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Premenopausal breast pain: what works?

Q What therapeutic options are there for breast tenderness now that gamolenic acid (evening primrose oil) has had its licence withdrawn? Anecdotally, it worked a treat!

A True cyclical breast pain occurs in 70 per cent of premenopausal women. Patients should be asked to fill in a breast pain chart, advised to take simple analgesia, wear a firm exercise support bra and take regular exercise for 30 minutes three or four times per week.

Exercise releases endorphins to relieve the pain, but also relieves anxiety, particularly premenstrually. Women with cyclical mastalgia have been shown to be particularly anxious and have high anxiety and depression scores premenstrually compared to the population. Up to 30 per cent of patients respond to lifestyle measures.

If the pain occurs for more than seven days per month, is severe and interfering with a woman's life, tamoxifen 10mg/day from days 10-25 of the menstrual cycle can be used for three to six months. Up to 90 per cent of women get relief with this regime, and the side-effect profile is reasonable.

Pain relief after a three-month course of tamoxifen will often last up to a year. Tamoxifen can only be used with non-hormonal contraception because of potential teratogenicity.

An alternative treatment is danazol 100mg/day for two to three months, followed by reducing the dose to 50mg/day. Danazol also gives a 90 per cent response with pain relief, but has occasional side-effects such as deepening of the voice, menorrhagia and muscle cramps.

Gamolenic acid was withdrawn for mastalgia because 'data does not support the current standard of efficacy required'. Three small trials showed GLA worked, while a larger trial showed it had some effect. There is no evidence that drinking less tea or coffee relieves breast pain.

Dr Nigel Bundred is professor of surgical oncology at South Manchester University Hospital

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