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A clinical trial found reduction or resolution of cyclic mastalgia with
15 days of therapy with the COX-2 selective NSAID nimesulide (100 mg PO
BID). 11 Nimesulide’s effectiveness is cited by those supporting its use for
cyclic mastalgia, but the drug’s hepatic side effect risk precludes a recommendation
for its use from the ED. 12
RCT assessment found relief of cyclic (as well as noncyclic) mastalgia with
topical application of diclofenac diethylammonium (2% gel, 11.6 mg/g,
50 mg diclofenac component TID). 4
Danazol (200 mg PO daily), a gonadotropin secretion inhibitor that
reduces ovarian estrogen production, is effective in reducing severe, cyclic
mastalgia. 13 Danazol is FDA-approved for treatment of mastalgia, although
it should be used for less than 6 months’ duration. Androgenic side effects
(e.g. hot flashes, acne, weight gain, GI disturbances) may be reduced
by limiting danazol administration to the patient’s luteal phase (i.e. days
15–25 for a 28 day menstrual cycle). 13
Selective estrogen receptor modulators such as tamoxifen (administered
PO) and afimoxifene (4-hydroxytamoxifen, applied topically as a gel)
may have a role in chronic therapy of mastalgia. 14 At this time, the risks of
these agents (e.g. venous thrombosis, gynecologic cancer) are either incompletely
characterized (with afimoxefene) or outweigh the benefits of therapy
as used in the ED setting. Thus, the acute care provider is advised to avoid
prescribing the selective estrogen receptor modulators for mastalgia.
n Summary and recommendations
NONCYCLIC MASTALGIA
First line:
n NSAID (e.g. ketorolac 30 mg IV every 6 h)
n topical diclofenac (2% gel, 11.6 mg/g, 50 mg diclofenac component TID)
Reasonable:
n other NSAIDs (e.g. ibuprofen 400–600 mg PO q6–8h)
n opioids (e.g. hydromorphone 1 mg IV, then titrate)
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