold of maximum ductal dilatation that predicts breast pain cannot be evaluated on the basis of our data.
The term duct ectasia is frequently associated with periductal mastitis. Two theories for its development have been formulated. The first proposes that milk ducts dilate with age and that stagnant secretion in these dilated ducts leaks into the surrounding tissue to cause periductal mastitis.28 The second theory specifies that periductal inflammation predominates in younger women, whereas duct dilatation increases in frequency with advancing age.29,30 Periductal mastitis is frequently combined with clinical episodes of periductal mastitis and abscess formation.30 This especially affects women between the ages of 18 and 45.3,30 In our study, however, only two women reported a recent clinical mastitis, whereas typical symptoms of duct ectasia, such as nipple discharge and nicotine addiction,30 were mainly observed in patients with noncyclical mastalgia, in whom the greatest proportion of duct ectasia was seen. Breast biopsy was not indicated in the patients of this study. Consequently, we cannot report any data on periductal mastitis in noncyclical mastalgia. Because this clinical study found dilated ducts within an age group that is not typical for histologically proven duct ectasia,30 it seems possible that duct ectasia is a symptomatic variation of this condition that develops earlier in life.
The reason milk ducts are dilated in patients with mastalgia is unknown; however, the study presented here provides a reasonable explanation for the general morphology underlying this disease.
In conclusion, these results demonstrate for the first time that duct ectasia is a major factor in determining the severity of mastalgia. The site of pain is positively correlated with the site of duct dilatation in a considerable number of patients.
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Footnotes |
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The authors are indebted to the mathematician B. Nafe for statistical analysis and to Martin Hahn, MD, for his critical advice.
This study is dedicated to Professor Dr. Klaus-Dieter Schulz, President of the World Society of Breast Health, in appreciation of his indefatigable efforts to improve women’s health care.
Received March 20, 2002. Received in revised form July 4, 2002. Accepted August 1, 2002.
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REFERENCES |
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