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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 158-162

Ultrasound and hormonal (Thyroid stimulating hormone and prolactin) evaluation in mastalgia


1 Senior Resident, Gynecological Oncology, Dept. of Gynecological Oncology, IGIMS, Patna, Bihar, India
2 Consultant Gynecology, Dept. of Gynecological Oncology, IGIMS, Patna, Bihar, India
3 Professor & Head, Dept. of Gynecological Oncology, IGIMS, Patna, Bihar, India

Date of Submission14-May-2019
Date of Acceptance19-Jun-2019
Date of Web Publication12-Aug-2019

Correspondence Address:
Sangeeta Pankaj
Professor & Head, Gynecological Oncology, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Background: Breast pain (mastalgia) is a significant issue within the general population warranting increased investigation, awareness, and treatment. This study is being performed to study role of ultrasound and to evaluate Thyroid Stimulating Hormone (TSH) and Prolactin levels in our patient population with the complaint of mastalgia .
Methods: This was a prospective observational study in which 100 patients of mastalgia were included. Pregnant and lactating women, known cases of breast cancer, patients with palpable breast lumps and those with breast abscesses, women on antidepressants, antihypertensives and oral contraceptive pills were excluded from the study. Ultrasound findings and serum TSH and Prolactin levels were assessed in all patients included in the study. Those with hypothyroidism and hyperprolactinemia were treated with thyroxine and bromocryptine respectively and the response to treatment observed.
Results: Mean age of women in study was 35.37 years. Most of them (90%) were multiparous. Ultrasound findings included 57% normal results, 32% benign cystic disease of the breast, 6% small fibroadenomas, 4% duct ectasia and 1 case of filariasis of breast. Out of 100, 18 women (18%) had hypothyroidism (TSH >5). 8 (8%) women in our study with mastalgia had elevated serum prolactin levels. Decrease in mastalgia in 15 women with hypothyroidism and in all women with hyperprolactinemia was observed after appropriate therapy.
Conclusion: Sonological findings can be the baseline while starting the treatment in patients with mastalgia. Our study strengthens the association of thyroid dysfunction and raised prolactin levels with mastalgia. Women with mastalgia should be screened for hypothyroidism and for raised serum prolactin levels because simple correction of these changes may result in clinical improvement.

Keywords: Mastalgia, Ultrasound, TSH, Prolactin


How to cite this article:
Nazneen S, Kumari A, Kashyap J, Kumari A, Kumari J, Kumari P, Pankaj S. Ultrasound and hormonal (Thyroid stimulating hormone and prolactin) evaluation in mastalgia. J Indira Gandhi Inst Med Sci 2019;5:158-62

How to cite this URL:
Nazneen S, Kumari A, Kashyap J, Kumari A, Kumari J, Kumari P, Pankaj S. Ultrasound and hormonal (Thyroid stimulating hormone and prolactin) evaluation in mastalgia. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2022 Oct 2];5:158-62. Available from: http://www.jigims.co.in/text.asp?2019/5/2/158/301103




  Background : Top


A palpable mass, mastalgia, and nipple discharge are common breast symptoms for which women seek medical attention. Breast pain or mastalgia is the most common symptom in the breast.[1] Mastalgia is defined as pain, dull ache or heaviness in the breast that may affect up to 70% of women in their lifetime. The etiology of mastalgia is not well understood. It can occur during adolescence, pregnancy and perimenopause.[2]

Mastalgia can be divided into three categories: cyclical mastalgia, non-cyclical mastalgia and extramammary causes of breast pain.[3] The underlying physiology may be different for noncyclic and cyclic breast pain. Cyclic pain is classically related to the menstrual cycle; it is bilateral, diffuse, and often radiates to the axillae. It most often occurs during the luteal phase as a result of increased water content in breast stroma caused by increasing hormone levels. Noncyclic pain is not related to the menstrual cycle and may be unilateral or focal. Oral contraceptives, hormone therapy, psychotropic drugs and some cardiovascular agents are associated with breast pain.[4]

Breast pain is a significant issue within the general population warranting increased investigation, awareness, and treatment.[5] Cases of mastalgia without clinical findings of nodularity or lump are still a challenge for diagnosis and management. Rarely is mastalgia the only symptom of breast cancer. Mastalgia is often associated with breast nodu- larity that may be tender or without a discrete lump. Some amount of breast nodularity and mastalgia are found in normal population.[6],[7]

Breast imaging should be done taking into concern the age of the patient, risk for breast cancer, and other aspects of the clinical presentation Ultrasound (USG) breast is one of the most convenient and painless investigation that can be done in women complaining of breast pain. In many medical centers, ultrasonography is used alone to evaluate focal breast pain in younger women and as an adjunct to mammography in older women. Breast imaging alone provides reassurance in women who present with pain. A mammogram should be considered in women with focal breast pain who are aged 30 to 35 years or older, have a family history of early breast cancer, or have other risk factors for breast.

Maturation of breast is hormone dependent. This process of growth and cell division and breast maturation is under control of estrogen, progesterone, adrenal hormones, pituitary hormones and trophic effect of insulin and thyroid hormone. Several hormonal imbalances have been studied in the pathophysiology of mastalgia like increased estrogen secretion from ovary, decreased secretion of progesterone, increased prolactin levels or alterations in the estrogen/progesterone ratio and each has findings in support and opposition.8 One hormonal abnormality frequently detected in mastalgia is increased thyrotropin- induced prolactin secretion.[9] Though increased prevalence of thyroid disorders in women with benign breast diseases (BBD) has been observed , the association between thyroid dysfunction and BBD has not been well established and there is no consensus regarding monitoring of thyroid function in these patients.

This study is being performed to study role of ultrasound and to evaluate Thyroid Stimulating Hormone (TSH) and Prolactin levels in our patient population with the complaint of mastalgia .


  Methodology : Top


In this study, 100 patients of mastalgia visiting Gynaecological Oncology Out Patient Department of State Cancer Institute at Indira Gandhi Institute of Medical Sciences, Patna, Bihar were included. The study design was prospective observational. Pregnant and lactating women, known cases of breast cancer, patients with palpable breast lumps and those with breast abscesses, women on antidepressants, antihypertensives and oral contraceptive pills were excluded from the study. After taking detailed history and doing clinical examination, the patients were sent for ultrasound of bilateral breasts and axilla. Serum TSH and Prolactin levels were assessed in all patients included in the study. The normal reference range for serum TSH from our laboratory was 0.3-5.0 mIU/l. Hypothyroidism was defined as a serum TSH concentration above the defined upper limit of the reference range. Normal serum prolactin level ranged from 2 to 29 ng/ml and 30ng/ml or more was considered abnormal. The demographic characteristics of the study population and results of the hormone levels and ultrasound were analysed using simple percentages. Those women with subclinical hypothyroidism were treated with starting daily dose of 0.25 mg of Thyroxin and TSH level was assessed after 4 weeks. If TSH had not reached to normal levels, the dose was increased accordingly and again followed in 4 weeks. In those with clinical hypothyroidism, higher doses were given. Women with hyperprolactinemia with serum prolactin less than 50 ng/ml were treated with 1.25 mg bromocryptine twice daily. After two weeks, the level of prolactin was assessed and if not normalised, the dose of bromocryptine was increased to 2.5 ng/ml. In those with prolactin 50 or more, bromocryptine was started in doses of 2.5 mg twice daily and escalated by 2.5mg every 2 weeks. Maximum of 5 mg twice daily of bromocryptine was needed in these women. Response to mastalgia after replacement therapy was assessed at each visit.


  Results : Top


A total of 100 patients with breast pain were included in the study. Their ages ranged from 23 years to 60 years, with a mean age of 35.37 years. Most of the women were between 30 to 40 years of age and only 4% were aged more than 40 years.[Figure 1]
Figure 1: Age groups of women with mastalgia

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Most of the women were multiparous (90%) and only 2 women were nullipara. [Figure 2]
Figure 2: Parity of women with mastalgia.

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The pain was noncyclical in most of them (84%), 34 women (34%) had unilateral breast pain and 66 had bilateral breast pain (66%). Feeling of lump or lumpiness was complained by 42 (42%) women. 12 women (12%) with mastalgia had associated complain of nipple discharge. Interestingly, many (46%) women with mastalgia had undergone bilateral tubal ligation for family planning and 22 (22%) had undergone hysterectomy. Clinically 30 (30%) women had fibrocystic breast disease, 14 (14%) had nipple discharge and the rest 56 (56%) were normal.

Ultrasound findings included 57% normal results, 32% benign cystic disease of the breast, 6% small fibroadenomas, 4% duct ectasia and 1 case of filariasis of breast. [Figure 3].
Figure 3: Ultrasound findings in women with mastalgia.

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Out of 100, 18 women (18%) had hypothyroidism (TSH >5). [Figure 4] Among the 18, 15 (83.3%) had subclinical hypothyroidism and 3 (16.6%) had clinical hypothyroidism. TSH in these women ranged from 5.2 to 96.81 mIU/l. Symptomatic improvement in mastalgia was seen in 15 women ( 83.3%) with effect seen after 3 to 4 weeks of therapy.
Figure 4: TSH in mastalgia.

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8 (8%) women in our study with mastalgia had elevated serum prolactin levels. Out of these eight, one had associated hypothyroidism. Serum prolactin levels in these women ranged from 34.8 to 146 ng/ml. Decrease in mastalgia after bromocryptine administration was observed in all these women with effect seen after 6 to 8 weeks of therapy.


  Discussion : Top


Mastalgia is a common symptom among females from puberty to after menopause. It accounts for up to 66 percent of physician visits for breast symptoms.[10] Focal breast pain should be evaluated with diagnostic imaging. Targeted ultrasonography can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older.[4]

In areas where mammography is not accessi-ble or very expensive especially in developing countries like ours, ultrasound may be used as a primary modality to further evaluate breast pain and for ultrasound guided procedures. Although ultrasound is not of much diagnostic value in women with breast pain as the only symptom, it can be very helpful in reducing anxiety in women. A recent study showed that the severity of pain and anxiety after ultrasonography decreased significantly concluding that ultrasound findings reassure the patients that they do not have specific pathology.[11] Another study established that even in the presence of mam-mography, breast sonography should be included in the work-up of symptomatic breast disease.[12] However, one recent study observed that if the result of examination is normal, the patient of age 30 or below and there is no family history, imaging is not necessary and medical therapy can be started directly.[13]

Ultrasound findings in our study included 56% normal results and the rest (44%) had benign pathology with 32% benign cystic disease of the breast, 6% small fibroadenomas, 4% duct ectasia, 1 case of filariasis. Similar findings were reported in other studies. In a recent study of 789 cases it was determined that of the female patients with only breast pain who had undergone ultrasonography, 42.3% had normal findings, 37.1% had a cyst, followed by ductal dilatation with 9.9%, fibroadenoma with 6.4% and the incidence of breast cancer was only 0.2%.[14] In a study of 110 targeted breast ultrasonographic examinations performed for focal breast pain in the absence of palpable mass, no breast cancer was found, 77.3% negative findings and a benign finding at the site of pain was identified in the rest.[15] In another study, the incidences of simple cysts and fibroadenomas were higher in the mastalgia group (p < 0.05).[16] No case in our study with mastalgia had malignancy. Mastalgia is usually not an indication of underlying malignancy. In several studies, mastalgia has not been shown to be a risk factor for breast cancer.[17],[18]

Hormonal factors have a role in cyclic mastalgia as this condition is defined by its relationship to the menstrual cycle and its tendency to change during pregnancy, menopause, and hormone therapy. However, consistent hormonal abnormalities have not been identified.

In the present study, 8/100 (8%) women with mastalgia had elevated serum prolactin concentrations. There are several studies regarding association between raised serum prolactin levels, mastalgia and benign breast diseases. Similar to the present syudy, one study reported that 6.25% of women with mastalgia and 30% of the patients with benign breast disease had elevated serum prolactin.[19] Another study reported that the the basal PRL level was significantly elevated in patients with cyclical mastalgia.[20] In contrast, in another study prolactin mean levels were within the normal range and although there was a trend toward a higher basal prolactin concentration in patients with BBD, this was not statistically significant.[21] Some studies have shown hyperresponsiveness of prolactin to stimulation by thyrotropin-releasing hormone, to be the cause of mastalgia.[9],[22]

Role of prolactin in pathophysiology of benign breast diseases explains the rationale behind treatment of mastalgia with dopamine agonists. Bromocriptine inhibits the release of prolactin from the pituitary. It has been shown to be effective in the treatment of mastalgia. Bromocriptine significantly decreased breast pain, heaviness, and tenderness in several studies.[9]

Our study reported 18% of women with mastalgia having hypothyroidism. Similar results were observed in other studies. A study in 2009 showed the overall prevalence of hypothyroidism was 23.2% of women with benign breast disorders and in 23% of women with mastalgia as their symptom. This study by Bhargava et al also reported that the symptoms were alleviated in 83% of the hypothyroid patients with only thyroxine replacement.[23] One recent study by P Tanwar et al reported even higher prevalence (30%) of hypothyroidism in women with benign breast disease out of which 24.5% cases were overt hypothyroid while 75.5% cases were subclinical hypothyroid.[24] These studies observed that hypothyroidism should be considered as underlying cause of BBD and adequate screening should be done in patients of BBD as thyroid replacement might be the only definitive treatment required in most of these cases.

In another study by E Giustarini et al, FT4 and TSH concentration showed no differences between breast cancer patients, BBD patients and controls. The prevalence of thyroid antibodies in breast cancer patients was found to be significantly higher than in benign breast disorder patients and in controls suggesting that the relation of thyroid disturbances to breast disease seems to be nonspecific in character but thyroid hormone imbalance does appear to affect breast disease.[25]

In our study it was observed that among all women with mastalgia, many (46%) had underwent tubal ligation for family planning. This may be explained by the occurrence of post-tubal ligation syndrome, the existence of a which has long been debated. There is no clear consensus on the symptoms and signs of this syndrome, which remains ill-defined. While some authors have merely described it as abnormal uterine bleeding and/or pelvic pain, others have correlated it with exacerbated premenstrual symptoms, menstrual cycle irregularity, dysmenorrhea, pelvic pain and changes to sexual behavior and psychoemotional state. In one study, the rate of reported adverse premenstrual symptoms (headache, edema, mastalgia, dizziness and irritability) increased from 55.4% to 74.6% after sterilization, regardless of the operative technique used.[26] 22% of females in our study with mastalgia were already hysterectomised. Though there are no published studies till date on mastalgia in hysterectomised women, it has been observed that hormone levels can fluctuate immediately after hysterectomy and cause breast tenderness, which can be painful in some cases whether or not ovaries are retained. The ovarian blood supply can be interrupted with the removal of the uterus, causing them to work less efficiently. As a result, hormonal imbalance and breast tenderness may occur as a new blood supply is established.

In conclusion, sonological findings can be the baseline while starting the treatment in patients with mastalgia without palpable lesion. Though it is not of much value in the management of such cases, it is a very useful, cheap and non invasive modality which helps a lot to alleviate patient anxiety and reduces pain by its effect on psychological status of the patient. Our study strengthens the association of thyroid dysfunction with mastalgia. Though the prevalence of hyperprolactinemia is less than that of hypothyroidism in women with mastalgia in this study, it is more common than in general population. Hence women with mastalgia should be screened for hypothyroidism and for raised serum prolactin levels because simple correction of these changes may result in clinical improvement.



 
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