Does Breast Pain Always Mean Something Bad?

Although there isn’t a moment in our lives that “the girls” aren’t by our side (or rather on our front), on most days we are unaware of their presence. Sure, we have the daily AM bra conversation with ourselves…what color, what material, strapless vs. racer-back, but in reality we spend a very modest amount of time paying attention to our breasts. This is except when one or both starts to hurt.

Breast pain makes us say, hmm, what could that be? And while most of the time our mind goes to that scary place, the majority of breast pain is totally benign. Let us unveil the A, B, C, and Ds (and maybe even the double A or double Ds) of breast pain with these basic facts.

A: Breast pain is one of the most common reasons women visit their GYNs.

B: The medical term for breast pain is mastalgia.

C: The easiest way to figure out what is bothering your breasts is to break out your calendar. Pain that moves with your menses (a.k.a. changes throughout the menstrual cycle) is considered cyclic. Cyclic breast pain is almost always caused by hormonal changes. Pain that comes on any calendar day (a.k.a. is constant) is considered noncyclic. Noncyclic breast pain is almost never caused by hormonal changes.

D: There are other structures (think of your muscles and your ribs) that are “roomies” with your breasts. Their close proximity to the breast can often masquerade as breast pain. So problems such as trauma to the chest, a fracture of the ribs, herpes, reflux, inflammation of the cartilage connecting the ribs, and angina make one think one’s breasts are in big-time trouble—when in reality they are nothing more than innocent bystanders!

Getting into the nitty gritty of it (or the double As and Ds as we like to say), hormonal or cyclic breast pain can occur from any medication that is either made from or modifies your hormones. Think OCPs (or any form of hormonal contraception), fertility medications, and medications used to treat abnormal vaginal bleeding.

When it comes to noncyclic breast pain, hormones are not the issue. While the breast is involved, the pain has nothing to do with your period. Think of things like trauma, infection, cysts, tumors, and cancers. Therefore, non-cyclic breast pain, specifically when it is in one breast, is intense, and is getting worse, makes us a bit more nervous. It definitely needs to be checked out.

In most cases, pain prompts a physical exam and an in-person chat: when did the pain start, what makes it better or worse, how often does it occur, and what where you doing when you felt it first? Depending on what these initial evaluations show, your doctor may decide to send you for a mammogram, a breast ultrasound, and/or an MRI. But because most breast pain winds up being no big deal (not cancer), the best thing to do is take a deep breath: it will very likely be okay. After this, it is not a bad idea to consider changing your bra (more supportive, better fitting) and changing your diet (less salt, caffeine, and fat). These modifications might just do the trick.

When nothing works, you may need to move on to medications. Starting an OCP or changing your OCP can help alleviate cyclic breast pain. Additionally, lowering the dose of a hormonal medication can also be helpful. Last, if the pain is non-cyclic and related to the muscles of the chest, an anti-inflammatory like Ibuprofen or Advil can certainly do the trick.  

Your breasts are sort of a big deal, no matter what size you are. And when they don’t feel right, you want to look into what’s making them hurt. While the pain is most likely from normal hormonal ebbs and flows, this is not a tide you should just watch roll in and roll out. Go looking for the lifeguard (your GYN) to make sure you weather this storm safely. It may be a pain (no pun intended), but it will keep you and your breasts protected.

Forever Young? Egg Freezing

How many of you can remember playing superheroes when you were a kid? Running around with your friends zapping, ka-powing, and bamming the bad guys was a fairly typical afternoon in the life of a child. Whether you were Wonder Woman or Super Girl, you probably kicked butt (and was pretty good at concocting the most awesome of superpowers).

Fast-forward nearly 30 years. Although you probably don’t play superheroes anymore (although we wouldn’t judge if you did!), if given the chance to have a superpower, we bet you could come up with a pretty long list. As fertility specialists and women who know how hard it can be to fit in careers and baby making, our greatest superpower would be to stop the inevitable biological clock: the decline in egg quality and quantity that happens as you age.

From the moment you make your debut into this world, it’s a downhill process. And for years, there was nothing anyone could do about it. Your ovaries didn’t really care what you ate, where you lived, and if you exercised—they were like a typical teenager (headstrong and independent). They just kept on going in a downhill fashion. And while they still don’t care, we have found a way to instill some discipline into them.

Cue egg freezing. While egg freezing has been around for nearly 30 years, it didn’t become mainstream until about five years ago. Around this time, it gained serious popularity and notoriety. With research, data, and the American Society of Reproductive Medicine (ASRM) removing the experimental label from egg freezing, more and more women signed up for the procedure. Nowadays, the press and social media are all over egg freezing. And taking it one step further, some companies now even cover the cost of egg freezing (e.g., Facebook, Apple)—its become pretty prevalent.

Why, you may ask, are women electively shooting themselves up with hormones, waking up at the crack of dawn for vaginal ultrasounds, and having a needle put in their vagina? All good questions…and here’s why. Because egg freezing may save your fertility and your chance of having a genetic child. The eggs you store today may make you a mother in the future when egg quality and egg quantity have taken a serious downturn. Nothing, with the exception of egg freezing, can halt the decline of ovarian reserve that occurs over time.

Although pregnancy, polycystic ovarian syndrome (PCOS), thyroid disease, too much exercise, eating disorders, and the pill may show your periods the red light, they will do nothing in terms of stopping the loss of eggs. The only thing that can show this process the yellow light is egg freezing.

If you want to freeze your eggs, don’t let fear about how long it will take you and what the process will do to your body and mind hold you back. All in all, egg freezing is a pretty quick and painless process (we need no more than about two weeks of your life before we can get those eggs into the freezer). Yes, you will need to give yourself shots. Yes, you will need to cut back on your exercise. Yes, you will have some transient weight gain, and yes, you will need to set your alarm an hour or so earlier than usual. Overall, though, it’s pretty tolerable.

Most women start the injectable fertility medications on day two or three of their period. The shots are administered twice a day for usually about 10 days; their primary job is supposed to help your body produce multiple follicles (a.k.a. eggs). Think of the shots as the gas fueling the development of the eggs present in your ovaries at the start of the menstrual cycle. They get them all going. But we can only put in as much gas as the tank will allow; if your starting antral follicle count (a.k.a. AFC) is 10, more medication will not make more eggs.  Your baseline, or AFC, is a measurement of your underlying reserve. Simply stated, those with more will have more eggs retrieved; those with less will have less retrieved. Here, there is no funny math.

However, while a car needs fuel to get going, we don’t want to overfill the tank. The same goes for the ovaries and the dose of fertility hormones. Too high of a dose can be dangerous and can result in overstimulation. Too low of dose will keep you idling in the parking lot. For this reason, your doctor will probably want to see you every other day for ultrasound exams or blood checks to make sure that your ovaries are running but not racing.

Once the follicles reach a certain size (usually about 17–19 mm), and the estrogen level is at a specific peak (we like to see about 150–200 pg/mL of estrogen/follicle), you will likely be instructed to take your “trigger” shot. This shot is either human chorionic gonadotropin (hCG ) (brand names: Novarel or Ovidrel) or Lupron (or a combo of both). It will prepare the follicles/eggs for the final stages of development needed to achieve maturity (remember only mature eggs can be fertilized in the future). The eggs will be extracted (a.k.a. retrieved) vaginally. That means a needle will puncture the vaginal wall, enter the ovary/follicle, and out comes the egg within the follicular fluid. The whole procedure takes no more than 20–30 minutes, although to you it will feel like seconds (this is the part you will be sleeping for). When you open your eyes, most will be relaxing in the recovery room snacking on graham crackers and apple juice. On occasion, the pain can be severe, but this is definitely not the norm!

Unlike most things that sit in your freezer, your eggs never really go bad. They can remain frozen until you are ready to defrost them; there is no expiration date. And while their Ice Age can be long, it’s important to remember that at some point you may no longer want to be pregnant. While women can carry pregnancies well into their forties and even fifties, the complications do increase as women age. This doesn’t mean that you have to freeze and thaw ASAP, but it does mean you need to make a personal timeline about when they will be used.

Although the sperm thing may seem like a problem, don’t let this part stand in your way.  Your eggs can be fertilized with partnered sperm or donor sperm—it’s totally up to you. In either case, the eggs will be thawed and inseminated in a process called ICSI (intracytoplasmic sperm injection). The resulting embryos will be grown in the laboratory, and the best embryo (s) will be selected for transfer about five days later. Any remaining high quality embryos can be frozen for future use.

Although egg freezing is good, it’s most certainly not perfect and is in no way a guarantee. It is not even a really good insurance policy. The success rates after egg freezing are never better than about 50–55% (and this is in women less than 35 years old). In the over-40 age group, it’s really no greater than about 15%. We say this not to bum you out but to bring reality to the situation. Egg freezing is expensive and a commitment. So before you drop some serious dough and time, you should know what you are doing and how much it can do for you. Egg freezing is a big decision—your doctor should go through it in detail before you sign on the dotted line.

While we may still lose to villains, we are getting stronger and stronger each day. Not only are more women choosing to freeze their eggs, but even more importantly, more women are also becoming aware of what will happen to their fertility, particularly their eggs, over time. Beating the “bad guys” is way more about brain power than muscle power—if you know what you are fighting, you will be able to devise a pretty awesome plan to beat them. Freezing your eggs may not be one of your weapons, but knowing about the process and the process of egg loss will ensure that you are not a victim of a surprise attack.

Mother Knows Best: Your Reproductive History

As much as we hate to admit it, it’s hard to find many things that our moms were wrong about. From the most basic (eat your veggies!) to the most complex (bad boys will always break your heart!), their words of advice were thoughtful, poignant, and basically spot on. But it’s funny that, no matter how much we talked and shared with the woman who gave us life, the sordid details of her menstrual cycle, her fertility, and her menopause are all too often taboo subjects. When did you get your first period, did you have trouble getting pregnant, did you suffer multiple miscarriages, and when did you go through menopause are questions that over half of our patients have never discussed with their mothers. When asked, they stare back blankly, and together we attempt to piece together a timeline of events based on when their mother was shouting, “I’m too hot, I’m too cold” multiple times a day.

Much of what dictates the timeline of reproductive life (first period to the last period) is unknown. Why some women go through menopause at 30 and others at 60 remains in many ways a mystery. Sure, women who are given certain types of chemotherapy or have multiple surgeries on their ovaries will frequently have a shortened “reproductive life,” but for most women who experience the premature stop, we don’t have good answers to the question of why. As frustrating as this is for the patient, it can be in many ways equally as frustrating for us as doctors. We, like you, want answers. Not knowing why something happened can often make the experience even harder to deal with.

Here’s what we do know. We know that a large piece of the reproductive life timeline puzzle can be answered by genetics. Genes inherited from your mother will frequently dictate your personal reproductive path. Because of this, when we see a girl who is late to have her first period or a woman who appears to be going through an early menopause, we ask detailed questions about the family history, specifically the female members of the family. We can often find reassurance (in a girl who is late to get her first period) or an answer (in a woman who is having an early menopause) when we put a microscope to the women on your family tree.

Despite major strides in genetic testing, most of the genes that make us who we are, particularly our ability to reproduce, still elude us. But while we may not know exactly what genes are controlling how fast our eggs disappear, we do know that how it all went down for your mom, your grandmother, and your older sisters is important. Simply stated, if your mom had menopause before the average age (~51), you should know about it, and you should consider doing something about it. In fact, research has shown us that we tend to have a pretty hard time getting pregnant about 10 years before our mom went through menopause.

So let’s do some math; if your mom had an early menopause at 45, you may have some serious fertility issues at 35! (Remember, menopause is defined as one year without a period.) If you ask your mom and she remembers mood changes, irregular cycles, and hot flashes starting at 45 but her last period was at 50, her menopause was at 51 (get it?). The fun and wonderful changes associated with menopause (aka the peri-menopause or menopausal transition) can actually go on for several years before the real hammer (menopause) is dropped.

It’s safe to say that, in 10 years, our knowledge about the genes that code for reproduction will be vastly different from what we know today. Genetics is the fastest growing field in medicine; long gone are the days of Mendel and his fruit flies! Pretty soon, you might know more about yourself (and your future children) than you even dreamed (or desired) possible. We don’t want to go all Pandora and her box on you, but remember that, with discovery can come disappointment. So while we all wish to know more about ourselves, some information can be hard to swallow.  

But here’s the simple take-home message: we can’t predict a whole lot about what will happen to your ovaries just by looking at you. But we can predict a lot by talking to you. Start the conversation with your mom, your sister, and your gynecologist early. Know your own body as well as what happened to your mom and grandmother’s body. Whether you look like your mom or not does not dictate whether your insides do. If you want to plan for your reproductive future, the best person to seek advice from is your mom. Once again, she knows best.

While much of what dictates the timeline of a woman’s “reproductive life” (first period to the last period) and a woman’s fertility is unknown, many of these answers are in our genes (aka what happened to your mom or your grandmother may very well happen to you).  What we don’t know today about the genes that dictate fertility (specifically egg quantity and quality), we will likely know in a few tomorrows. Genetics is the fastest-growing field in medicine.