The algorithm also addresses pharmacologic approaches for debilitating and nondebilitating breast pain.15-22 A short course of a scheduled oral nonsteroidal anti-inflammatory medication can improve breast comfort.
Anecdotally, addition of daily omega-3 has shown beneficial anti-inflammatory effects. Fish oil (1,000 to 1,200 mg daily) is an easily accessible and cost-effective option. An old study suggests that oil of evening primrose can significantly diminish cyclic breast pain,23 but four additional studies have found no evidence of benefit.24-27 Furthermore, this treatment requires frequent dosing and is prohibitively expensive.
The associated side effects of the various pharmacologic approaches to the management of breast pain make them a less appealing option for patient and clinician alike.
Extra-mammary pain falls in the category of myofacial or musculoskeletal pain (Table 1). Such referred pain is treated by managing the underlying cause. Strategies can include referral to a pain-management specialist for steroid injections, topical analgesic application, and oral therapies.28
Because the etiology of breast pain is multifactorial, the clinical management is fluid in nature. Many management strategies take time to work. We routinely have women return for re-evaluation in three to six months. Additional research investigating causation of breast pain and new techniques for breast-pain management is warranted.
Glenda Bell Flynn, FNP-C, AOCNP, and Catherine Tipton, MSN, FNP-BC, are family nurse practitioners at Baystate Surgical Oncology’s Comprehensive Breast Center in Springfield, Mass.
- Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and management of breast pain. Mayo Clin Proc. 2004;79:353-372.
- Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 4th ed. Philadelphia, Pa.: Lippincott Williams and Wilkins; 2010:52-57.
- Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination. 5th ed. Philadelphia, Pa.: Mosby; 2003.
- Hughes LE, Mansel RE, Webster DJ. “Aberrations of normal development and involution (ANDI): a new perspective on pathogenesis and nomenclature of benign breast disorders.” Lancet. 1987;2:1316-1319.
- Ecochard R, Marret H, Rabilloud M, et al. “Gonadotropin level abnormalities in women with cyclic mastalgia.” Eur J Obstet Gynecol Reprod Biol. 2001;94:92-6.
- Jørgensen J, Watt-Boolsen S. “Cyclical mastalgia and breast pathology.” Acta Chir Scand. 1985;151:319-321.
- Watt-Boolsen S, Andersen AN, Blichert-Toft M. “Serum prolactin and oestradiol levels in women with cyclical mastalgia.” Horm Metab Res. 1981;13:700-702.
- Walsh PV, McDicken IW, Bulbrook RD, et al. “Serum oestradiol-17 beta and prolactin concentrations during the luteal phase in women with benign breast disease.” Eur J Cancer Clin Oncol. 1984;20:1345-1351.
- Auerbach RD. A Guide to Breast Health Care. Trumbull, Conn.: Budlong Press, 2006:25.
- Barros AC, Mottola J, Ruiz CA et al. “Reassurance in the treatment of mastalgia.” Breast J. 1999;5:162-165.
- Ernster VL, Goodson WH 3rd, Hunt TK, et al. “Vitamin E and benign breast ‘disease’: a double-blind, randomized clinical trial.” Surgery. 1985;97:490-494.
- Colin C, Gaspard U, Lambotte R. “Relationship of mastodynia with its endocrine environment and treatment in a double blind trial with lynestrenol.” Arch Gynakol. 1978;225:7-13.
- Gunston KD. “Premenstrual syndrome in Cape Town. Part II. A double-blind placebo-controlled study of the efficacy of mefenamic acid.” S Afr Med J. 1986;70:159-160.
- Ernster VL, Mason L, Goodson WH 3rd, et al. “Effects of caffeine-free diet on benign breast disease: a randomized trial.” Surgery. 1982;91:263-267.
- Mansel RE, Wisbey JR, Hughes LE. “Controlled trial of the antigonadotropin danazol in painful nodular benign breast disease.” Lancet. 1982;1:928-930.
- Döberl A, Tobiassen T, Rasmussen T. “Treatment of recurrent cyclical mastodynia in patients with fibrocystic breast disease. A double-blind placebo-controlled study — the Hjørring project.” Acta Obstet Gynecol Scand Suppl. 1984;123:177-184.
- Mansel RE, Dogliotti L. “European multicentre trial of bromocriptine in cyclical mastalgia.” Lancet. 1990;335:190-193.
- Fentiman IS, Caleffi M, Brame K, et al. “Double-blind controlled trial of tamoxifen therapy for mastalgia.” Lancet. 1986;1:287-288.
- Messinis IE, Lolis D. “Treatment of premenstrual mastalgia with tamoxifen.” Acta Obstet Gynecol Scand. 1988;67:307-309.
- Kontostolis E, Stefanidis K, Navrozoglou I, Lolis D. “Comparison of tamoxifen with danazol for treatment of cyclical mastalgia.” Gynecol Endocrinol. 1997;11:393-397.
- Mansel R, Goyal A, Nestour EL, et al. “A phase II trial of Afimoxifene (4-hydroxytamoxifen gel) for cyclical mastalgia in premenopausal women.” Breast Cancer Res Treat. 2007;106:389-397.
- Mansel RE, Goyal A, Preece P, et al. “European randomized, multicenter study of goserelin (Zoladex) in the management of mastalgia.” Am J Obstet Gynecol. 2004;191:1942-1949.
- Preece PE, Hanslip JI, Gilbert L, et al. “Evening primrose oil for mastalgia.” In: Horrobin D. Clinical Uses of Essential Fatty Acids. Montreal: Eden Press; 1982:147-154.
- Budeiri D, Li Wan Po A, Dornan JC. “Is evening primrose oil of value in the treatment of premenstrual syndrome?” Control Clin Trials. 1996;17:60-68.
- Collins A, Cerin A, Coleman G, Landgren BM. “Essential fatty acids in the treatment of premenstrual syndrome.” Obstet Gynecol. 1993;81:93-98.
- Khoo SK, Munro C, Battistutta D. “Evening primrose oil and treatment of premenstrual syndrome.” Med J Aust. 1990;153:189-192.
- Blommers J, de Lange-De Klerk ES, Kuik DJ, et al. “Evening primrose oil and fish oil for severe chronic mastalgia: a randomized, double-blind, controlled trial.” Am J Obstet Gynecol. 2002;187:1389-1394.
- 28. Colak T, Ipek T, Kanik A, et al. “Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment.” J Am Coll Surg. 2003;196:525-530.
All electronic documents accessed September 15, 2011.