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Danazol
Bromocryptin
Tamoxifen
LHRH agonist
Abstention from medications
Recent start of any medication, especially hormones or phenothiazines, coinciding
with the onset of breast pain should be suspected. Withdrawal of oestrogenic drive by
means of oestrogen medication often can produce dramatic relief.
Nutritional Treatment
Restriction of methylxanthines and dietary fat has doubtful value.
Iodine and Vitamins B1, B6 and E have no proven value.
NSAID
When the pain is not very severe, occasionally a choice of any commonly used
NSAID may be enough to alleviate the patients symptom. However prospective
randomized trial using oral analgesic is not available.
Oil of evening primrose
This is in fact gamma-linolenic acid. Given 3 g/day it is only effective in 44% and
27% of cyclic and noncyclic mastalgia, respectively.
Danazol
This attenuated androgen is the 2,3-isoxazol derivative of 17-a-ethynyl testosterone
(ethisterone). At doses of 100mg/day, it inhibits the mid-cycle surge of LH. LH and
FSH remain normal during treatment. It also competitively inhibits oestrogen and
progesterone receptors in breast, hypothalamus, and pituitary, as well as ovarian
steroidogenesis. It can be given up to 400 mg per day in 2 divided doses. It is
effective in 70% of cyclic and 30% noncyclic cases. Side effects include water
retention, GI upset, and headache. One can start and maintain therapy at 100 mg twice
daily for 2 months while maintaining a record of breast pain. If an incomplete
response or no response is obtained, the dose is increased to 200 mg twice daily. If
still no response occurs, another drug should be tried. Therapy should not be
continued for longer than 6 months and should be tapered.
Bromocryptin
This is an ergot alkaloid that acts as a dopaminergic agonist on the
hypothalamic-pituitary axis resulting in suppression of prolactin secretion. Usually
given in doses of 25 mg/day, it is effective in 47% and 20% of cyclic and noncyclic
cases respectively. Side effects include generalised weakness, feeling of cold and
nausea and vomiting. There are reports of serious side effects including seizures,
strokes and fatalities.
Tamoxifen
This is a non-steroidal triphenylethylene derivative that is an estrogen
agonist-antagonist that competitively inhibits the action of oestradiol on the mammary
gland. It is usually given in doses of 20mg/day. It is effective in 85% of cases.
However, it has the potential danger of causing uterine cancer. It is seldom used as the
first line drug.
Luteinizing Hormone-Releasing Hormone Agonist (LHRH)
The mechanism of action is incompletely understood. The potent antigonadotropic
action of LHRH agonist induces complete ovarian inhibition, resulting in low blood
levels of oestradiol, progesterone, ovarian androgens, and prolactin. It may be
effective in up to 80% of severe refractory cases. Side effects can include hot flushes,
myasthenia, depression, vaginal atrophy, decreased libido, visual disorders, and
hypertension, but they usually do not require therapy cessation. LHRH agonist
induces significant loss of trabecular bone, however. For this reason, LHRH
analogues should be reserved for severe refractory cases of mastalgia and are not used
routinely or for longer than 3 months.
Conclusion
Mastalgia can be caused by a variety of causes. It can be cyclic or non-cyclic.
Generally speaking, cyclic mastalgia is more amenable to treatment as compared to
non-cyclic mastalgia. Patients are generally more troubled by the worry of breast
cancer than the actual pain itself. Adequate explanation and reassurance would be able
to alleviate the patients worry and no further treatment is needed in the majority of
cases. In case the patients symptom is severe enough to warrant drug treatment, a
variety of drugs may be used.