Clinical Evidence Handbook
A Publication of BMJ Publishing Group
Am Fam Physician. 2016 May 15;93(10):872-873.
Author disclosure: Amit Goyal is an author of references cited in this review.
Breast pain (mastalgia) may be cyclic (worse before a period) or noncyclic, originating from the breast or the chest wall, and occurs at some time in 70% of women.
Cyclic breast pain resolves spontaneously in 20% to 30% of women but tends to recur in up to 60% of women.
Noncyclic pain responds poorly to treatment but tends to resolve spontaneously in about one-half of women.
An accurate diagnosis of true breast pain should be made, and other non-breast pathology should be excluded. The differential diagnosis includes pain arising from the chest wall.
We found limited evidence that topical diclofenac may be effective at relieving symptoms of cyclic and noncyclic breast pain, but it has been associated with adverse effects.
There is consensus that topical non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving breast pain and should be considered as a first-line treatment, as the benefits are thought to outweigh the risk of adverse effects.
We found insufficient evidence to assess the effects of oral NSAIDs on breast pain.
We do not know whether topical NSAIDs are more effective than oral NSAIDs at reducing breast pain.
Danazol, tamoxifen, and gonadorelin analogues (goserelin) may reduce breast pain, but all can cause adverse effects. These agents would usually be prescribed only by a subspecialist.
Danazol can cause weight gain, deepening of the voice, menorrhagia, and muscle cramps, and has androgenic effects on a fetus.
There is consensus to limit the use of tamoxifen to no more than six months at a time under expert supervision, and with appropriate nonhormonal contraception, because of the high incidence of adverse effects, including teratogenicity and venous thromboembolism.
Goserelin injection is associated with vaginal dryness, hot flashes, decreased libido, oily skin or hair, decreased breast size, and irritability. There is consensus that goserelin injections should be reserved for severe refractory mastalgia and that treatment should be limited to six months.
Danazol may be less effective than tamoxifen at reducing breast pain and has a less favorable adverse effect profile compared with tamoxifen (10 mg daily).
Tamoxifen (10 mg daily), under expert supervision, or danazol may be considered when first-line treatments are ineffective.
Tamoxifen (20 mg daily) may increase the risk of venous thromboembolism.
There is consensus that progestogens do not have a role in treating mastalgia.
We do not know whether the combined oral contraceptive pill or wearing a bra reduces breast pain, as we found no randomized controlled trials.
This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required).
This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.
A collection of Clinical Evidence Handbook published in AFP is available at http://www.aafp.org/afp/bmj.
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