Approach
Symptom control is the mainstay of treatment. Treatment is based on patient symptoms and physical findings.
Mastalgia
For patients who present with breast pain, the first-line options are reassurance, lifestyle changes including the avoidance of caffeine-containing food and beverages, use of a supportive bra, and modification of hormone replacement therapy regimen (in postmenopausal women). Nonnarcotic analgesics (e.g., acetaminophen, aspirin, ibuprofen) may be used adjunctively if required.
It has been proposed that a deficiency in prostaglandin E, from a deficiency in its precursor gamma-linolenic acid (GLA), may make breast tissue more sensitive to the normal elevation in prolactin during the luteal phase of the menstrual cycle.[27] GLA is the active component of evening primrose oil. Despite evidence for its lack of efficacy, it may be appropriate to add evening primrose oil to initial supportive measures if pain persists despite treatment and advice, or has already been severe or prolonged by time of initial presentation. A trial of 3 to 6 months is necessary to observe a definitive effect.[28]
If breast pain is severe, has persisted for more than 6 months, and significantly interferes with daily activities, hormonal therapy with tamoxifen, bromocriptine, or danazol can be considered, whether pain is cyclic or noncyclic.[29][30][31] Due to the recurrent nature and long duration of these symptoms, several months of therapy may be indicated.[13][32]
Flaxseed and topical nonsteroidal anti-inflammatory drug (NSAID) gels, such as diclofenac, are considered useful by the Society of Obstetricians and Gynaecologists of Canada (SOGC) for the treatment of mastalgia.[33] Evidence for efficacy of flaxseed is lacking, and while some data support the use of topical NSAIDs, neither treatment is routinely recommended.[34] Vitamin E, soy, and chasteberry extract (vitex agnus-castus) have all been studied for treatment of cyclic mastalgia; however, the evidence supporting their use is limited.[35]
Breast cysts
Aspiration of symptomatic breast cysts is recommended. Repeat aspiration or excision of the cyst may be indicated in cases of recurrent cysts.[36]Non-painful fluid-filled breast cysts (confirmed as simple cyst with an ultrasound) do not need to be drained unless bothersome to the patient or there are other concerns. [37]
Breast mass
Patients with a breast mass require accurate diagnosis to exclude breast cancer or identify a high-risk histology. If biopsy reveals fibrocystic breast without atypia, no further therapy is necessary. If there is evidence of atypical ductal hyperplasia, removal of the entire lesion and consideration of breast cancer risk reduction strategies is advised.[21][38][39]
Nipple discharge
Patients with nonsuspicious nipple discharge require no further intervention. Reassurance and observation are sufficient.
However, patients with any nipple discharge and a palpable accompanying mass or mammographic abnormality should be referred to a surgeon immediately. Specialist consultation must be obtained when suspicious nipple discharge is encountered, even if no palpable mass is present and mammography is normal.[40]
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