Among all signs and symptoms that characterize the premenstrual syndrome, mammary swelling, engorgement and pain constitute some of the more frequent ones. Even many women who do not complain from other premenstrual disturbances, often report variable degrees of mammary congestion and/or pain on the days that precede menstruation. Mammary congestion and engorgement is the most frequent objective premenstrual manifestation and, therefore, the one that is more easily verified at clinical examination. This happens because the increase of density and volume of the mammary parenchyma thickenings and nodules that characterize the so-called "functional mastopathies" ( or "benign functional alterations of the breasts" ) becomes more evident in the premenstrual phase. In turn, this premenstrual increase in the density and thickness of the mammary tissues is mostly due to the premenstrual congestion and swelling of the breasts.

Even so, concerning the precise etiology of this mammary congestion that frequently occurs a few days or a week before the coming of the menses, we have to recognize that it still remains obscure – in the same way as that of the other edemas and congestive phenomena that take place in other parts of the female body along the premenstrual period. However, I would like to remark once again that it is exactly in the breasts that the hydric retention and the congestive phenomena that often precede menstruation become more evident and easily detectable at clinical examination. In this way, besides the probable action of local causative factors at the mammary level, there are also indications suggesting the existence of a wider inter-relation among all premenstrual edematous and congestive manifestations.

The cyclical premenstrual engorgement of the breasts becomes clinically evident by: 1) a more or less diffuse increase in the volume and/or turgescence of these organs; 2) an evident increase in the thickness and volume of their glandular and ductal structures, as well as of the connective tissue that surround them. As it is widely known, all these alterations often go along with various painful phenomena that occur spontaneously or induced by a simple touch or pressure. It is important to observe that considerable variations in the intensity of all those manifestations can be found in the same woman from one breast to the other – a fact that demonstrates the importance of the specific response of the "target" organ in relation to the stimuli that cause the congestive reactions. In a similar way to what happens to most of the other signs and symptoms that appear on the days that precede the menses, this cyclical premenstrual mammary congestion and pain also uses to reduce quickly with the beginning of menstruation.

Remaining on the etiology of this premenstrual engorgement of the breasts, it is possible that, in this phase of the cycle, there can be very specific reactions of the mammary tissues to the estrogens and progesterone, to the interaction between these hormones and/or to the fall in their respective levels. These very specific reactions might give rise to a local formation of substances capable of altering the permeability of the capillary vessels of the breast tissues, resulting on the accumulation of interstitial fluid and the consequent congestive phenomena. The already mentioned variations in the intensity of these phenomena from one breast to the other in the same woman reinforce this hypothesis. On the other hand, the mammary premenstrual congestion can also be regarded as being only a more localized manifestation of the systemic hydric retention that many women present on the days that precede menstruation and that is part of the premenstrual syndrome *.

Also due to this premenstrual mammary engorgement, women whose breasts present the thickenings and increased nodularity that characterize the "functional mastopathies" (or "benign functional alterations of the breasts") often suffer from stronger premenstrual mammary pain and discomfort.

Over the last decades, several treatments have been used and proposed for this premenstrual mammary congestion and pain. The traditional treatments are commonly based on the use of hormones ( mostly progesterone and progestins ** ) and diuretics that cause the elimination of sodium and water, with a consequent reduction of the mammary edema. Other medicines have also been experimented in the last years, with uncertain results and many times controversial indications. Therefore, it is fundamental to emphasize that each case needs to be carefully analyzed individually so that the correct treatment can be prescribed.

Though there is no relation between the usual premenstrual mammary congestion and breast cancer, even so I would like to emphasize that the clinical management of all breast problems must necessarilly include, as a routine, full attention to the prevention and early detection of breast cancer.

Note 1: *Another more localized manifestation of these edemas that precede the menses is the premenstrual pelvic congestion. Though involving mostly the genitals, this congestive reaction also spreads to other near structures. Premenstrual pelvic congestion becomes clinically evident by a diffuse painfulness and sensation of "weight" and discomfort in the lower belly. Lumbosacral pain is also another frequent symptom.

Note 2: **According to recent studies, some effects of progesterone and progestins ( synthetic "progesterones" ) on the breast glandular structures are becoming somewhat controversial. Even so, to my point of view, it is still too early for radically changing the basic principles that rule the use of these hormones for several mammary problems.

Nelson Soucasaux is a gynecologist dedicated to Clinical, Preventive and Psychosomatic Gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993.

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