Clinical management of idiopathic mastalgia: a systematic review
Shazia P. Hafiz 1 , Nicola L. P. Barnes 2 , Cliona C. Kirwan 2
+ Author Affiliations
- Author Affiliations
1 Health Education North West (HENW), UK
2 Institute of Cancer, University of Manchester, University Hospital South Manchester (UHSM) Wythenshawe, Manchester, UK
Correspondence to: Shazia P. Hafiz, Apartment XQ7 Room 1203, Taylorson Street South, Salford, M5 3FY, UK. Email: shaziahafiz@doctors.org.uk
Journal of Primary Health Care 10(4) 312-323 https://doi.org/10.1071/HC18026
Published: 19 December 2018
Journal Compilation © Royal New Zealand College of General Practitioners 2018.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Abstract
INTRODUCTION: Idiopathic mastalgia (benign breast pain of unknown origin) is often poorly managed because of its subjective nature and unclear aetiology. Mastalgia is a reason for up to 50% of breast outpatient referrals. Existing systematic reviews discuss dated treatment options that provide limited symptomatic relief.
METHODS: A systematic review was conducted for aetiology and treatment of idiopathic mastalgia in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Databases such as PubMed, MEDLINE, Cochrane Database and the Clinical Trial Registry were searched (February 2016).
RESULTS: Reassurance plus bra-fitting advice provides relief for most women. If symptoms persist, addition of topical non-steroidal anti-inflammatory drugs (NSAIDs) provides relief in 70–92% of women. There is some benefit in reducing dietary coffee and fat intake. Medical treatments have serious side-effects (often androgenic or menopausal) and should be considered only in cases resistant to simpler measures. Dopamine agonists are useful, but less effective than endocrine treatments such as Danazol or Tamoxifen. Of the Selective Oestrogen Receptor Modulator drugs, Ormeloxifene appears most effective, but is not licenced in the United Kingdom. Relaxation therapy, acupuncture and kinesiology may be useful but currently lack good evidence of effectiveness.
DISCUSSION: First-line management of breast pain should be explanation, reassurance and a bra-fitting advice. Subsequent drug therapy should be balanced against its side-effects; topical NSAIDs and Ormeloxifene show greatest benefit with least side-effects. Newer agents (Ormeloxifene) currently being used for mastalgia in India could be considered in the developed world.
KEYWORDS: breast pain; bra-fitting; mastalgia
References
[1] Cairncross L. Mastalgia. Contin Med Ed. 2010; 28 504[2] Gateley CA, Miers M, Mansel RE, Hughes LE. Drug treatments for mastalgia: 17 years’ experience in the Cardiff mastalgia clinic. J R Soc Med. 1992; 85 12–5.
[3] Iddon J, Dixon MJ. ABC of Breast Diseases. 4th edn. Oxford: Wiley-Blackwell; 2012.
[4] Singletary SE, Robb GL, Hortobagy GN. Advanced Therapy of Breast Disease. 2nd edn. City: BC Decker Inc.; 2004.
[5] Gong C, Song E, Jia W, et al. A double blind randomized controlled trial of Toremifene therapy for mastalgia. Arch Surg. 2006; 141 43–7.
| A double blind randomized controlled trial of Toremifene therapy for mastalgia.Crossref | GoogleScholarGoogle Scholar |
[6] Kumar S, Mansel RE, Scanlon MF, et al. Altered responses of prolactin, luteinizing hormone and follicle stimulating hormone secretion to thyrotrophin releasing hormone/gonadotrophin releasing hormone stimulation in cyclical mastalgia. Br J Surg. 1984; 71 870–3.
| Altered responses of prolactin, luteinizing hormone and follicle stimulating hormone secretion to thyrotrophin releasing hormone/gonadotrophin releasing hormone stimulation in cyclical mastalgia.Crossref | GoogleScholarGoogle Scholar |
[7] Maddox PR, Harrison BJ, Horobin JM, et al. A randomised controlled trial of medroxyprogesterone acetate in mastalgia. Ann R Coll Surg Engl. 1990; 72 71–6.
[8] Sitruk-Ware LR, Sterkers N, Mowszowicz I, Mauvaus-Jarvis P. Inadequate corpus luteal function in women with benign breast diseases. J Clin Endocrinol Metab. 1977; 44 771–4.
| Inadequate corpus luteal function in women with benign breast diseases.Crossref | GoogleScholarGoogle Scholar |
[9] Kumar S, Mansel RE, Hughes LE, et al. Prolactin response to thyrotropin-releasing hormone stimulation and dopaminergic inhibition in benign breast disease. Cancer. 1984; 53 1311–5.
| Prolactin response to thyrotropin-releasing hormone stimulation and dopaminergic inhibition in benign breast disease.Crossref | GoogleScholarGoogle Scholar |
[10] Kumar S, Mansel RE, Hughes LE, et al. Prediction of response to endocrine therapy in pronounced cyclical mastalgia using dynamic tests of prolactin release. Clin Endocrinol (Oxf). 1985; 23 699–704.
| Prediction of response to endocrine therapy in pronounced cyclical mastalgia using dynamic tests of prolactin release.Crossref | GoogleScholarGoogle Scholar |
[11] Mansel RE, Dogliotti L. European multicentre trial of bromocriptine in cyclical mastalgia. Lancet. 1990; 335 190–3.
| European multicentre trial of bromocriptine in cyclical mastalgia.Crossref | GoogleScholarGoogle Scholar |
[12] Preece PE, Richards AR, Owen GM, Hughes LE. Mastalgia and total body water. BMJ. 1975; 4 498–500.
| Mastalgia and total body water.Crossref | GoogleScholarGoogle Scholar |
[13] Rose DP, Boyar AP, Cohen C, Strong LE. Effect of a low-fat diet on hormone levels in women with cystic breast disease, serum steroids and gonadotropins. J Natl Cancer Inst. 1987; 78 623–6.
[14] Sharma AK, Mishra SK, Salila M, et al. Cyclical mastalgia: is it a manifestation of aberration in lipid metabolism? Indian J Physiol Pharmacol. 1994; 38 267–71.
[15] Goodwin PJ, Miller A, Del G, et al. Elevated high-density lipoprotein, cholesterol and dietary fat intake in women with cyclic mastalgia. Am J Obstet Gynecol. 1998; 179 430–7.
| Elevated high-density lipoprotein, cholesterol and dietary fat intake in women with cyclic mastalgia.Crossref | GoogleScholarGoogle Scholar |
[16] Goyal A, Mansel RE, Efamast Study Group A randomized multicentre study of Gamolenic Acid (Efamast) with and without antioxidant vitamins and minerals in the management of mastalgia. Breast J. 2005; 11 41–7.
| A randomized multicentre study of Gamolenic Acid (Efamast) with and without antioxidant vitamins and minerals in the management of mastalgia.Crossref | GoogleScholarGoogle Scholar |
[17] Parsay S, Olfati F, Nahidi S. Therapeutic effects of vitamin E on cyclic mastalgia. Breast J. 2009; 15 510–4.
| Therapeutic effects of vitamin E on cyclic mastalgia.Crossref | GoogleScholarGoogle Scholar |
[18] Allen SS, Froberg DG. The effect of decreased caffeine consumption on benign proliferative breast disease: a randomized clinical trial. Surgery. 1987; 101 720–30.
[19] Murshid KR. A review of mastalgia in patients with fibrocystic breast changes and the non-surgical treatment options. J Taibah Univ Med Sci. 2011; 6 1–18.
[20] Ernster VL, Masno L, Goodson WH, et al. Effects of caffeine free diet on benign breast disease: a randomised trial. Surgery. 1982; 91 263–7.
[21] Russell LC. Caffeine restriction as medical treatment for breast pain. Nurse Pract. 1989; 14 36–7.
[22] Ingram DM, Hickling C, West L, et al. A double blind randomized controlled trial of isoflavones in the treatment of cyclical mastalgia. Breast. 2002; 11 170–74.
| A double blind randomized controlled trial of isoflavones in the treatment of cyclical mastalgia.Crossref | GoogleScholarGoogle Scholar |
[23] Fleming RM. What effect, if any does soy protein have on breast tissue? Integr Cancer Ther. 2003; 2 225–8.
| What effect, if any does soy protein have on breast tissue?Crossref | GoogleScholarGoogle Scholar |
[24] Ader DN, South-Paul J, Adera T, Deuster PA. Cyclical mastalgia: prevalence and associated health and behavioral factors. J Psychosom Obstet Gynaecol. 2001; 22 71–6.
| Cyclical mastalgia: prevalence and associated health and behavioral factors.Crossref | GoogleScholarGoogle Scholar |
[25] Baron JA. Smoking and estrogen-related disease. Am J Epidemiol. 1984; 119 9–22.
| Smoking and estrogen-related disease.Crossref | GoogleScholarGoogle Scholar |
[26] Brown N, White J, Brasher A, Scurr J. The experience of breast pain (mastalgia) in female runners of the 2012 London Marathon and its effects on exercise behaviour. Br J Sports Med. 2014; 48 320–5.
| The experience of breast pain (mastalgia) in female runners of the 2012 London Marathon and its effects on exercise behaviour.Crossref | GoogleScholarGoogle Scholar |
[27] Jenkins PL, Jamil N, Gateley C, Mansel RE. Psychiatric illness in patients with severe treatment-resistant mastalgia. Gen Hosp Psychiatry. 1993; 15 55–7.
| Psychiatric illness in patients with severe treatment-resistant mastalgia.Crossref | GoogleScholarGoogle Scholar |
[28] Preece PE, Mansel RE, Hughes LE. Mastalgia: psychoneurosis or organic disease? Br Med J. 1978; 1 29–30.
| Mastalgia: psychoneurosis or organic disease?Crossref | GoogleScholarGoogle Scholar |
[29] Yilmaz ED, Deveci E, Kadioglu H, et al. Anxiety and depression levels and personality traits of mastalgia patients. J Psychiatr. 2014; 17 118
[30] Fox H, Walker LG, Heys SD, et al. Are patients with mastalgia anxious and does relaxation therapy help?’ Breast. 1997; 6 138–42.
| Are patients with mastalgia anxious and does relaxation therapy help?’Crossref | GoogleScholarGoogle Scholar |
[31] Ramirez AJ, Jarret SR, Hamed H, et al.Psychosocial Distress Associated with Severe Mastalgia. Recent Developments in the Study of Benign Breast Disease. London: Parthenon; 1994.
[32] National Institute for Health Care Excellence. Breast Pain – Management. London: NICE; 2015.
[33] Barros AC, Mottola J, Ruiz CA, et al. Reassurance in the treatment of mastalgia. Breast J. 1999; 5 162–5.
| Reassurance in the treatment of mastalgia.Crossref | GoogleScholarGoogle Scholar |
[34] Abdel Hadi MSA. Sports brassiere: is it a solution for mastalgia? Breast J. 2000; 6 407–9.
| Sports brassiere: is it a solution for mastalgia?Crossref | GoogleScholarGoogle Scholar |
[35] Wilson MC, Sellwood RA. Therapeutic value of a supporting brassiere in mastodynia. BMJ. 1976; 2 90
| Therapeutic value of a supporting brassiere in mastodynia.Crossref | GoogleScholarGoogle Scholar |
[36] White J, Scurr J. Evaluation of professional bra fitting criteria for bra selection and fitting in the UK. Ergonomics. 2012; 55 704–11.
| Evaluation of professional bra fitting criteria for bra selection and fitting in the UK.Crossref | GoogleScholarGoogle Scholar |
[37] McFadyen IJ, Chetty U, Setchell KDR, et al. A randomized double blind cross over trial of soya protein for the treatment of cyclical breast pain. Breast. 2000; 9 271–6.
| A randomized double blind cross over trial of soya protein for the treatment of cyclical breast pain.Crossref | GoogleScholarGoogle Scholar |
[38] Pruthi S, Wahner-Roedler DL, Torkelsen CJ, et al. Vitamin E and Evening Primrose Oil for management of cyclical mastalgia: a randomized pilot study. Altern Med Rev. 2010; 15 59–67.
[39] Saied GM, Kamel RM, Dessouki N. Low intensity laser therapy is comparable to bromocriptine-evening primrose oil for the treatment of cyclical mastalgia in Egyptian females. Tanzan Health Res Bull. 2007; 9 196–201.
[40] Qureshi S, Sultan N. Topical non-steroidal anti-inflammatory drugs versus oil of evening primrose in the treatment of mastalgia. Surgeon. 2005; 3 7–10.
| Topical non-steroidal anti-inflammatory drugs versus oil of evening primrose in the treatment of mastalgia.Crossref | GoogleScholarGoogle Scholar |
[41] Tavaf-Motamen H, Ader DN, Browne MW, Shriver CD. Clinical evaluation of mastalgia. Arch Surg. 1998; 133 211–4.
| Clinical evaluation of mastalgia.Crossref | GoogleScholarGoogle Scholar |
[42] Cheung KL. Management of cyclical mastalgia in oriental women: pioneer experience of using Gamolenic acid (Efamast) in Asia. Aust N Z J Surg. 1999; 69 492–4.
| Management of cyclical mastalgia in oriental women: pioneer experience of using Gamolenic acid (Efamast) in Asia.Crossref | GoogleScholarGoogle Scholar |
[43] Srivastava A, Mansel RE, Arvind N, et al. Evidence-based management of mastalgia: a meta-analysis of randomised trials. Breast. 2007; 16 503–12.
| Evidence-based management of mastalgia: a meta-analysis of randomised trials.Crossref | GoogleScholarGoogle Scholar |
[44] Irving AD, Morrison SL. Effectiveness of topical non-steroidal anti-inflammatory drugs in the management of breast pain. J R Colle Surg Edinb. 1998; 43 158–9.
[45] Colak T, Ipek T, Kanik A, et al. Efficacy of topical nonsteroidal anti-inflammatory drugs in mastalgia treatment. J Am Coll Surg. 2003; 196 525–30.
| Efficacy of topical nonsteroidal anti-inflammatory drugs in mastalgia treatment.Crossref | GoogleScholarGoogle Scholar |
[46] Kaviani A, Mehrdad N, Najafi M, et al. Comparison of Naproxen with placebo for the management of noncyclical breast pain: a randomized double blind controlled trial. World J Surg. 2008; 32 2464–70.
| Comparison of Naproxen with placebo for the management of noncyclical breast pain: a randomized double blind controlled trial.Crossref | GoogleScholarGoogle Scholar |
[47] Shaughn O’Brien PM, Abukhalil IEH. Randomized controlled trial of the management of premenstrual syndrome and premenstrual mastalgia using luteal phase-only danazol. Am J Obstet Gynecol. 1999; 180 18–23.
| Randomized controlled trial of the management of premenstrual syndrome and premenstrual mastalgia using luteal phase-only danazol.Crossref | GoogleScholarGoogle Scholar |
[48] Tejwani PL, Srivastava AM, Nerakr H, et al. Centchroman regresses mastalgia: a randomized comparison with Danazol. Indian J Surg. 2011; 73 199–205.
| Centchroman regresses mastalgia: a randomized comparison with Danazol.Crossref | GoogleScholarGoogle Scholar |
[49] Peters F. Multicentre study of Gestrinone in cyclical breast pain. Lancet. 1992; 339 205–8.
| Multicentre study of Gestrinone in cyclical breast pain.Crossref | GoogleScholarGoogle Scholar |
[50] Blichert-Toft M, Andersen AN, Henriksen OB, Mygind T. Treatment of mastalgia with bromocriptine: a double blind cross-over study. BMJ. 1979; 1 237
| Treatment of mastalgia with bromocriptine: a double blind cross-over study.Crossref | GoogleScholarGoogle Scholar |
[51] Schulz KD, Del Pozo E, Lose KH, et al. Successful treatment of mastodynia with the prolactin inhibitor Bromocriptine (CB154). Arch Gynakol. 1975; 220 83–7.
[52] Kaleli S, Aydin Y, Erel CT, Colgar U. Symptomatic treatment of premenstrual mastalgia in premenopausal women with Lisuride Maleate: a double-blind placebo-controlled randomized study. Fertil Steril. 2001; 75 718–23.
[53] Halaska M, Beles P, Gorkow C, Sieder C. Treatment of cyclical mastalgia with a solution containing a vitex agnus castus extract: results of a placebo-controlled double-blind study. Breast. 1999; 8 175–81.
| Treatment of cyclical mastalgia with a solution containing a vitex agnus castus extract: results of a placebo-controlled double-blind study.Crossref | GoogleScholarGoogle Scholar |
[54] Fentiman IS, Caleffi M, Brame K, et al. Double blind controlled trial of Tamoxifen therapy for mastalgia. Lancet. 1986; 327 287–8.
| Double blind controlled trial of Tamoxifen therapy for mastalgia.Crossref | GoogleScholarGoogle Scholar |
[55] Jain BK, Bansal A, Choudhary D, et al. Centchroman vs Tamoxifen for regression of mastalgia: a randomized controlled trial. Int J Surg. 2015; 15 11–6.
| Centchroman vs Tamoxifen for regression of mastalgia: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar |
[56] Mansel R, Goyal A, Le Nestour E, et al. A phase II trial of afimoxifene (4-hydroxyTamoxifen gel) for cyclical mastalgia in premenopausal women. Breast Cancer Res Treat. 2007; 106 389–97.
| A phase II trial of afimoxifene (4-hydroxyTamoxifen gel) for cyclical mastalgia in premenopausal women.Crossref | GoogleScholarGoogle Scholar |
[57] Gotfredsen A, Christiansen C, Palshof T. The effect of Tamoxifen on bone mineral content in premenopausal women with breast cancer. Cancer. 1984; 53 853–57.
| The effect of Tamoxifen on bone mineral content in premenopausal women with breast cancer.Crossref | GoogleScholarGoogle Scholar |
[58] Kumar S, Agarwal RR, Dwivedi V, Das SKV. A randomized double blind placebo controlled trial of ormeloxifene in breast pain and nodularity. Natl Med J India. 2013; 26 69–74.
[59] Dhar A, Srivastava A. Role of Centchroman in regression of mastalgia and fibroadenoma. World J Surg. 2007; 31 1180–86.
| Role of Centchroman in regression of mastalgia and fibroadenoma.Crossref | GoogleScholarGoogle Scholar |
[60] Oksa S, Luukaala T, Maenpaa J. Toremifene for premenstrual mastalgia: a randomised placebo controlled crossover study. BJOG. 2006; 113 713–18.
| Toremifene for premenstrual mastalgia: a randomised placebo controlled crossover study.Crossref | GoogleScholarGoogle Scholar |
[61] Hamed H, Chaudary MA, Fentiman IS, Caleffi M. LHRH analogue for treatment of recurrent and refractor mastalgia. Ann R Coll Surg Engl. 1990; 72 221–4.
[62] Mansel RE, Goyal A, Preece P, et al. European randomized, multicentre study of goserelin (Zoladex) in the management of mastalgia. Am J Obstet Gynecol. 2004; 191 1942–9.
| European randomized, multicentre study of goserelin (Zoladex) in the management of mastalgia.Crossref | GoogleScholarGoogle Scholar |
[63] Davies EL, Cochrane RA, Stansfield K, et al. Is there a role for surgery in the treatment of mastalgia? Breast. 1999; 8 285–8.
| Is there a role for surgery in the treatment of mastalgia?Crossref | GoogleScholarGoogle Scholar |
[64] Salgado CJ, Mardini S, Chen H. Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction? Plast Reconstr Surg. 2005; 116 978–83.
| Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction?Crossref | GoogleScholarGoogle Scholar |
[65] Khan HN, Rampaul R, Blamey RW. Local anaesthetic and steroid combined injection therapy in the management of non-cyclical mastalgia. Breast. 2004; 13 129–32.
| Local anaesthetic and steroid combined injection therapy in the management of non-cyclical mastalgia.Crossref | GoogleScholarGoogle Scholar |
[66] Chan J. Magic for Mastalgia with HT7. Acupunct Med. 2015; 33 82
[67] Thicke LA, Hazelton JK, Bauer BA, et al. Acupuncture for treatment of non cyclical breast pain: a pilot study. Am J Chin Med. 2011; 39 1117–29.
| Acupuncture for treatment of non cyclical breast pain: a pilot study.Crossref | GoogleScholarGoogle Scholar |
[68] Gregory WM, Mills SP, Hamed H, Fentiman IS. Applied kinesiology for treatment of women with mastalgia. Breast. 2001; 10 15–9.
| Applied kinesiology for treatment of women with mastalgia.Crossref | GoogleScholarGoogle Scholar |
[69] Öztürk AB, Özenli Y, Özturk SB, et al. The effect of psychoeducation on anxiety and pain in patients with mastalgia. Nord J Psychiatry. 2015; 69 380–5.
| The effect of psychoeducation on anxiety and pain in patients with mastalgia.Crossref | GoogleScholarGoogle Scholar |
[70] Bra-fitting guide. Triumph. [Cited 2018 December 7] Available from: http://uk.triumph.com/help-information/Help_Fitting_Guide.html
