Bra Prescriptions for Mastalgia. Is this part of your job?

Mastalgia can be a difficult symptom to treat in patients. It may be cyclical or not, and patients can have difficulty lining up their breast pain with the luteal phase of their cycle. 

After ruling out other possible causes of mastalgia, treating benign breast pain should include a discussion about tracking symptoms, rating of pain severity and about bras. 

Frustratingly, despite relatively positive research on bras, there is a scarce number of articles that have become the authority on this topic. Oftentimes, after a landmark trial is published (in this case, Hadi 2000), many studies follow. Subsequent studies seek to confirm the findings of the original trial and continue to elaborate on the nuances of prescribing. Are there some patients who benefit more than others? Are there circumstances where this intervention doesn’t work at all?

In this case, the Hadi article has become almost our only intervention trial looking at bras and mastalgia. The trial uses 24-hour a day sports bra wearing for patients with benign breast pain. It compares sports bra wearing against danazole treatment. The drug is effective in the trial, with 58% of participants reporting a relief of symptoms. 42% of the group also reported drug side effects. After 8 weeks the patients in the bra arm of the trial reported a significant improvement in breast pain with 85% of the participants demonstrating improvement. 

Unfortunately, given that it was a direct head-to-head trial against medication, there was no control group. The cyclical and wax/wane nature of benign breast pain makes it notoriously subject to the placebo effect (or just plain old “natural resolution”). It’s likely why we don’t focus enough research studies on mastalgia. It’s like trying to grab smoke in your fist. 

The most recent article on bras and mastalgia uses a slightly different trial design, with participants being ‘fitted’ with a bra using very clear instructions (Sharland 2021). We’ve included the instructions in an example patient handout that you can download at the end of this article. It’s an example of the hundreds of time-saving resources we offer clinicians at The Confident Clinician. 

What is most curious about this recent study is the path to improvement that patients take. It highlights the importance of clear communication around timelines and expectations when patients begin a plan. Although many of the patients in the bra arm reported improvement of their symptoms, statistically significant improvement wasn’t achieved until the group reached the 4-week mark. The graph in the paper highlights that some progress was achieved at the 2-week mark, but it didn’t reach significance until 4 weeks. 

We can speculate that these findings are due to the cyclical nature of breast pain. Likely, approximately half of menstruating participants will be in the luteal phase and half in the follicular phase during any given week of a study (unless of course, they used the pill to commence menstruation at the same time in all participants, which is occasionally done to control for the cycle). 

If half of the participants were in the follicular phase of their cycle (and arguably would have lower breast pain) we may not see the full impact of the intervention until all participants have moved through a full cycle. It’s also possible in menstrual-connected symptoms that patients won’t see an improvement in the first cycle, as they need time with the intervention before the effect is observed. 

Reading papers on symptoms that correlate with the mensrual cycle requires a unique lens, including reading between the lines of how long symptoms take to improve. It highlights how important patient communication can be and why clinicans need to clearly outline expectations to their patients. 

Occasionally, we can get lucky and see an improvement in menstrual-related symptoms in the first month of treatment (ginger for dysmenorrhea for example), but more often we’re setting an expectation of 2 or more cycles and require prospective symptom tracking to best understand a patient’s course of treatment.