How to decrease breast mastalgia?

Management of Breast Mastalgia

For most women with breast mastalgia, reassurance alone resolves symptoms in 86% of mild cases and 52% of severe cases, with simple non-pharmacological measures being the first-line approach before considering medication. 1

Types of Breast Pain and Evaluation

• Breast pain is typically categorized into cyclical (70% of cases), noncyclical (25% of cases), and extramammary (10-15% of cases) 2
• Cyclical mastalgia is related to hormonal fluctuations, waxes and wanes with menstrual cycle, and is typically bilateral or unilateral with diffuse pain 2
• Noncyclical mastalgia is usually unilateral, more focal, often located in the subareolar area or lower inner breast, and is predominantly inflammatory rather than hormonal in nature 2
• Extramammary causes include musculoskeletal conditions (costochondritis, muscle strains), nerve entrapment, and referred pain from cardiac, pulmonary, or gastrointestinal sources 2

Initial Management Approach

• Reassurance that breast pain alone rarely indicates cancer is crucial and often sufficient for symptom resolution 1, 3
• A pain diary tracking symptoms in relation to menstrual cycle helps determine pain pattern and guide treatment 4, 5
• For mild to moderate pain, start with these non-pharmacological measures:
  • Wearing a well-fitted supportive bra, especially during exercise 1, 4
  • Application of ice packs or heating pads for comfort 1
  • Regular physical exercise (many patients with mastalgia have low physical activity) 2, 4
  • Weight reduction if appropriate 4

Lifestyle Modifications

• Despite widespread belief, there is no convincing scientific evidence that eliminating or reducing caffeine intake significantly affects breast pain 2
• However, some clinicians still recommend caffeine reduction as part of initial management 4, 5
• Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) can provide symptomatic relief 1, 5
• For women with large breasts experiencing pain related to breast size, which may also cause neck, shoulder, and back pain, a properly fitted supportive bra is essential 2

Pharmacological Management for Persistent Pain

• If pain persists despite non-pharmacological measures and is severe enough to affect quality of life (approximately 15% of cases), consider medication 6
• Low-dose tamoxifen (10mg) for 3-6 months has shown effectiveness with fewer side effects compared to other hormonal treatments 4
• Other medications with proven efficacy but higher side-effect profiles include:
  • Danazol (androgenic side effects limit long-term use) 4, 6
  • Bromocriptine (effective but with significant side effects) 3, 6
  • Topical NSAIDs for localized pain 4, 6

Special Considerations

• For noncyclical mastalgia, hormonal treatments are generally less effective 2, 7
• For chest wall pain (extramammary), local anesthetic injections or NSAIDs may provide relief 6
• For pain during pregnancy or breastfeeding, reassurance is key as it is usually self-limiting 2
• For smokers with periductal inflammation and burning pain behind the nipple, smoking cessation should be advised 2

Pitfalls to Avoid

• Dismissing breast pain without proper evaluation, as some cancers (especially invasive lobular and anaplastic carcinomas) can present with pain 2
• Ordering unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal 1
• Prescribing hormonal medications without first trying non-pharmacological approaches 4, 6
• Failing to consider extramammary causes when breast exam and imaging are normal 2, 1