What are the treatment options for mastodynia?

Treatment Options for Mastodynia (Breast Pain)

The first-line treatment for mastodynia should be non-opioid analgesics such as acetaminophen/paracetamol or NSAIDs, which can effectively manage mild to moderate breast pain with minimal side effects. 1

Types of Breast Pain

• Breast pain is typically categorized into two main types: cyclical and noncyclical, which require different treatment approaches 2
• Cyclical mastalgia is hormone-related, accounts for up to 70% of breast pain cases, and typically waxes and wanes with the menstrual cycle 2
• Noncyclical mastalgia is predominantly inflammatory, usually unilateral and focal, accounting for up to 25% of breast pain cases 2

First-Line Treatments

Non-Pharmacological Approaches

• Proper breast support with well-fitted bras to reduce pain, particularly for women with larger breasts 2
• Avoiding known triggers that may exacerbate mast cell activation and related pain 2
• Lifestyle modifications including low-fat diet and reduction of caffeine intake 3

Pharmacological Options

• NSAIDs (ibuprofen, diclofenac, naproxen) are effective for inflammatory pain and are considered first-line therapy 1, 4
• Acetaminophen/paracetamol (up to 4000 mg/day) is recommended for mild pain 1
• H1 and H2 antihistamines can help control skin symptoms including pruritus and inflammation that may contribute to breast pain 2

Second-Line Treatments

• For moderate pain unresponsive to first-line treatments, consider adding weak opioids or low doses of strong opioids 1

• Topical treatments:

  • Water-soluble sodium cromolyn cream can be applied 2-4 times daily for associated urticaria or pruritus 2
  • Topical corticosteroids may help reduce inflammation 2

• Hormonal therapies:

  • Danazol has shown marked and sustained decrease in mastodynia in double-blind placebo-controlled studies 5
  • Bromocriptine (a prolactin inhibitor) has demonstrated effectiveness in treating mastodynia, particularly in cases with elevated prolactin levels 6

Third-Line Treatments

• For severe or refractory pain, stronger interventions may be necessary:
  • Strong opioids such as morphine (oral route preferred) or hydromorphone 1
  • Tamoxifen, goserelin, or testosterone may be considered for severe recurrent or refractory mastalgia, though their adverse effects limit their use as first-line agents 3
  • Omalizumab (anti-IgE monoclonal antibody) can be used for management of mast cell activation symptoms insufficiently controlled by other therapies 2

Special Considerations

• For nursing mothers, ibuprofen and paracetamol are considered safe during lactation 4
• Aspirin should be avoided in nursing mothers due to potential risks 4
• For chest wall pain (Tietze syndrome), which can mimic breast pain, local anesthetic injections or NSAIDs are often effective 3
• Schedule analgesics around-the-clock rather than as-needed for consistent pain control in patients with persistent pain 1

Treatment Algorithm

1. Begin with NSAIDs and/or acetaminophen for mild pain 1
2. If pain persists, add antihistamines (H1 and H2 blockers) particularly for cyclical mastalgia 2
3. For moderate pain unresponsive to above measures, consider danazol or bromocriptine 5, 6
4. For severe pain, consider tamoxifen or stronger pain medications under close supervision 3, 1
5. For patients with mastodynia during lactation, prioritize ibuprofen or paracetamol 4

Monitoring and Follow-up

• Approximately 14-20% of cyclical mastalgia cases resolve spontaneously within 3 months 2
• Noncyclical mastalgia tends to be of shorter duration with spontaneous resolution occurring in up to 50% of patients 2
• Monitor for medication side effects, particularly with hormonal therapies 5