How best to address breast pain in nonbreastfeeding women

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Applied Evidence

How best to address breast pain in nonbreastfeeding women

J Fam Pract. 2019 September;68(7):379-382,384-388

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References

1. Salzman B, Fleegle S, Tully AS. Common breast problems. Am Fam Physician. 2012;86:343-349.

2. Chetlen AL, Kapoor MM, Watts MR. Mastalgia: imaging work-up appropriateness. Acad Radiol. 2017;24:345-349.

3. Expert Panel on Breast Imaging: Jokich PM, Bailey L, D’Orsi C, et al. ACR Appropriateness Criteria Breast Pain. J Am Coll Radiol. 2017;14:S25-S33.

4. Arslan M, Küçükerdem HS, Can H, et al. Retrospective analysis of women with only mastalgia. J Breast Health. 2016;12:151-154.

5. Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clin Proc. 2004;79:353-372.

6. Mansel RE. ABC of breast diseases. Breast pain. BMJ. 1994;309:866-868.

7. Ader DN, South-Paul J, Adera T, et al. Cyclical mastalgia: prevalence and associated health and behavioral factors. J Psychosom Obstet Gynaecol. 2001;22:71-76.

8. Iddon J, Dixon JM. Mastalgia. BMJ. 2013;347:f3288.

9. Eren T, Aslan A, Ozemir IA, et al. Factors effecting mastalgia. Breast Care (Basel). 2016;11:188-193.

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12. Michigan Medicine. University of Michigan. Common breast problems: guidelines for clinical care. https://www.med.umich.edu/1info/FHP/practiceguides/breast/breast.pdf. Updated June 2013. Accessed September 3, 2019.

13. Millet AV, Dirbas FM. Clinical management of breast pain: a review. Obstet Gynecol Surv. 2002;57:451-461.

14. American College of Radiology. ACR Appropriateness Criteria: Breast Pain. https://acsearch.acr.org/docs/3091546/Narrative/. Revised 2018. Accessed July 2, 2019.

15. American College of Radiology. ACR Appropriateness Criteria: Palpable Breast Masses. https://acsearch.acr.org/docs/69495/Narrative/. Revised 2016. Accessed September 3, 2019.

16. Loving VA, DeMartini WB, Eby PR, et al. Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 2010;195:1472-1477.

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20. Wilson JP, Massoll N, Marshall J, et al. Idiopathic granulomatous mastitis: in search of a therapeutic paradigm. Am Surg. 2007;73:798-802.

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22. Olawaiye A, Withiam-Leitch M, Danakas G, et al. Mastalgia: a review of management. J Reprod Med. 2005;50:933-939.

23. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Gynecology. Practice Bulletin No. 164: Diagnosis and management of benign breast disorders. Obstet Gynecol. 2016;127:e141-e156.

24. Mirghafourvand M, Mohammad-Alizadeh-Charandabi S, Ahmadpour P, et al. Effects of Vitex agnus and flaxseed on cyclic mastalgia: a randomized controlled trial. Complement Ther Med. 2016;24:90-95.

25. Vaziri F, Zamani Lari M, Sansami Dehaghani A, et al. Comparing the effects of dietary flaxseed and omega-3 fatty acids supplement on cyclical mastalgia in Iranian women: a randomized clinical trial. Int J Fam Med. 2014;2014:174532.

26. Sohrabi N, Kashanian M, Ghafoori SS, et al. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: “a pilot trial”. Complement Ther Med. 2013;21:141-146.

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28. Pruthi S, Wahner-Roedler DL, Torkelson CJ, et al. Vitamin E and evening primrose oil for management of cyclical mastalgia: a randomized pilot study. Altern Med Rev. 2010;15:59-67.

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Treatment: When reassurance isn’t enough

Nonrandomized studies suggest that reassurance that mastalgia is benign is enough to treat up to 70% of women.^8,22,23 Cyclic breast pain is usually treated symptomatically since the likelihood of breast cancer is extremely low in absence of clinical breast examination abnormalities.² Because treatment for cyclic and noncyclic mastalgia overlaps, available treatments are discussed together on the following pages.

Lifestyle factors associated with breast pain include stress, caffeine consumption, smoking, and having breastfed 3 or more children (P < .05).⁹ Although restriction of caffeine, fat, and salt intake may be attempted to address breast pain, no randomized control trials (RCTs) of these interventions have demonstrated effectiveness in reducing mastalgia.^8,10

Breast imaging is critical in patients with a palpable mass or focal pain but is not necessary in patients with cyclic pain.

Although not supported by RCTs, first-line treatment of mastalgia includes a recommendation that women, particularly those with large, heavy breasts, wear a well-fitted and supportive bra.^8,10

Complementary and alternative medicine treatments for mastalgia

A number of complementary and alternative medicine treatments have demonstrated benefit in treating mastalgia and are often tried before pharmacologic agents (TABLE 3^24-28). Keep in mind, though, that these therapies are not regulated by the US Food and Drug Administration (FDA). So it’s wise to review particular products with your patient before she buys them (or ask her to bring in any bottles of product for you to review).

Flaxseed, omega-3 fatty acids, and soy milk. Flaxseed, a source of phytoestrogens and omega-3 fatty acids, has been shown to reduce cyclic breast pain in 2 small RCTs.^24,25 Breast pain scores were significantly lower for patients ingesting 25 g/d of flaxseed powder compared with placebo.^24,25 Omega-3 fatty acids were also more effective than placebo for relief of cyclic breast pain in 2 small RCTs.^25,26 Another small RCT demonstrated that women who drank soy milk had a nonsignificant improvement in breast pain compared with those who drank cow’s milk.²⁷

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