What are the treatment options for breast pain?

Treatment Options for Breast Pain

For most women with breast pain, reassurance alone is sufficient—resolving symptoms in 86% with mild pain and 52% with severe pain—making it the most effective first-line intervention. 1

Initial Assessment and Risk Stratification

Before initiating treatment, determine the pain pattern and whether imaging is needed:

• Diffuse or cyclical breast pain: No imaging required regardless of age; proceed directly to symptomatic management 2, 1
• Focal, noncyclical breast pain in women <30 years: Ultrasound may be appropriate for reassurance 2, 1
• Focal, noncyclical breast pain in women 30-39 years: Mammography and ultrasound are equivalent options 2
• Focal, noncyclical breast pain in women ≥40 years: Mammography (with or without tomosynthesis) plus ultrasound 2

The cancer risk with breast pain alone is extremely low (0-3%), and imaging primarily serves to provide reassurance rather than detect malignancy 2, 1, 3

Stepwise Treatment Algorithm

First-Line: Conservative Non-Pharmacologic Measures

Start here for all patients with breast pain, as 85% will not require medication beyond reassurance: 4

• Reassurance: Explicitly inform patients that breast pain alone rarely indicates cancer 1, 5
• Well-fitted supportive bra: Proper breast support throughout the day 1, 5
• Topical comfort measures: Ice packs or heating pads as preferred 1, 5
• Over-the-counter analgesics: NSAIDs (ibuprofen, naproxen) or acetaminophen as needed 1, 5
• Regular physical exercise: May help reduce cyclical mastalgia 1

These conservative measures are effective for mild to moderate pain and should be trialed for at least 2-3 months before escalating therapy 5, 6

Second-Line: Topical NSAIDs

For persistent pain after conservative measures fail, topical NSAIDs are the preferred next step: 6

• Applied directly to the painful breast area
• Lower systemic side effects compared to oral medications
• Particularly useful for localized noncyclical pain 6

Third-Line: Pharmacologic Therapy (For Severe, Refractory Pain Only)

Reserve these medications for the 15% of patients with severe pain significantly impacting quality of life, as they carry substantial side effects: 4

Evidence-Based Pharmacologic Options:

Danazol 3, 4

• Only FDA-approved medication specifically for mastalgia
• Effective in 70-80% of patients with cyclical mastalgia
• Major limitation: Androgenic side effects (weight gain, acne, voice deepening, menstrual irregularities)
• Use lowest effective dose (100-200 mg daily) for shortest duration

Tamoxifen 3, 4

• Effective for both cyclical and noncyclical mastalgia
• Lower doses (10 mg daily) often sufficient
• Major limitation: Hot flashes, increased thromboembolism risk, endometrial changes
• Requires careful patient selection and counseling

Bromocriptine 3, 4

• Dopamine agonist that suppresses prolactin
• Effective primarily for cyclical mastalgia
• Major limitation: Nausea, dizziness, headache (often limits tolerability)
• Less commonly used due to side effect profile

Evening primrose oil (Gamolenic acid/EF-12) 4

• Historically used as first-line pharmacologic therapy
• Contains gamma-linolenic acid
• Evidence of efficacy is mixed; some studies show benefit for cyclical mastalgia 4
• Well-tolerated with minimal side effects

Treatment Success Rates

When using the stepwise approach with pharmacologic therapy reserved for severe cases: 4

• 92% of patients with cyclical mastalgia achieve clinically useful improvement
• 64% of patients with noncyclical mastalgia achieve clinically useful improvement

Special Considerations

Extramammary (Chest Wall) Pain

If breast examination and imaging are normal but pain persists, consider non-breast sources: 2

• Costochondritis (Tietze syndrome): Most common musculoskeletal cause 2
• Pectoral muscle strain or spasm 2
• Nerve entrapment: Lateral cutaneous branch of third intercostal nerve 2

Treatment for chest wall pain: 4

• Local injection of corticosteroid plus local anesthetic
• Oral NSAIDs
• Physical therapy for musculoskeletal causes

Duration of Treatment

• Most breast pain is self-limiting and resolves spontaneously within weeks to months 6
• For cyclical mastalgia, symptoms often improve after menopause 3
• Pharmacologic therapy should be time-limited (3-6 months) with reassessment 5

Critical Pitfalls to Avoid

Do not order mammography for routine breast pain in women <40 years: Exposes patients to unnecessary radiation without benefit (ACR rating 1/9 "usually not appropriate") 1, 7

Do not order MRI for breast pain evaluation: No evidence supports its use; leads to unnecessary biopsies of benign findings without improving cancer detection 1, 7

Do not aspirate small cysts found incidentally on ultrasound: These are unlikely to cause pain and aspiration provides no benefit 1, 7

Do not dismiss focal pain with a palpable finding based on negative imaging alone: Up to 10-15% of breast cancers can be mammographically occult; proceed to ultrasound and consider biopsy based on clinical judgment 8

Do not start pharmacologic therapy without adequate trial of conservative measures: The potentially serious adverse effects of hormonal medications (danazol, tamoxifen, bromocriptine) limit their use to selected patients with severe, sustained pain that impacts daily activities 3, 5

When to Reassess or Escalate

Return for re-evaluation if: 7

• Pain becomes persistently focal and noncyclical in a specific location
• A discrete palpable mass develops
• Associated symptoms emerge (bloody nipple discharge, skin dimpling, asymmetric thickening)
• Pain characteristics change significantly