Mastalgia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Medical Therapy

Acute Pharmacotherapies

• Symptomatic Treatment

  • Indicated for severe pain or pain lasting > a few days each month
  • Analgesia: acetaminophen or NSAIDs (nonsteriodal anti-inflammatory drugs)
  • Premenstrual engorgement: thiazide diuretic for several days during premenstrual symptoms
  • Other potentially beneficial treatments

    • Avoidance of caffeine: no efficacy in randomized controlled trials (RCTs), but some patients report relief
    • Vitamin E: 400 IU bid beneficial in some studies but not others (2 negative RCTs)
    • Primrose oil (linoleic acid): 1.5-3 g qd effective in 40-60%; may take 3 months for results
    • Danazol

      • Only FDA approved therapy for breast pain
      • Inhibits luteinizing hormone/follicle stimulating hormone (LH/FSH) secretion (decreased exocrine secretion); blocks exocrine effects on breast
      • 100-200 mg qd reduces pain and nodularity in patients with fibrocystic disease
      • Response rate 50-75% for both cyclic and noncyclic breast pain
      • Significant side effects in 20% (weight gain, acne, irregular menses, hirsutism)

    • Tamoxifen: 10 mg bid reduces pain in ~70% via antiestrogen effect
    • Bromocriptine: 1.25-5 mg qd may reduce pain via inhibition of prolactin secretion; +/- data
    • Oral contraceptive pills (OCPs): can reduce fibrocystic changes via progestin component; efficacy for pain uncertain
    • Reduction in hormone replacement therapy (HRT) dose: for postmenopausal women, lower E dose may reduce pain

Treatments for cyclical breast pain

Specific treatment for cyclical breast pain will be determined by your physician(s) based on:

• your overall health and medical history
• extent of the condition
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the condition

Treatments vary significantly and may include the following:

• caffeine avoidance
• a low-fat diet
• evening primrose oil
• vitamin E
• any over-the-counter pain-reliever

In some cases, various supplemental hormones and hormone blockers are also prescribed. These may include:

• birth control pills
• Bromocriptin (which blocks prolactin in the hypothalamus)
• Danazol, a male hormone
• thyroid hormones
• Tamoxifen, an estrogen blocker

Supplemental hormones and hormone blockers may have side effects. In addition, the risks and benefits of such treatment should be carefully discussed with your physician.

Treatments for non-cyclical breast pain

Determining the appropriate treatment for noncyclical breast pain is more difficult, not only because it is hard to pinpoint where the pain is coming from, but also because the pain is not hormonal. Specific treatment for noncyclical breast pain will be determined by your physician(s) based on:

• your overall health and medical history
• extent of the condition
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the condition

Generally, physicians will perform a physical examination and may order a mammogram. In some cases, a biopsy of the area is also necessary. If it is determined that the pain is caused by a cyst, the cyst will be aspirated. Depending on where the pain originates, treatment may include analgesics, anti-inflammatory drugs, and compresses.

Reassurance

• Pain resolves spontaneously in 60-80% and will not require further therapy in 90% of patients
• Pain, fibrocystic changes, and simple fibroadenomas pose no increase in breast cancer risk
• Pendulous breasts: soft bra with adequate support