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134 Breast pain
COX-2 selective NSAIDs for acute mastalgia. Relevant information is found in
the breast augmentation literature. A controlled trial demonstrated that a
single 400 mg PO preoperative dose of celecoxib effectively reduced postoperative
breast pain (i.e. resulted in less opioid requirement). 3 Since the
cardiovascular adverse effects of the COX-2 selective NSAIDs (see the Arthritis
chapter, p. 94) may be less applicable to short-term use in patients with
breast pain, celecoxib remains a potentially useful approach to mastalgia.
Assessment in an RCT found relief of mastalgia with topical application of
the NSAID diclofenac diethylammonium (2% gel, 11.6 mg/g, 50 mg diclofenac
component TID). 4
All NSAIDs are contraindicated in pregnancy. For mild pain in pregnant
patients, acetaminophen (paracetamol) is a good choice, although it will
often need to be combined with an opioid for more severe pain. 5,6
As is the case with NSAIDs, there is little clinical trial evidence addressing use
of opioids for breast pain. Potentially useful data include demonstrations of
efficacy, for breast cancer pain, of hydrocodone or oxycodone; the available
evidence does support a role for oral opioid use for treating breast pain (e.g.
from inflammatory carcinoma) too severe for NSAID monotherapy. 7 Breast pain
from infections ranging from cellulitis to abscess can also be severe; opioids
may be used to complement appropriate medical and surgical therapy. 8
Lactation pain, caused by a combination of breast overfilling, nipple
cracking, and ulceration (with occasional fungal or bacterial overgrowth
owing to the presence of breast milk “culture media”) is treated with breast
pumping and occasional antimicrobials. 9 Nipple vasospasm, an unusual but
probably underappreciated cause of lactation-related pain, is successfully
(and safely, for mother and infant) treated with once-daily nifedipine if warm
compresses fail to alleviate symptoms. 10
CYCLIC (PREMENSTRUAL) MASTALGIA
The unclear etiology of cyclic breast pain (i.e. usually presenting during luteal
phase and resolving with onset of menses) translates into lack of consensus
on treatment of this form of mastalgia. The current focus of therapy is based
on use of systemic or topical NSAIDs.