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Am Fam Physician. 2003;68(12):2448-2450

Mastalgia, cyclic and noncyclic, is common among women. It can cause severe pain and disrupt routine daily activities. Many medical treatments have been used successfully to relieve mastalgia, but medications such as bromocriptine, tamoxifen, and gonadotropin-releasing hormone analogues produce undesirable side effects. First-line treatments have included nonhormonal drugs such as primrose oil and vitamin B6, but relapses are common. Primrose oil, which contains gammalinolenic acid, is thought to improve fatty acid profiles and result in pain relief. Attempts to treat mastalgia with vitamin B6, caffeine reduction, or vitamin E have been less successful. Gel forms of nonsteroidal anti-inflammatory drugs (NSAIDs) often are used successfully for topical pain management and appear to have no serious adverse effects. Colak and associates conducted a prospective, randomized, blinded, placebo-controlled study to evaluate the use of topical NSAIDs in the treatment of cyclic (60 women) and noncyclic (48 women) mastalgia.

Patients with mastalgia who had normal results on routine biochemistry and hormonal testing and negative evaluations for breast cancer were enrolled in the study. Many participants had received previous treatments that had been discontinued because of adverse effects or inadequate benefit. Patients were assigned randomly to use of a topical NSAID preparation of diclofenac diethylamonium every eight hours or a topical placebo cream applied to the breast skin. All of the patients were advised to decrease their intake of caffeine. Pain was measured using a visual analog scale during the six months of treatment.

After six months, the pain score was markedly improved among participants receiving the topical NSAID treatment. This was true of patients with cyclic and noncyclic mastalgia. Almost 50 percent of the treated participants reported no pain at the end of the study. No side effects occurred among any of the participants.

The authors conclude that applying topical NSAIDs over a six-month period can relieve the pain of mastalgia with minimal adverse effects.

editor's note: Mastalgia is generally mild and most frequently occurs in women older than 20 years. The condition is associated with pre-menstrual syndrome and tends to run in families. No confirmatory diagnostic tests exist, and pathologic findings on breast biopsy are most commonly fibrocystic changes. Mammography may be used to distinguish benign disease from malignancy, if necessary. Other potentially useful diagnostic tests include measurement of thyroid-stimulating hormone and prolactin levels if galactorrhea is present. Reduction of dietary fat intake to 20 percent of total calories can reduce mastalgia. Patients also might consider wearing a more supportive bra, weight reduction, smoking cessation, and education about the benign nature of the condition. Pharmacologic treatment often includes acetaminophen, ibuprofen, or topical NSAIDs, and alternative therapies such as diuretics, vitamin E, evening primrose oil, or oral contraceptives. Danazol and bromocriptine are helpful but may cause more serious side effects. Discomfort often spontaneously disappears at menopause unless hormone therapy is used. An excellent patient information handout prepared by the American Academy of Family Physicians is available at —r.s.

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