Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

mastalgia

1st line – supportive measures

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ONGOING
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mastalgia
1st line – 

supportive measures

Reassurance through an explanation of the effects of menstrual hormonal cycling and estrogen effects is effective in relieving patient anxiety.

Most women find the use of a bra that provides good support to be helpful.

Some women seem to experience less discomfort when restricting caffeine or sodium intake in their diet; however, this has not been scientifically documented. Additionally, dietary supplementation with isoflavones (soy products) and a low fat, high fiber diet have been suggested as helpful for women with mastalgia; however, the evidence for these interventions is weak.[35]

In postmenopausal women receiving hormone replacement therapy (HRT), modification of therapy regimens is a reasonable approach given that the reported rates of HRT-induced breast pain vary for different combinations and preparations compared with placebo.[13][32]

Consider – analgesia

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mastalgia
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

A trial of a non-narcotic analgesic such as acetaminophen, ibuprofen, or aspirin is suggested.

Primary options

acetaminophen: 325-1000 mg every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-800 mg every 4-6 hours when required, maximum 3200 mg/day

OR

aspirin: 325-1000 mg every 4-6 hours when required, maximum 4000 mg/day

Consider – evening primrose oil (EPO)

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mastalgia
Consider – 

evening primrose oil (EPO)

Treatment recommended for SOME patients in selected patient group

Gamma-linolenic acid (GLA) is the active component of EPO.

Placebo-controlled, randomized trials have studied GLA with variable results. A meta-analysis of these trials demonstrates significant heterogeneity among them with overall absence of demonstrable benefit.[41]

Despite the lack of overwhelming data, EPO may be useful for some patients and has limited untoward effects.

May add on 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]

Primary options

evening primrose oil (Oenothera biennis): 1 g/day orally initially for 3 weeks, increase by 1 g/day increments every 3-4 weeks according to response, maximum 3 g/day

2nd line – hormonal therapy

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mastalgia
2nd line – 

hormonal therapy

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.[29][30][31]

Tamoxifen is a competitive inhibitor of estrogen acting as an estrogen agonist/antagonist; bromocriptine is a prolactin inhibitor; and danazol suppresses gonadotropins resulting in androgenic, antiestrogenic, and antiprogestogenic activity.[29][30][31]

Danazol is the only one of these medications approved by the Food and Drug Administration (FDA) for breast pain; however, tamoxifen is more frequently used because it may be more effective and surgeons are more familiar with its use and adverse-effect profile. Danazol is rarely used owing to its masculinizing adverse effects.

These treatments are infrequently used in the US because of unwanted adverse effects.

Primary options

tamoxifen: 10 mg orally once daily on days 15-25 of menstrual cycle for 3 months

Secondary options

bromocriptine: 1.25 mg orally once daily at bedtime initially, increase by 1.25 mg/day increments over 2 weeks, usual dose is 2.5 mg twice daily

Tertiary options

danazol: 100 mg orally twice daily initially, starting on day 2 of menstrual cycle, decrease to 100 mg once daily starting on day 2 of cycle after 2 months, and then decrease to 100 mg once daily on days 14-28 of cycle or 100 mg on alternate days if amenorrheic

Consider – analgesia

Back
ONGOING
|
mastalgia
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

A trial of a nonnarcotic analgesic such as acetaminophen, ibuprofen, or aspirin is suggested.

Primary options

acetaminophen: 325-1000 mg every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400-800 mg every 4-6 hours when required, maximum 3200 mg/day

OR

aspirin: 325-1000 mg every 4-6 hours when required, maximum 4000 mg/day

Plus – cyst aspiration

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mastalgia
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symptomatic breast cyst
Plus – 

cyst aspiration

Treatment recommended for ALL patients in selected patient group

No treatment is required for an asymptomatic patient in whom a simple cyst is discovered on a screening examination or mammography.[36]

Aspiration is performed in most patients with a palpable cyst, especially if it is symptomatic (painful) or if there is concern about the exact diagnosis from the appearance on ultrasound (and aspiration is therefore for diagnostic purposes). The American Society of Breast Surgeons recommends that if an ultrasound confirms that a breast mass is a simple cyst, it does not need to be drained unless it is bothersome to the patient or has concerning features.[37][Figure caption and citation for the preceding image starts]: Ultrasound image of a breast cyst (note the characteristic smooth and sharp margins of the anechoic lesion with posterior acoustic enhancement)Courtesy of Limin Yang, MD, and Justin Boatsman, MD, Department of Radiology, University of Iowa Hospital and Clinics; used with permission [Citation ends].com.bmj.content.model.Caption@5b41acb4

Plus – removal of lesion and risk reduction strategies

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mastalgia
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atypical ductal hyperplasia
Plus – 

removal of lesion and risk reduction strategies

Treatment recommended for ALL patients in selected patient group

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

1st line – reassurance with observation

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nipple discharge
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nonsuspicious and breast mass not present
1st line – 

reassurance with observation

Patients with nonsuspicious nipple discharge require no further intervention. Reassurance and observation are sufficient.

1st line – referral to a surgeon

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nipple discharge
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nonsuspicious and breast mass present
1st line – 

referral to a surgeon

Patients with any nipple discharge and a palpable accompanying mass or mammographic abnormality should be referred to a surgeon immediately.

1st line – referral and surgery

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nipple discharge
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suspicious
1st line – 

referral and surgery

Specialist consultation must be obtained when suspicious nipple discharge is encountered, even if no palpable mass is present or mammography is normal.[40]

If discharge is bloody and very profuse, it may be necessary to perform either microductectomy (removal of single symptomatic milk duct) or central duct excision.

In patients with nonsuspicious nipple discharge and negative imaging studies for malignancy and prolactinoma, but in whom the discharge is profuse and significantly impacts a patient's quality of life, excision of the central duct complex may help control the discharge.[40][42]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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