Initiate Non-Pharmacologic and/or Pharmacologic Intervention(s)
- The first line of treatment for breast pain is to reassure the patient that she does not have breast cancer. The risk of malignancy following a negative examination has been estimated to be only 0.5%, so reassurance following a negative evaluation is appropriate. Approximately 15% of women choose a treatment intervention to reduce the symptom of pain. During encounters for breast pain, the patient's description of the pain, quantitative assessment of the pain, and decisions regarding reassurance, follow-up, or therapeutic intervention should be documented.
- Few women will require treatment with more than reassurance and well-tolerated medications such as evening primrose oil. For those with severe, refractory breast pain, the significant side effects of some of these medications must be balanced against the potential benefit in ameliorating breast discomfort and pain.
- Non-pharmacologic interventions for breast pain are appropriate for women with breast pain. Although there has been little scientific investigation into the effectiveness of these non-pharmacologic approaches, they are frequently found to improve breast pain symptoms in clinical practice and are of low risk and expense to the patient.
Potential non-pharmacologic therapies include:
Mechanical Support
A professionally fitted support bra, irrespective of age, cup size, or underlying breast disease, has been shown to relieve breast pain even in patients who have not responded to hormonal treatments. Support bras are recommended for exercise. A soft supportive bra during sleep may also improve symptoms.
Lifestyle Changes
Lifestyle changes such as smoking cessation, stress reduction, and improving coping skills may be possible low-risk interventions. Hot packs, cold packs and massage may also relieve symptoms.
The effectiveness of dietary measures is unclear. Studies have demonstrated improvement in breast pain symptoms following dietary reduction of saturated fat. Caffeine reduction or elimination has been found to be helpful by some patients, particularly those who consume large quantities of caffeine. Clinical studies have not shown this to be a consistent outcome.
Pharmacologic Interventions
The decision whether to treat breast pain along with the selection of a particular agent to utilize requires balancing the need for symptom relief against the likelihood of medication side effects. If considering a pharmacologic therapy, consult with a specialist should be considered.
Pharmacologic interventions may include the adjustment of medications that may be contributing to breast pain, such as oral contraceptives, hormone therapy, spironolactone, and others. Eliminating or decreasing the dose of estrogen in an oral contraceptive or hormone regimen is often effective.
Possible pharmacologic therapies include:
Evening Primrose Oil
Evening primrose oil is often used as an initial treatment for breast pain because of its low incidence of side effects and positive response rates for cyclic and non-cyclic pain. It is rich in gamma-linolenic acid and is believed to alter the saturated/polyunsaturated fat balance and decrease sensitivity to hormonal influences. The average dose is 2 x 500 mg soft-gel capsules three times a day for a minimum of three to four months.
Analgesics
Analgesics, such as ibuprofen, 400 mg every 4 to 6 hours, may reduce breast pain.
Danazol
Danazol is the only medication that is labeled by the United States Food and Drug Administration for treatment of breast pain. Danazol is an antigonadotropin with some androgenic activity.
Danazol relieves breast pain in 75% to 92% of women. A typical initial dose of 200 mg per day is recommended with gradual tapering to an alternate day or luteal phase dosing; doses from 100 to 400 mg per day have also been described. Reported side effects are common and include hair loss, acne, decrease in voice pitch, weight gain, irregular menses, and depression. There may also be a possible increase in venous thromboembolic events. Barrier contraception must be utilized. Danazol administered in the luteal phase only has been found to relieve premenstrual breast pain in women with premenstrual syndrome with minimal side effect. It was not effective for other premenstrual syndrome symptoms.
Bromocriptine
One of the few hormonal abnormalities detected in breast pain has been an increase in thyrotropin induced prolactin secretion. Bromocriptine has been shown to decrease serum prolactin levels in normal and hyperprolactinemic women and may decrease dynamic secretion of prolactin in cyclic mastalgia patients. In several European studies, bromocriptine has shown significant decreases in breast pain (approximately 54%), as well as heaviness and tenderness in the breasts. Prolactin levels decline during therapy while estrogen, progesterone, testosterone, and gonadotropin releasing hormones do not significantly change. Side effects are common and dose related, including nausea, vomiting, headache, dizziness, and fatigue. An incremental dosing regimen is used beginning with 1.25 mg at bedtime, gradually increasing until a dose of 2.5 mg twice daily is reached. The beneficial effects lasted three to six months after bromocriptine was discontinued.
Tamoxifen
Tamoxifen is a selective estrogen receptor modulator (SERM) utilized for the prevention and treatment of breast cancer. Response rates have demonstrated tamoxifen to be effective in reducing pain in 75% to 90% women with cyclic and 56% of women with non-cyclic mastalgia in controlled trials. Tamoxifen has significant side effects, with the principle concerns being from thromboembolic disease and endometrial cancer. Additional side effects include hot flashes, nausea, menstrual irregularity, and vaginal dryness or discharge. The 10 mg daily dose of tamoxifen appeared to be as effective as the 20 mg daily dose, with fewer side effects. Tamoxifen, like other hormonal interventions, should be reserved for women with severe mastalgia. Contraception must be utilized.
Other medications that have been found to be effective for the treatment of breast pain include goserelin, gestrinone, buserelin, leuprolide, quinagolide, cabergoline, thyroxine, and topical nonsteroidal anti-inflammatory agents. Medroxyprogesterone has shown variable results in the treatment of breast pain. In general, antibiotics, diuretics, and most vitamins have not been effective in the treatment of breast pain.