How best to address breast pain in nonbreastfeeding women
This guide—with accompanying algorithms—will help you to streamline your approach to breast pain in a patient who isn’t breastfeeding.
PRACTICE RECOMMENDATIONS
› Instruct patients to maintain a pain diary, which, along with a careful history and physical examination, helps to determine the cause of breast pain and the type of evaluation needed. C
› Treat cyclic, bilateral breast pain with chasteberry and flaxseed. B
› Consider short-term treatment with danazol or tamoxifen for women with severe pain. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Chasteberry. One RCT demonstrated that Vitex agnus-castus, a chasteberry fruit extract, produced significant and clinically meaningful improvement in visual analogue pain scores for mastalgia, with few adverse effects.29 Another RCT assessing breast fullness as part of the premenstrual syndrome showed significant improvement in breast discomfort for women treated with Vitex agnus-castus.30
Evening primrose oil (EPO). In at least one small study, EPO was effective in controlling breast pain.28 A more recent meta-analysis of all of the EPO trials including gamolenic acid (the active ingredient of EPO) showed no significant difference in mastalgia compared with placebo.31
Pharmacologic Tx options: Start with NSAIDs
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended as a first-line treatment for mastalgia and are likely effective for some women; however, there is currently insufficient evidence that oral NSAIDs (or acetaminophen) improve pain (TABLE 432-37; FIGURE 25,13,17). Nevertheless, the potential benefits are thought to outweigh the risk of adverse effects in most patients. A small RCT did demonstrate that topical diclofenac was effective in patients with cyclic and noncyclic mastalgia.38
SSRIs. A meta-analysis of 10 double-blind RCTs of SSRIs used in women with premenstrual symptoms, including 4 studies that specifically included physical symptoms such as breast pain, showed SSRIs to be more effective than placebo at relieving breast pain.35
Progesterones. Several studies have found topical, oral, and injected progesterone ineffective at reducing breast pain.8,36,39 However, one RCT did show topical vaginal micronized progesterone used in the luteal phase to be effective in reducing breast pain by at least 50%.36
Continue to: Oral contraceptives
