What are the treatment modalities for significant breast pain with normal mammogram (mammography) and ultrasound results?

From the Guidelines

For significant breast pain with normal mammogram and ultrasound results, I recommend starting with non-pharmacological approaches, including wearing a supportive bra, applying warm or cold compresses, and reducing caffeine intake, as these methods can help alleviate symptoms and improve quality of life. According to the NCCN guidelines 1, the risk of cancer in women presenting with breast pain as the only symptom is low, and reassurance alone has shown to help resolve the symptom in a significant percentage of women.

Non-Pharmacological Approaches

• Wearing a supportive bra to reduce breast movement and alleviate strain on the breast tissue
• Applying warm or cold compresses to help relax the muscles and reduce pain
• Reducing caffeine intake, as it can exacerbate breast pain in some women

First-Line Medication Therapy

• Over-the-counter NSAIDs, such as ibuprofen (400-600mg three times daily) or naproxen (250-500mg twice daily) for 1-2 weeks, to reduce inflammation and alleviate pain
• Acetaminophen (650-1000mg every 6 hours, not exceeding 4000mg daily) if pain persists, to provide additional pain relief

Cyclical Breast Pain Management

• Evening primrose oil (1000mg three times daily for at least 6 months) may help alleviate cyclical breast pain related to hormonal fluctuations, as suggested by the American College of Radiology Appropriateness Criteria 1
• Hormonal contraceptives may also help regulate cyclical pain by stabilizing hormonal influences on breast tissue

More Severe Cases

• Topical diclofenac gel applied to painful areas 3-4 times daily, or oral hormonal treatments such as tamoxifen (10mg daily) or danazol (100-200mg daily) for 3-6 months, may be considered for more severe cases, although these options carry more significant side effects
• Referral to a breast specialist is warranted if pain remains severe despite these interventions, to explore additional options or reconsider the diagnosis, as recommended by the NCCN guidelines 1 and the American College of Radiology Appropriateness Criteria 1.

From the Research

Treatment Modalities for Significant Breast Pain

• The management of breast pain is often supportive, as most breast pain resolves spontaneously 2
• If pain persists, imaging and management should follow a step-wise approach 2
• Conservative measures are the first line of treatment, and if these fail, second-line therapy includes topical nonsteroidal anti-inflammatory drugs 2
• For severe and resistant breast pain, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications 2

Imaging Evaluation for Breast Pain

• Cyclical breast pain does not require an imaging work-up 2
• The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older 2
• For women with focal breast pain, targeted ultrasound may be deferred in women 40 and older with no other clinical findings and a negative mammogram 3

Breast Pain and Mammography

• Women treated conservatively for breast cancer experience significantly greater pain during mammography of their treated breast 4
• Breast pain is not a sign of breast cancer, and the presence of cancer in patients with breast pain is comparable to the concurrent cancer detection rate in the screening population 5
• Patients presenting with coexisting breast lumps and preexisting breast pain, and those diagnosed with inflammatory conditions of the breast and fibrocystic changes, experience more pain during mammography 6