Treatment	Comments
Clear benefit (cost-benefit analysis)
Bra fit²⁵	70% of women wear poorly fitting bras Mechanism of action: proper bra fit reduces tension on Cooper ligaments, particularly in large-breasted women Effectiveness: evidence suggests benefit in 85% of women who adjust fit
Danazol (200 mg daily, reduced to 100 mg daily after relief of symptoms)^13,14,16,18	Only drug FDA-approved for treatment of mastalgia Mechanism of action: anterior pituitary suppressant Effectiveness: less effective than tamoxifen with less favorable adverse effect profile Adverse effects: androgenic effects (e.g., weight gain, deepening of voice), menorrhagia, and muscle cramps Contraindications: pregnancy, lactation, history of thromboembolic disease
Goserelin (Zoladex)^13,14,28	Reserved for severe refractory mastalgia Mechanism of action: induces reversible ovarian suppression to postmenopausal levels Effectiveness: limited data but compelling evidence of pain reduction Adverse effects: vaginal dryness, hot flashes, decreased libido, and irritability Treatment duration: less than six months
Tamoxifen (10 mg daily)^13,14	Preferred hormonal treatment; limited duration of therapy because of potential for serious adverse effects Effectiveness: highly effective, but high rate of symptom reemergence after discontinuation Adverse effects: antiestrogenic effects (hot flashes and vaginal discharge), venous thromboembolism, endometrial cancer, and teratogenicity Treatment duration: initially prescribed for three months, but may be extended for an additional three months if a response is observed
Topical NSAIDs (diclofenac)^13,14	First-line pharmacologic agent (preferred over oral NSAIDs because of adverse effect profile) Effectiveness: significant pain reduction for cyclic/noncyclic pain Adverse effects: elevated liver enzyme levels, photosensitivity
Unknown effectiveness, limited data, or strongly limiting adverse effects
Bromocriptine (Parlodel)^13,14,18	FDA approval has been withdrawn because of serious adverse effects Effectiveness: proven long-lasting effectiveness Adverse effects: nausea, dizziness, and hypotension are common; stroke and death reported after use for lactation inhibition
Caffeine avoidance^14,20	Caffeine is often cited as a causative factor in breast pain Effectiveness: RCTs do not show clear evidence of pain reduction
Dietary modifications (low fat, high fiber)^14,20	Effectiveness: limited and low-quality RCTs show no clear evidence of pain reduction
Evening primrose oil^14,27	Proposed mechanism of action: augments low levels of gamma-linolenic acid metabolites in women with cyclic mastalgia Effectiveness: no more effective than placebo Adverse effects: may reduce seizure threshold; questionable safety during pregnancy and lactation
Lisuride (not available in the United States)^14,17	Effectiveness: limited, low-quality evidence shows possible effectiveness Adverse effects: generally well tolerated, but may be associated with pathologic gambling and hypersexuality
Oral contraceptives^13,18	Effectiveness: no RCTs have evaluated effectiveness
Oral NSAIDs^14,17	Effectiveness: limited poor-quality studies show potential effectiveness Adverse effects: limited utility secondary to gastrointestinal adverse effects and liver toxicity
Surgery^17,29	Limited role for mastectomy or partial mastectomy because of high risk of complications and persistent pain after surgery in nearly one-half of patients
Vitamin E¹⁴	Effectiveness: no high-quality systematic reviews or RCTs show effectiveness; general consensus is it should not be used Adverse effects: long-term use may increase risk of hemorrhagic stroke