What are the treatment options for mastalgia?

Treatment Options for Mastalgia

The most effective treatment approach for mastalgia depends on whether the pain is cyclical or non-cyclical, with 92% of patients with cyclical mastalgia and 64% with non-cyclical mastalgia obtaining relief through appropriate therapy selection. 1

Types of Breast Pain

Cyclical Mastalgia

• Accounts for up to 70% of breast pain cases 2
• Diffuse, bilateral or unilateral pain that waxes and wanes with menstrual cycle
• Most common in women in their 30s
• Hormonal in origin, though no consistent abnormalities in hormone levels have been found
• 14-20% resolve spontaneously within 3 months 2

Non-cyclical Mastalgia

• Accounts for up to 25% of breast pain cases 2
• Usually unilateral and more focal
• More common in women in their 40s
• Often inflammatory rather than hormonal
• Up to 50% resolve spontaneously 2

Extramammary Pain

• 10-15% of "breast pain" cases are actually referred pain 2
• Sources include costochondritis, musculoskeletal conditions, spinal issues, cardiac or pulmonary disease

Diagnostic Approach

1. Characterize the pain pattern:

   • Cyclical vs. non-cyclical
   • Focal vs. diffuse
   • Unilateral vs. bilateral
   • Duration and severity
   • Impact on daily activities 3

2. Imaging recommendations:

   • For focal, unilateral pain in women ≥30: diagnostic mammography with targeted ultrasound
   • For women <30 with focal pain: targeted ultrasound
   • Diffuse, cyclical pain without other findings may not require imaging 3

Treatment Algorithm

First-Line Treatments (for all types of mastalgia)

1. Reassurance and education:

   • Explain benign nature of condition
   • 14-20% resolve spontaneously within 3 months 2

2. Supportive measures:

   • Well-fitted, supportive bra (especially during exercise) 3
   • Local heat or cold application 3
   • NSAIDs (e.g., ibuprofen) for pain relief 4

3. Lifestyle modifications:

   • Low-fat, high-carbohydrate diet 5
   • Regular exercise 3
   • Stress reduction techniques 3

Second-Line Treatments (for persistent pain)

1. For cyclical mastalgia:

   • Evening primrose oil (contains gamma-linolenic acid) - fewer side effects than hormonal options 1
   • Topical NSAIDs 6

2. For non-cyclical mastalgia:

   • Topical NSAIDs 6
   • Local anesthetic injections (for chest wall pain) 7

Third-Line Treatments (for severe, refractory pain)

1. For cyclical mastalgia:

   • Danazol - most effective drug but has side effects; FDA-approved for mastalgia 5, 1
   • Bromocriptine - similar efficacy to evening primrose oil but more side effects 1
   • Tamoxifen - effective but limited by side effects 5

2. For non-cyclical mastalgia:

   • Treatment response is generally poorer than for cyclical mastalgia 5
   • Danazol may be considered for severe cases 1

Special Considerations

Red Flags Requiring Prompt Evaluation

• Pain associated with a palpable mass
• Persistent focal pain
• Signs of infection
• Skin changes
• Nipple discharge 3

Perioperative Management for Patients with Mastocytosis

• For patients with systemic mastocytosis who require surgery:
  • Pre-anesthetic treatment with anxiolytics, antihistamines, and possibly corticosteroids
  • Avoid certain muscle relaxants (atracurium, mivacurium)
  • Use caution with opiates 2

Pregnancy-Related Breast Pain

• Common and usually self-limiting
• Typically managed with conservative measures
• Well-fitted supportive maternity bra recommended 3

Pitfalls to Avoid

1. Assuming all breast pain requires imaging

   • For diffuse, cyclical pain without other findings, additional imaging may not be necessary 3

2. Overlooking extramammary causes

   • Up to 15% of "breast pain" cases are actually referred pain from other sources 2

3. Inadequate reassurance

   • Many women fear breast cancer; proper reassurance after appropriate evaluation can resolve anxiety 8

4. Premature use of hormonal therapies

   • Reserve for severe cases due to side effect profiles 5, 1

5. Missing PCOS as an underlying cause

   • Consider evaluation for PCOS in patients with breast pain, irregular menses, and other suggestive findings 3

By following this structured approach to mastalgia management, clinicians can effectively address breast pain while minimizing unnecessary interventions and optimizing patient outcomes.