The Breast 18 (2009) 123–125
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Original article
A new radiological approach to cyclic mastalgia: Venous doppler ultrasound _ Zeynep Ilerisoy Yakut a, Hasan Kafali b, *, Mustafa Karaoglanoglu a, Asli Ko¨ktener a, Candan iltemir Duvan b a b
Department of Radiology, School of Medicine, Fatih University, Çankaya Hospital, Yukarıayrancı/Ankara, Turkey Department of Obstetrics and Gynecology, School of Medicine, Fatih University, Yukarıayrancı/Ankara, Turkey
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 September 2008 Received in revised form 10 January 2009 Accepted 16 February 2009
Objective: To evaluate the role of the venous system in cyclical mastalgia.
Keywords: Breast pain Venous Doppler Mastalgia Cyclic mastalgia
Materials and methods: 25 healthy women and 39 women with cyclic mastalgia underwent venous Doppler examination in both pre- and postmenstrual period. Upper-outer quadrant veins of breast were evaluated. The impedance indices of both groups were compared in both the premenstrual and postmenstrual period. Results: During the premenstrual period, venous impedance indices were significantly higher in the patients with cyclic mastalgia (p ¼ 0.004) than in the control group. After the menstrual period, there was no difference in venous impedance indices between the groups. Conclusion: Excessive tissue oedema might be responsible for both a tension-mediated pain and a compression of the venous system thereby showing higher impedance than that in control group. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Mastalgia is a common symptom affecting up to 70% of women at some time or the other in their lives.1 From a clinical point of view, it is divided into cyclical mastalgia and noncyclical mastalgia. The cause of cyclical mastalgia is unknown. Since cyclical mastalgia responds to hormone treatment and fat restriction or administration of essential fatty acids, it is believed that cyclical mastalgia is hormone based or mediated by fat intake, especially saturated fatty acids.2,3 The role of the venous system in the mechanism of pain in different parts of body, such as migraine, varicose vein and varicocele is well known. The cranial and cerebral veins and sinuses are pain sensitive and a venous dilatation and neurogenic inflammation are thought to be probable mechanisms of pain,4 but involvement of the venous system in breast pain is not known. The use of Doppler ultrasound for the differentiation of benign and malignant lesions by demonstrating abnormal flow parameters has been known for more than 20 years. There are, on the other hand, only a few studies about the Doppler ultrasound of normal breast tissue in the literature and to our knowledge no Doppler studies have been published in mastalgia patients without any breast lesions. This is the first study to investigate
* Corresponding author. E-mail address:
[email protected] (H. Kafali). 0960-9776/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2009.02.005
whether there is any change in breast venous-system blood flow in mastalgia patients. Materials and methods 39 patients with cyclic mastalgia were prospectively evaluated from July 2006 to August 2007 at Fatih University, Çankaya Hospital. The patients who complained of premenstrual breast pain or tenderness for a period of at least 3 months were included in the study. The exclusion criteria were patients with any physical illnesses, pregnancy, lactation, irregular menses or those who had undergone any hormonal treatment during the previous 3 months. None of the patients had a history of galactorrhea or polycystic ovary syndrome. Women who did not report any significant breast symptoms were classified as the control group. Breast ultrasound was performed to exclude any pathology that might be the cause of breast pain. Only patients with normal breast ultrasound, and/or mammogram, suffering from cyclic breast pain were included in the study. The study was approved by the institutional review board and informed consent was obtained from all the patients. Sonographic imaging was performed using colour Doppler and Bscan modes on a Sonoline Antares sonographic system (Siemens AG, Munich, Germany) with a VF 13-5 MHz transducer. For consistency, the sonographic examination was performed on the same day of the menstrual cycle by the same radiologist. Premenstrual measurements were taken 5 days prior to the expected onset of menses and postmenstrual measurements were obtained on day 5 of the menstrual cycle. The Doppler measurements were taken
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from the veins of upper-outer quadrants of both breasts at subaxillary regions. The patient was asked not to move, speak or take deep breaths since it might increase venous flow. The impedance index, also commonly known as the resistive index, was recorded for each patient. Impedance indices were obtained from a single breast in both the control and the mastalgia group. For patients with bilateral breast pain; impedance indices were obtained from the breast in which the pain was predominantly felt.
was no statistically significant difference between the two groups after menses. For the patients with bilateral breast pain, right breast impedance index was 0.38 0.096 and left breast impedance index was 0.32 0.10. There was no statistical difference between the two breasts when compared to that during the premenstrual period (p > 0.05).
Discussion Statistical analysis Statistical evaluation of the results was performed using SPSS version 11.5 for Windows (SPSS Chicago IL). To compare personal variables (age, impedance index) between the two groups, we used the Student t-test. The level of impedance indices in premenstrual and postmenstrual period in patients with cyclic mastalgia and controls were estimated using the Student t-test. A value of p less than 0.05 was considered statistically significant. Results Our case–control study group included 39 patients aged between 21 and 46 years (mean 30.7) and 25 controls, aged between 22 and 45 years (mean 28.8). The age difference between the groups was statistically not significant (p > 0.05). Of the 39 patients, 15 demonstrated bilateral cyclic pain. Ten of these demonstrated pain predominantly in the left breast. The remaining 25 patients had unilateral breast pain, 10 of whom had pain on the right side. The mean venous impedance index of the mastalgia group in the premenstrual period was 0.42 0.097 (Fig. 1) and the mean venous impedance index of the control group in the premenstrual period was 0.35 0.080. The difference between these groups was statistically significant (p < 0.004). After menses, the mean venous impedance index of the mastalgia group was 0.30 0.098, and that of the control group was 0.32 0.075. There
Fig. 1.
In order to explain the breast pain, we hoped to find that venous impedance index of the mastalgia group would be lower than that of the control group and, if so, venous dilatation could have been the explanation for the pain; but contrary to our expectations, the data presented here indicate that the venous impedance index of the cyclic mastalgia group was higher than that of the control group during the premenstrual period. After menstruation, both groups were found to have similar venous impedance indices. The impedance of a haemodynamic system is defined as the ratio of each harmonic component of blood pressure to that of the flow. The Doppler examination of the arterial tree includes measuring the resistive index, which is defined as the systolic velocity minus the diastolic velocity divided by the systolic velocity; that is, resistive index ¼ (systolicdiastolic)/systolic. This index actually measures impedance, which is a combination of both the downstream resistance and the vessel compliance. The downstream resistance on the venous side of the arterial tree is usually minimal because the veins act as capacitance vessels; therefore, the term resistive index is confusing, and the term impedance index is preferred on the venous side of the vascular tree. What is the meaning of impedance index measured on the venous side? On the arterial side, the impedance index measures both resistance and compliance of a vessel simultaneously.5 On the venous side, the normal resistance is negligible, and the pulsatility directly relates to compliance. In the present study, we supposed that increased
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venous impedance index mostly resulted from decreased venous compliance. This speculation raises a question – which factor causes reduction of compliance? Dampening of the hepatic vein signal has been observed in patients with acute and chronic liver disease and has been attributed to reduced hepatic compliance.6 Similarly, the compliance of the vessels in the kidney is reduced when the interstitial pressure is increased due to ureteric obstruction.7 A similar mechanism is believed to occur in the breast. The increase of breast volume during the premenstrual period is a well-known phenomenon. Fluid retention within the breast may provide a possible explanation for compliance reduction. For understanding the structural change of the breast during the premenstrual period, we should know the mechanism of how hormones affect the breast during the menstrual cycle. Follicular phase oestradiol stimulates epithelial proliferation. Luteal phase progesterone affects lobular– alveolar proliferation and acinar secretions resembling the changes during pregnancy. As oestradiol and progesterone levels fall, intralobular stromal oedema and venous congestion result in about 40% increase in breast volume prior to menstrual involution.8 In cyclical mastalgia, elevated prolactin response to thyrotropinreleasing hormone, and thus a higher daily prolactin production, has been documented.3 A possible mechanism of action of prolactin may be fluid and electrolyte absorption. It has been shown that prolactin stimulates the retention of fluid and electrolytes in the intestine and kidney in rats.3 Prolactin-related fluid retention within the breast may provide a possible explanation for premenstrual mastalgia. To conclude, the mechanism of pain associated with cyclic mastalgia is not directly related to the venous system. Excessive tissue oedema in the mastalgia group may be responsible for a tension-mediated pain and may result in a compression of the venous system that shows lower compliance than that of the
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control group. Despite our final speculation, it should be kept in mind that the potential role of the venous system in the genesis of cyclic mastalgia cannot be totally excluded based on results of this study, because first, the number of subjects in this study was limited, and second, the venous system may initially have played a role in the breast stromal oedema (venous congestion) which can have a secondary effect on its compliance. Further studies are needed for a more comprehensive conclusion.
Conflict of interest statement None declared.
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