What are the management options for premenstrual mastalgia?

Management of Premenstrual Mastalgia

For premenstrual mastalgia, start with reassurance and supportive measures (well-fitted bra, NSAIDs), which resolve symptoms in 86% of mild cases and 52% of severe cases; if symptoms persist after 3 months, escalate to luteal phase-only danazol (200 mg daily from cycle day 5-24), which demonstrates superior efficacy for breast pain specifically. 1, 2

Initial Non-Pharmacological Management

Reassurance is the cornerstone of treatment and should be provided first, as breast pain alone rarely indicates cancer and this knowledge alone resolves symptoms in the majority of patients. 1

First-line supportive measures include:

• Wearing a well-fitted supportive bra, especially during exercise, which can effectively alleviate symptoms in women with cyclical mastalgia. 1, 3
• Application of ice packs or heating pads for comfort and symptom relief. 1
• Regular physical exercise to help reduce breast pain intensity. 1

Important caveat: Despite widespread belief, there is no convincing scientific evidence that eliminating or reducing caffeine intake significantly affects breast pain, so this should not be emphasized as a treatment strategy. 1

First-Line Pharmacological Treatment

Over-the-counter NSAIDs such as ibuprofen (600-800 mg every 6-8 hours with food) or naproxen (440-550 mg every 12 hours) provide effective symptomatic relief and should be the first pharmacological option. 1, 3

• Ibuprofen is safe and effective even during lactation if needed. 3
• Naproxen is widely used for pain management including postpartum settings. 3
• Paracetamol (acetaminophen) is also safe with minimal infant exposure if breastfeeding. 3

Second-Line Pharmacological Treatment for Severe or Refractory Cases

For severe premenstrual mastalgia unresponsive to conservative measures, luteal phase-only danazol (200 mg daily from cycle day 5-24) is highly effective specifically for breast pain. 2

The evidence supporting this approach:

• A randomized controlled trial demonstrated significant improvement in mastalgia visual analog scores in months 1 (P=0.03), 2 (P=0.004), and 3 (P=0.01) compared to placebo. 2
• This regimen is associated with minimal side effects, unlike continuous danazol therapy, making it more tolerable for patients. 2
• The luteal phase-only approach avoids many of the androgenic side effects seen with continuous danazol use. 2

Alternative hormonal option: Tamoxifen (10 mg daily from cycle day 5-24) showed 89% of patients free from symptoms at the end of treatment, with 53% remaining symptom-free 12 months after stopping therapy. 4 However, this is less commonly used in current practice given danazol's favorable side effect profile when used cyclically.

Complementary and Alternative Medicine Options

Vitex agnus-castus (VAC) 20-40 mg/day for 3 months is a safe and effective alternative treatment option with moderate effect size (SMD: 0.67,95% CI: 0.5-0.85) favoring VAC over placebo. 5

• VAC works through dopaminergic activity and may address latent hyperprolactinemia associated with cyclical mastalgia. 5
• It is noninferior to pharmaceutical therapies including dopamine agonists and NSAIDs. 5
• Associated only with mild and reversible adverse events. 5

Acupressure techniques can be offered as adjunctive therapy:

• Bilateral stimulation of Large Intestine-4 (LI4) acupressure point during symptomatic periods. 6
• Spleen-6 (SP6) stimulation, which is effective for primary dysmenorrhea and may help with premenstrual breast pain. 6
• Patients can perform self-stimulation at home to reduce symptoms. 6

Treatment Algorithm

1. Months 1-3: Reassurance + well-fitted supportive bra + NSAIDs (ibuprofen or naproxen) as needed
2. If inadequate response after 3 months: Add luteal phase-only danazol 200 mg daily (cycle day 5-24) OR Vitex agnus-castus 20-40 mg daily
3. If still inadequate response: Consider tamoxifen 10 mg daily (cycle day 5-24) or referral to specialist

Critical Pitfalls to Avoid

• Do not dismiss breast pain without proper evaluation, as some cancers (especially invasive lobular and anaplastic carcinomas) can present with pain. 1
• Do not order unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal, as this leads to patient anxiety without clinical benefit. 1
• For smokers with periductal inflammation and burning pain behind the nipple, advise smoking cessation, as this condition is often associated with heavy smoking. 1
• Avoid aspirin in analgesic doses during lactation if the patient is breastfeeding. 3
• If symptoms don't improve after 3 months of any specific therapy, reevaluate the diagnosis rather than continuing ineffective treatment. 7