Management of Mastalgia Breast pain is an unlikely symptom of malignancy, and when malignancy is excluded by a clinical breast examination and age-appropriate breast imaging for focal breast pain, the most important treatment is reassurance. Treatments include medications, such as anesthetics, diuretics, bromocriptine, and tamoxifen; vitamins and supplements, such as evening primrose oil; mechanical support with a well-fitting bra; local excision; and decreased fat intake and reduction in methylxanthines from caffeine, tea, and chocolate (108,116). Discontinuation of hormone therapy may be effective in some women. Maintenance of a pain score diary is important to understand the relationship of pain to factors such as the menstrual cycle, activities of daily living, and stress. External support may be effective for breast pain associated with generalized fibrocystic changes and is best treated by avoiding trauma and by wearing (night and day) a brassiere that gives good support and protection (120). One study evaluated resolution of symptoms in 200 women randomized either to a regimen of danazol (200 mg per day) or to mechanical support with a sports brassiere worn for regular activities for 12 weeks. The group using mechanical support had 85% relief of symptoms compared with 58% improvement in the danazol group. Symptoms recurred after discontinuance of treatment with danazol (113). The danazol group experienced drug-related side effects in 42%, which led to discontinuance of the medication in 15%. The breast has minimal structural support and is at significant risk for motion-related displacement resulting in mastalgia. The use of external support to minimize breast motion appears to be effective in reducing breast pain. The application of heat packs or cold packs and light breast massage may reduce symptoms in some individuals (116).
Hormone-modulating drugs, including danazol, bromocriptine, tamoxifen, and Depo-Provera, are recognized drug treatments for mastalgia, although tamoxifen is not approved for this use in the United States (116,121–124). These drugs are associated with significant side effects that limit their general use (116). Withdrawal of birth control pills or hormone therapy may be all that is required to alleviate symptoms (116).
Danazol is a synthetic androgen that suppresses release of pituitary gonadotropin, prevents luteinizing hormone surge, and inhibits ovarian steroid formation. It is the only medication approved by the U.S. Food and Drug Administration for mastalgia (116). The androgenic effects—acne, edema, change in voice, weight gain, headaches, depression, and hirsutism— often are intolerable, and many patients stop taking danazol even when symptoms are improved (122). It can be initiated at doses of 100 to 200 mg twice daily orally for patients with severe pain and then tapered to a lower dose of 100 mg per day (122). A survey of surgeons in Great Britain revealed that 75% prescribed danazol as first-line therapy (108). A study conducted to evaluate the response to administration of danazol revealed a 79% amelioration of symptoms (125). This approach reduced the premenstrual mastalgia and resulted in virtually no side effects.
The use of oral progesterone agents reduces cyclical breast pain (111). Further studies may be warranted to see whether medroxyprogesterone acetate suppresses cyclic mastalgia in reproductive-age women.