What are the treatment options for mastodynia (breast pain)?

Treatment Options for Mastodynia (Breast Pain)

First-line treatment for mastodynia should focus on reassurance and non-pharmacological approaches, as these resolve symptoms in 86% of mild cases and 52% of severe cases without medication. 1

Types of Breast Pain

• Cyclical mastalgia (70% of cases): Related to hormonal fluctuations, waxes and wanes with menstrual cycle, typically bilateral or unilateral with diffuse pain 2, 1
• Noncyclical mastalgia (25% of cases): Usually unilateral, more focal, often located in the subareolar area or lower inner breast, predominantly inflammatory rather than hormonal 2, 1
• Extramammary pain (10-15% of cases): Includes musculoskeletal conditions, nerve entrapment, and referred pain from cardiac, pulmonary, or gastrointestinal sources 1

Initial Management Approach

Non-pharmacological Interventions

• Reassurance that breast pain alone rarely indicates cancer (crucial first step) 1
• Wearing a well-fitted supportive bra, especially during exercise and for women with large breasts 1
• Application of ice packs or heating pads for comfort 1
• Regular physical exercise 1

Lifestyle Modifications

• Despite widespread belief, there is no convincing scientific evidence that eliminating or reducing caffeine intake significantly affects breast pain 2
• Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief 1

Pharmacological Treatment

For the 15% of patients with severe pain that affects their lifestyle and warrants drug therapy after non-pharmacological approaches have failed 3:

First-line Pharmacological Therapy

• Evening primrose oil (gammalinolenic acid) - can provide clinically useful improvement in 92% of patients with cyclical and 64% with noncyclical mastalgia 3

Second-line Pharmacological Options

• Danazol - commonly prescribed by 75% of consultants in the UK for resistant cases 4
• Bromocriptine - used by 15% of consultants for resistant cases 4

Third-line Options (for severe recurrent or refractory cases)

• Tamoxifen - effective but short and long-term adverse effects preclude its use as first-line agent 3
• Goserelin or testosterone - reserved for refractory cases due to side effect profiles 3

Treatment Based on Type of Breast Pain

For Cyclical Mastalgia

• Hormonal treatments are more effective 2
• Consider modifying or stopping oral contraception or adjusting hormone replacement therapy if applicable 5
• Evening primrose oil supplements as first-line pharmacological treatment 3

For Noncyclical Mastalgia

• Identify and treat underlying pathology if present 5
• Hormonal treatments generally less effective than for cyclical pain 1
• For chest wall pain: steroidal and local anesthetic injections or NSAIDs can provide symptomatic relief 3
• For smokers with periductal inflammation and burning pain behind the nipple, smoking cessation should be advised 2

Common Pitfalls to Avoid

• Dismissing breast pain without proper evaluation, as some cancers can present with pain 1
• Ordering unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal 1
• Failing to consider extramammary causes when breast exam and imaging are normal 1
• Overlooking that most cases (85%) can be managed with reassurance and non-pharmacological approaches 3

Special Considerations

• For pain during pregnancy or breastfeeding, reassurance is key as it is usually self-limiting 1
• Prognosis varies: cyclical breast pain often responds to hormonal changes, while noncyclical breast pain may last only 1-2 years 4
• Approximately 14-20% of patients with cyclical pain have spontaneous resolution within 3 months, though at least 60% of cases recur within 2 years 2