What are the latest guidelines for the treatment of mastalgia?

Latest Guidelines in Treatment of Mastalgia

Initial Management: Reassurance as First-Line Therapy

Reassurance alone resolves symptoms in 86% of women with mild mastalgia and 52% with severe cases, making it the most effective first-line intervention before any pharmacological treatment is considered. 1

• The primary goal is to exclude breast cancer through appropriate clinical evaluation, as breast pain alone carries an extremely low malignancy risk (0-3%), and most women require no treatment beyond reassurance. 2, 3
• After proper clinical assessment and exclusion of malignancy, 85% of patients can be managed without specific drug therapy. 4

Classification and Clinical Assessment

Mastalgia must be categorized into three distinct types to guide management:

• Cyclical mastalgia (70% of cases): bilateral or diffuse pain that waxes and wanes with the menstrual cycle, related to hormonal fluctuations. 1
• Noncyclical mastalgia (25% of cases): typically unilateral, focal, often subareolar or lower inner breast location, predominantly inflammatory rather than hormonal. 1
• Extramammary pain (10-15% of cases): includes costochondritis, muscle strains, nerve entrapment, or referred pain from cardiac, pulmonary, or gastrointestinal sources. 1

Key Clinical Features to Assess

• Pain characteristics: cyclical versus noncyclical, focal versus diffuse, duration, and impact on daily activities. 5
• Associated symptoms: palpable mass, asymmetric thickening, nipple discharge, skin changes, or ulceration. 5
• For focal pain, determine exact location and whether it correlates with any palpable findings. 3

Imaging Recommendations

Imaging is not routinely indicated for diffuse, non-focal breast pain with normal clinical examination, as it does not increase cancer detection but increases unnecessary additional testing. 2, 3

• For focal pain in women ≥30 years: diagnostic mammogram with ultrasound is appropriate. 1
• For focal pain in women <30 years: ultrasound alone is appropriate. 1
• For diffuse pain with normal examination: no imaging is indicated regardless of age. 3
• Targeted ultrasound for focal pain is useful primarily for patient reassurance and identifying treatable causes like symptomatic cysts (found in approximately 20% of cases). 2

Non-Pharmacological Management (First-Line)

These interventions should be implemented before any medication:

• Well-fitted supportive bra, especially during exercise and for women with large breasts. 1, 6
• Regular physical exercise to help alleviate symptoms. 1
• Ice packs or heating pads for comfort as needed. 1, 3
• Smoking cessation for patients with periductal inflammation and burning pain behind the nipple. 1
• Despite widespread belief, caffeine elimination has no convincing scientific evidence of benefit and should not be routinely recommended. 1, 6

Pharmacological Management

First-Line Pharmacological Treatment

• Over-the-counter NSAIDs (such as ibuprofen) for symptomatic relief. 1, 6, 7
• Topical NSAIDs are reasonable first-line agents with fewer systemic side effects. 8, 4

Second-Line Treatment (For Severe, Life-Altering Pain)

Only 15% of patients require pharmacological therapy beyond NSAIDs for pain severe enough to affect lifestyle. 8, 4

• Evening primrose oil (gammalinolenic acid/EF-12) as first-line hormonal therapy, with clinically useful improvement in 92% of cyclical mastalgia and 64% of noncyclical mastalgia. 4
• Danazol is the only FDA-approved hormonal treatment for mastalgia, best used in cyclic form to limit adverse effects, but side effects limit extensive use. 8, 4
• Bromocriptine as a second-line hormonal agent, though side effects limit use. 8, 4
• Tamoxifen for severe recurrent or refractory mastalgia, but short and long-term adverse effects preclude first-line use. 8, 4

Important Treatment Considerations

• Noncyclical mastalgia responds poorly to hormonal treatments but resolves spontaneously in up to 50% of cases. 8
• Cyclical mastalgia recurs in 60% of cases after treatment discontinuation. 8
• For simple cysts correlating with focal pain, drainage may provide symptom relief. 1

Complementary Therapies

• Acupuncture has been shown in meta-analyses to improve pain among breast pain sufferers. 1
• Acupressure at Large Intestine-4 (LI4) and Spleen-6 (SP6) points can be offered as adjunctive therapy, with patients able to perform self-stimulation at home. 1

Critical Pitfalls to Avoid

• Do not dismiss focal, persistent breast pain without proper evaluation, as invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia compared to other cancer types. 2, 1
• Avoid ordering MRI for breast pain evaluation, as there is no evidence supporting its use and it leads to unnecessary biopsies of benign findings without improving cancer detection. 3
• Do not pursue unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal, as this increases additional clinical and imaging utilization without increasing cancer detection. 2, 3
• Consider extramammary causes (musculoskeletal, chest wall conditions) when breast exam and imaging are normal. 1, 3
• Do not assume all breast pain is benign—advanced cancers can present with pain as the only symptom, especially if deep in large breasts or with chest-wall invasion. 2

Treatment Algorithm Summary

1. Clinical assessment to classify pain type and exclude malignancy
2. Imaging only if focal pain or concerning clinical findings
3. Reassurance as primary intervention (effective in 85% of cases)
4. Non-pharmacological measures: supportive bra, exercise, ice/heat
5. NSAIDs (oral or topical) if symptoms persist
6. Hormonal therapy (evening primrose oil, then danazol/bromocriptine/tamoxifen) only for severe, life-altering pain in the 15% who fail conservative measures
7. Complementary therapies (acupuncture, acupressure) as adjunctive options