What are the treatment options for mastodynia?

Treatment Options for Mastodynia

The first-line treatment for mastodynia includes non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, which is considered safe and effective for pain relief, even during lactation. 1

Types of Mastodynia

• Cyclical mastodynia: Related to hormonal fluctuations during menstrual cycle, typically affecting women in their third decade of life 2
• Non-cyclical mastodynia: More inflammatory in nature, usually unilateral and focal, commonly affecting women in their fourth decade 2

First-Line Treatments

Non-Pharmacological Approaches

• Avoidance of known triggers of pain 2
• Well-fitted supportive bras, particularly during exercise 2

Pharmacological Options

• NSAIDs:
  • Ibuprofen: Safe during lactation and effective for pain relief 1
  • Diclofenac: Detected in small amounts in breast milk but considered safe during lactation 1
  • Naproxen: Widely used for pain management, including postpartum 1
  • Paracetamol (acetaminophen): Safe during lactation with minimal infant exposure 1

Second-Line Treatments

• Evening primrose oil (containing gammalinolenic acid): Recommended as first-line therapy for persistent cases, with clinically useful improvement in 92% of patients with cyclical mastodynia 3
• Danazol: Effective for recurrent cyclical mastodynia with significant reduction in pain compared to placebo 4
• Bromocriptine: Prolactin inhibitor shown to provide complete relief in approximately two-thirds of patients with mastodynia 5

Third-Line Treatments (For Severe, Refractory Cases)

• Tamoxifen: Reserved for severe recurrent or refractory cases due to potential adverse effects 3
• Goserelin: Used in severe cases but limited by short and long-term side effects 3
• Testosterone: Considered for refractory cases but with significant side effect profile 3

Treatment Algorithm Based on Type of Mastodynia

For Cyclical Mastodynia:

1. Start with NSAIDs (ibuprofen, diclofenac) 1
2. If inadequate response after 2-3 cycles, add evening primrose oil 3
3. For persistent symptoms, consider danazol or bromocriptine 4, 5
4. For severe refractory cases, consider tamoxifen or goserelin under specialist supervision 3

For Non-Cyclical Mastodynia:

1. Identify and treat underlying cause if possible 6
2. NSAIDs for symptomatic relief 1
3. For chest wall pain, consider local anesthetic injections 3
4. Response rate to hormonal therapies is lower than for cyclical mastodynia (approximately 64%) 3

Special Considerations

• Avoid aspirin in analgesic doses during lactation 1
• Use codeine with caution due to genetic variability in metabolism affecting breast milk levels 1
• Oxicodone carries higher risk of infant sedation compared to other medications 1
• For pregnant or lactating women, ibuprofen and paracetamol are the safest options 1

Treatment Efficacy

• Approximately 85% of patients can be managed with reassurance and simple measures without specific drug therapy 3
• Only 15% of patients have pain severe enough to warrant pharmacological intervention 3
• Success rates with appropriate treatment: 92% for cyclical mastodynia and 64% for non-cyclical mastodynia 3