Management of Cyclic Mastalgia
For cyclic mastalgia, begin with reassurance and supportive measures (well-fitted bra, NSAIDs), which resolve symptoms in 86% of mild cases and 52% of severe cases, reserving pharmacological therapy only for the 15% with severe pain that affects lifestyle. 1
Initial Assessment and Reassurance
Reassurance that breast pain alone rarely indicates cancer is the cornerstone of management and often sufficient for symptom resolution. 1 The likelihood of breast cancer with cyclical pain alone is extremely low in the absence of other signs or symptoms. 2
Approximately 14-20% of cyclical mastalgia cases resolve spontaneously within 3 months, and most patients experience decreasing severity over time. 2, 1 However, 60% of cases recur within 2 years. 2
Cyclical mastalgia accounts for 70% of breast pain cases, is hormonally driven, typically bilateral or diffuse, and waxes and wanes with the menstrual cycle, being most pronounced in the luteal phase. 2, 1
First-Line Non-Pharmacological Management
Implement these measures before considering any medication:
Wear a well-fitted supportive bra, especially during exercise. 1 For women with large breasts experiencing pain related to breast size, a properly fitted supportive bra is essential. 1
Use over-the-counter NSAIDs (such as ibuprofen) for symptomatic relief. 1 This provides effective pain control without hormonal side effects. 3
Apply ice packs or heating pads for comfort as needed. 1
Encourage regular physical exercise, which can help alleviate symptoms. 1
Lifestyle Modifications: What NOT to Do
Do not recommend caffeine elimination. Despite widespread belief, there is no convincing scientific evidence that eliminating or reducing caffeine intake significantly affects breast pain. 2, 1
For smokers with periductal inflammation and burning pain behind the nipple (present in 25% of noncyclical cases), advise smoking cessation. 1
Complementary Approaches
For patients interested in adjunctive therapy:
Bilateral stimulation of Large Intestine-4 (LI4) acupressure point during symptomatic periods can be offered. 1 Patients can perform self-stimulation at home to reduce symptoms. 1
Spleen-6 (SP6) stimulation is effective for primary dysmenorrhea and may help with premenstrual breast pain. 1
Chamomile extract has demonstrated effectiveness in reducing cyclic mastalgia pain in randomized controlled trials. 4, 5
Herbal medicines including phytoestrogens, Vitex-agnus-castus, flaxseed, and evening primrose may have helpful effects on improving cyclic breast mastalgia. 5
Pharmacological Management for Severe Cases
Reserve hormonal therapy only for the 15% of patients with severe pain that affects lifestyle and has not responded to first-line measures. 6, 7
Danazol is the only FDA-approved hormonal treatment and is best used in cyclic form to limit adverse effects. 6 Using danazol as second-line therapy can achieve clinically useful improvement in 92% of patients with cyclical mastalgia. 7
Bromocriptine and tamoxifen have demonstrated efficacy but side effects limit their extensive use. 6, 7
Goserelin or testosterone may be considered for severe recurrent or refractory mastalgia, but short and long-term adverse effects preclude their use as first-line agents. 7
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. 1 Cyclical breast pain alone does not require imaging beyond routine screening recommendations. 8
Do not fail to consider extramammary causes (costochondritis, muscle strains, nerve entrapment) when breast exam is normal. 1
Expected Outcomes
Women with cyclical mastalgia tend to undergo more frequent breast investigations than women without cyclical breast pain. 2
Some women have increasing severity of symptoms until menopause, at which time about 40% experience resolution. 2
Women who start having cyclical pain before age 20 usually have a prolonged course. 2
Sixty percent of cyclic mastalgia recurs after treatment. 6