← Dr. Chapa’s OBGYN Clinical Pearls 
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All right, truth be told, we're recording this on September 11, 2025. And not only September 11, obviously a. An impactful day, but the events of the last 24 hours on September 10, 2025, with the assassination of Charlie Kirk. I have to be honest, I did not. I'm in no mood to do an episode at all. However, I was outvoted by our team and our producer, who I'm very thankful for, had a great point and he's right. Say, no, we have to go, we have to do this, or else they win. And we're going to continue and we're going to do this. We do want to make the point that whether you listened to Charlie Kirk or not, this is a deeper issue. This is about just the ability to. To disagree with someone and be okay with that. It's okay to disagree. It's not okay to kill somebody. And. And that. That's all. We're going to leave it at that. Just. God bless Charlie Kirk's memory, God bless the Kirk family, and we will move forward with today's episode. This is our first after a true turning point in our country. So for the Charlie Kirk family, we, we are there with you and God's loving touch and grace to you and the family. When we were looking for what to do for this, you know, we were actually going to record something on the 10th of September yesterday, and we canceled it because my producer had something on his phone. He got a little ding and from his contact at, who works with. With a marketing team, and we connected with Turning Point and like, you know, hold on a minute. What is happening here? So we were going to do a. A recording yesterday. All to say is, we're doing this now. So now that we've done that and acknowledged that we've got to be better as people, we have to be better as, as a country. Now that we've done that, let's get back to work. So in this episode, my goodness, in this episode, what we're going to do is we're going to Tackle something on the breast. Sorry, I'm trying to get back into the vibe. We're going to tackle something on the breast, which is a super common symptom. And I get this, especially in my patient population, who is a younger reproductive age. Again, while I do have some patients who come in asking more of a consult on menopausal stuff, really, I mean, I do obstetrics. I mean, that's my first love. That's my passion. And so this is my patient population. By age is a younger reproductive age population where, you know, breast pain, mastalgia is one of the most common symptoms that they come in outside of vaginal discharge and say, what is going on with my breast? Is it cancer? Okay, that. That's, of course, the first thing. And thankfully, the majority. The vast majority of the time, mastalgia has nothing to do with cancer because most cancers are. Are asymptomatic, unfortunately, and I don't mean this in a wrong way, but I wish cancer caused some breast pain so that we could catch it early if patients would come in and get ahead of the game. But that's not. Unfortunately, that's not how it is. Most breast cancers are, in fact, asymptomatic. So thankfully, while we should always do a full evaluation of a patient with mastalgia and including a full history, medication, exposure, including contraceptions and how they're taking contraceptions, and a full physical examination that may or may not include imaging. And of course, if they're under the age of 30, that's an ultrasound. If they have very high risk factors for a germline mutation, then MRI can be considered. But I don't want to get into imaging. I want to talk about specifically the symptom of breast pain, mastalgia. Okay? We've got to take that seriously. Never brush that off. That's just fibrocystic breasts. You're going to be okay. Don't worry about it. It's nothing. No, wait a minute. Hold on. Stop. That's a hard stop for us. Anything on the breast is. Is a. Is a. Do not forward. Do not move forward until we figure this out and investigate. Especially when it's not in the most typical areas. Okay? Because the most typical areas for mestalgia is upper outer. Upper outer quadrant. That's where most of the glandular tissue is. Upper outer. Which is also why you get more breast cancers in the upper outer quadrant. So if somebody comes in and says, oh, it hurts here more, you know, medial or closer to the sternum, you're like, well, that's weird because it should hurt up closer to your armpit. So not that mastalgia of course, can't happen in the medial portion, but it's, it's a little bit more odd there. And it brings up other likely differential diagnoses like costochondritis or muscular or other weird things potentially. Is it a little thrombophlebitis or a clot in a vein? That's possible. That's something called Mondor syndrome, that, that's rare. But there's things that you've got to look for. The point is very simple. Don't ignore mastalgia. Mastalgia has to be evaluated and based on who you read, it's anywhere from 30% up to 50% of women who have this. Whether it's cyclical or non cyclical, this is an issue and this is what we're getting into here. Because earlier in this month, In September of 2025, a new systematic review and meta analysis was published in BMC Women's Health. BMC Women's Health, looking at non pharmacological ways to treat mestalgia, mainly B6. Okay, so I've got a lot of patients who always come in, they're like, I'm taking B6, it's not really helping. And my answer is always the same. B6, phenomenal. B6 has a lot, it has its hands in a lot of the different things. It's not just for nausea, vomiting and pregnancy. B6 is used for a lot of issues, including some anti inflammatory properties. And we'll get into this after this brief intro when we come back in a minute. But, but the point is it, does it work? Because it's anecdotal, right? Some patients really feel better with it, some don't do anything. But what does it mean in the data? So we're going to take a look at B6. By the way, when we say B6, everybody goes to pyridoxine, right? Oh, it's pyridoxine. Okay, I get it. B6 and that's okay. But do you understand that when we say vitamin B6 it's actually a whole list of agents. It's actually six members that live in the vitamin B6 camp. And the one that gets most of the attention is pyridoxine. And it's okay. It should. The others are kind of more minor roles, but there's actually five others in addition to pyridoxine. Five other members, so six total in the vitamin B6 family. Okay, just wanted to put that out there. B6 is not just pyridoxine, it's actually a conglomerate, if you will, of six other components. So here's what we can get into. Does B6, is it effective in reducing mastalgia? Because it would be nice to use a non pharmacological agent. Now to be clear, ACOG does have of course some guidance on this. This was in their diagnosis and management of benign breast disorders. That was back in 2016 and nothing really changed from that. I mean it's, the data is still pretty valid. And that was a practice bulletin number 1, 6, 4 that was reaffirmed just two years ago in 2023, meaning it's coming up for reaffirmation here soon. And really the information is the same. So Practice bulletin number 164 on diagnosis and management of benign breast disorders does have a section of course on mastalgia. And in there it says, look, same thing we talked about. Full history, full, full physical, good supportive bra compression that totally works. And analgesics great, like potentially a Motrin ibuprofen based products that, that's the way to go. That's fine. There's some stuff out there potentially like bromocryptine derivatives like a Parlodel that, that potentially can help reduce some pain, but that has weird side effects and it's kind of pricey and nobody wants to take that if you don't have to. So it's very common as a, as a traditional over the counter recommendation for mastalgia for people to recommend B6, vitamin B6. But does it work? So that is the focus of our episode. This came out on BMC Women's Health on September 2, 2025. The title is the effectiveness of vitamin B6 in reducing a Systematic Review and Meta Analysis. Which is good that that's the title because that's exactly what I described. So that's where we're going. I think that's done for the intro. We're going to get back in here. And again, thank you for being part of our podcast community. And now that we've said all that, let's get out of the intro and we'll be right back. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OBGYN no Spin podcast.
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Let's briefly give you this thing on reassurance for patients just with mestalgia and no other findings, not mestalgia and a big hard rock in their breast or nostalgia and weird nipple discharge or mastalgia and their nipples now inverted when it wasn't before. It's just mestalgia. In general, though, we still have to do our due diligence and do our job. Reassurance can be part of that because the chance that it's something really bad is small now. It doesn't mean we ignore it. You still need a diagnosis. Remember, mastalgia is a symptom. It can be a diagnosis, but it's a symptom. Better to link a diagnosis that gives a symptom, like, oh, you've got a breast cyst or you have something called fibrocystic breast condition or fibrocytic breast changes. Whatever, you've gotta be able to link it to something. Although mastalgia as its own diagnosis is fine, although it's more of a symptom. Okay, so under ACOG's practice bulletin, there's one small little paragraph and I pull this up for patients and I show them. Look, I'm not just telling you this. This is what the evidence is that I know you're concerned something bad and I'm concerned too. But we can, we can do some reassurance here as we do the evaluation quote breast cancer rarely is identified in the patient presenting with mastalgia and no other clinical findings for reassurance is appropriate management. For patients with cyclic nostalgia and normal physical examination findings and appearance select use of diagnostic imaging may provide additional reassurance. End quote. So there it is. Breast cancer rarely, unless it's something else going on or hinging a nerve and it's pretty advanced, rarely is the presenting symptom. Usually it's hey, there's a weird mass, something's going on a little bit of breast asymmetry or swelling. So take breast complaints very, very seriously. This new systematic review and meta analysis. The short answer is we're limited here in the information. Now I want to show you this. Now there was 301 studies that went into this that were reviewed. Okay, 301 studies with three studies ultimately included in the meta analysis. Are you kidding me? 301. Because it's very difficult to evaluate a study on mastalgia because there's so many things that go into that breast size, age of the patient, a family history, fibrocystic breast condition, which is already very common in and of itself. So out of 301 studies, they ended up with three for the Meta analysis. So very limited here in the numbers and also very limited here by the high degree of heterogenicity among these studies. So this is an issue here. This, that's why the authors say, and I'm just going to just throw it out there now, the result, now we didn't really find any benefit. It doesn't really seem to help. But quote, the overall quality of this is pretty low. End quote. Now I don't want, I got to set this up correctly. Even though the evidence seems to be low that it helps, there doesn't really seem to be any big harm in taking B6 unless the patient for some reason is taking like mega doses, which is unusual and we should never endorse that anyway. So I mean, it might, could, but the evidence right now doesn't seem great. Now if you're thinking, well, why would B6 anyway? Why would that have to do with breast pain or with breast inflammation? And the short answer is we gotta stop thinking of B6 pyridoxine as just this little vitamin. It's active in a lot of things. B6, guys, has been studied in carpal tunnel syndrome, again with quasi beneficial effects in diabetic neuropathy because of the neuronal transmission and the inflammatory properties. It's been actually looked at for pms, of course, depression. All of these things have been looked at for migraine headache with, with some studies saying yes, others saying not so much. But no study, and be clear, no study says that taking B6 in general is, in general is harmful. Okay, so I'm all for it. I've taken it in the recommended amount. I think it's fine. But does it actually help? It's unclear. Okay, so B6, vitamin B6 is tied to a lot of issues here. It helps limit pro inflammatory cytokines. It actually can help in the regulation of neurotransmitters, guys like GABA and even serotonin, it helps with melatonin secretion. B6 does a lot of things. Okay, so when you ask what does B6 do? The answer is it do a lot. Okay, do a lot. From anti inflammatory stuff to neurotransmitter actions. Of course, B6 helps with nausea, vomiting in pregnancy because of these neurochemical transitions and resetting of the kind of the chemoreceptor in the brain. It works on a lot of different mechanisms. So potentially it could help with breast pain. Once again, I'm not against it. It's just based on this very limited data from this very recent systematic review and meta analysis. It just doesn't really seem to have that strength. But it could be because the studies are very hard to interpret. So remember, as I told you, I'm trying to just tell you what you need to do. So if a patient asks you about B6 and breast pain, the answer is, hey, if you want to take it and you don't have any weird contraindication, which it really shouldn't be, and you take it as prescribed, in addition to potentially a warm fitting bra, like a warm, they say warm, a tight fitting bra, like a sports bra. And after you do a full evaluation, I have no problem with B6. It might help, but the evidence that we have right now is very limited. Okay, so having very limited evidence is different than something not working because it may work. We just don't have that evidence to say that. But it is extremely limited here in the data. If you're asking about dosing, well, it really depends on who you read. In general, vitamin B6 has been recommended from as low as 40, that's 4,0 milligrams per day to as high as 200 milligrams per day. And now remember, the issue is you can take too much B6 and it does weird things to your nerves. So don't do that. I in general kind of split the difference and say no more than about 100 milligrams per day of pyridoxium. I think that's fine. I think that's reasonable. And if it's going to do something, then potentially it could do something with that dose. Now even though the data is limited for mastalgia, taking B6 can help with other things. Just in general, it's just good for overall micronutrient and vitamin homeostasis. I have no problem with taking B6 alone. I don't like it necessarily in multivitamin although a multivitamin is fine if there's B6 in it. Just be careful if they choose other additional B6 because they can get into high varied levels there if they're already taking a baseline B6amount in multivitamin. So if you want to take B6, just take B6. You want to take multivitamin, do that, but know how much B6 is in that to stay in your appropriate range. So in general it possibly could help, but as of right now, just as it is for depression and pms, not hurtful and potentially could help, but this goes to the point of limited evidence and this just came out published on September 2, 2025. So podcast family, as we get ready to leave this rather brief episode. I guess it's brief. Let me just give you a little excerpt here from this study, from this discussion, and then we'll call it a day. So is it bad to use this? No. As long as you don't get megavitamin ptosis of B6 from this, you know, take it up to about max 100 milligrams, no more than 200 milligrams a day, that should be fine. If it doesn't help, then it doesn't help. But. But here's why this data is very difficult to interpret. Quote Considering the key role of oxidation and inflammation in the presentation and expansion of mastalgia, it is believed that the use of vitamin supplements, especially those involved in this review, can successfully decrease the pain severity related to this phenomenon. Okay, fine, but. Well, here it is. However, that's not good. However, it seems that the dosage of vitamins, duration of administration and as well as the use of concomitantly used other standard therapies are all potential confounding variables of these regimens. And thus examining different regimens containing vitamin B6 is difficult to do, end quote. So short of it is too many confounding variables. A lot of these studies didn't have just vitamin B6 alone, because some of them used, of course, a tight bra, potentially decreased caffeine consumption, even though even that's widely recommended. It's unclear if that's actually evidence based or not, because in some women it helps, in others it doesn't. But why not? We know it. It reducing caffeine consumption can help and it potentially can hurt if they don't. So in general it's given as a recommendation, even though we really don't have that evidence either. So mastalgia kind of sucks, but at least there's reassurance as part of that, once the thorough history and physical and possibly imaging workup has been done that that we're going to get through this together. Podcast Family that brings us to a wrap. I think we've done what we're supposed to do as we highlight this systematic review and meta analysis from BMC Women's Health. And now that we've done all that on a weird week and today, again, as point of reference, September 11, 2025, we have not forgotten the tragedy of 24 years ago. Podcast Family, we're thankful for you, we care for you and we'll see you in the next episode of the no Spin Podcast, otherwise known as Clinical Pearls. Michael, let's take it home. Podcast Family, we're thankful for all of the support, support that you've given us throughout the years. This has been the Ob GYN no Spin podcast. We'll see you on the next episode.