What helps treat nipple vasospasm? A case and reflections

There's no evidence to support the use of nifedipine for vasospasm of the nipples

I almost never prescribe nifedipine or other drugs for nipple vasospasm. Although this treatment is widespread, it is typically prescribed in the context of unresolved breast tissue drag. Many of the women I see are already taking nifedipine but come in to see me anyway because of ongoing nipple pain and vasospasm.

A case of severe lactation-related nipple vasospasm

I saw a woman once who had such severe and frequent vasospasm of the nipples, without a predisposing history, that she said to me: ‘When the baby comes on, I can’t do anything, I can’t move, I can’t do the micromovements.’ She had been taking nifedipine for weeks.

I could see her freezing with the severity of the pain from frequent and extreme vasospasm during breastfeeding during the consultation. Her vasospasm also occurred constantly throughout the day. This was at the most severe end of the spectrum of vasomotor instability.

I suggested a break from direct breastfeeding and very gentle pumping just for comfort, with formula use as required, at the same time as we worked on the gestalt method of fit and hold (without baby), preparing for when her nipples were more healed and she recommenced direct breastfeeding.

I saw little benefit in changing her from the nifedipine to another medication in the same family, because the underlying problem was clearly repetitive micro-trauma from breast tissue drag. That was what we worked on, and that is how her nipple pain and vasospasm finally resolved, after more than a week’s breastfeeding pause. It did take time for her supply to recover.

What might help, in addition to fit and hold work?

Warmth has a role, because change of temperature can trigger a vasospasm in damaged nipples with blanching and pain. Some women like to use specially designed, very soft woollen breast pads.

I’m concerned though about advice not to ‘air’ the nipples when a woman has vasospasm. In fact, as we’ve seen, moisture increases the risk of inflammation in the nipple epithelium, and the nipples need to be kept dry, but without irritating triggers like harsh breast pads.

It’s widely acknowledge that avoiding the triggers of cold, stress, vibrations, sympathomimetic (or stimulant) drugs, and repetitive mechanical stress will help reduce vasospasm – but there is a blind spot around the repetitive mechanical stress of breast tissue drag during lactation.

It makes sense to avoid beta-blockers and vasoconstrictors eg. propranolol or pseudoephedrine if a woman has nipple vasospasm.

What doesn’t help?

Drugs for vasospasm have actually not been studied in breastfeeding women, so no-one knows if they make any difference compared to the passage of time, and I suspect not. Important research has shown that both doctors and patients overestimate the benefits of medications and underestimate the side-effects.

You might hear some doctors say that nifedipine increases vascularisation, which is not the case.

Vasodilators such as calcium channel blockers (which include nifedipine and amlodipine) are regularly prescribed for vasospasm, though there is no evidence to show that they improve a woman’s pain. Commonly, women are prescribed Nifedepine 30 mg Slow Release once daily.

• Nifedipine increases nitric oxide levels which induce vasodilation. Nitric oxide also dilates systematic veins, which then decreases venous return.

• With these drugs, there is decreased oxygen demand and increased oxygen supply. They act not just on the nipple vascular plexus but on all the peripheral blood vessels in the body.

• This is why, when taking Nifedipine, women commonly experience headaches, which be severe, due to cerebral vasodilation. They may also experience ankle swelling, flushing and dizziness, fatigue and body aches.

Our American colleagues, who use medications aggressively, increase Nifedipine to 60 mg SR daily, and then if the vasospasm is not resolving, might prescribe Verapamil 120 mg SR daily and even increase to 240 mg/day or 360 mg/day.

If this doesn’t help (or if the breast tissue drag and nipple pain hasn’t resolved by itself with the passage of time, quite mercifully and by accident), instead of questioning the diagnoses or efficacy of pharmaceutical treatment, they may try amlodipine up to 10mg bd. (Amlodipine 5-10 mg daily causes less oedema in the warmer months.) Diltiazem may also be prescribed.

Is there a role for investigating psychological stressors?

Although it is vital to remain alert to psychological stressors and mental health challenges in our patients, and to offer appropriate support, I notice that there has been in recent years an inappropriate focus on mental health problems by some breastfeeding medicine doctors, as an explanation for persistent nipple pain.

For example, these doctors explore psychological issues when a woman has recalcitrant vasospasm, inquiring into depression, gender dysphoria, and past traumas. I find this trend concerning.

There is a belief among these doctors that patients use the language of breastfeeding to express deeper psychological traumas. Although there is no evidence to support it, I've heard breastfeeding medicine doctors claim that a history of abuse is common with chronic nipple pain.

The implication here is that the woman has an exaggerated experience of pain due to an untreated depression or history of trauma. Vasospasm pain is thought of as a variation in biological sensitivity to pain, which overlaps with perinatal mood disorders. These doctors prescribe Selective Serotonin Reuptake Inhibitors (SSRIs) to decrease neuropathic pain perception. I am concerned that this attempt to be attuned to women’s psychological realities, which is so important, can be applied inappropriately in consultations, and can accidentally perpetuate ‘mother-blaming’ as a compensation for failure of our clinical tools.

Other unhelpful treatments for vasospasm

The following lack an evidence base and are not helpful for lactation-related nipple vasospasm.

• Many women with vasospasm are also put on antibiotics for inappropriate diagnoses of mammary dysbiosis, which is said to underlie the vasospasm, but this doesn’t make physiological sense.

• B6 and magnesium (300 mg magnesium twice daily) may be prescribed. It is said that magnesium relaxes the blood vessels, but there is no evidence and no biologically plausible mechanism to support this theory. Too much vitamin B6 can cause neurological effects, again without evidence or plausible biological mechanisms to warrant its use.

• Calcium and fish oil supplements may be prescribed, because fish oil capsules (containing essential fatty acids) or evening primrose oil (gamma linoleic acid) are said to improve blood vessel relaxation.

Selected references

Anderson PO. Drug treatment of Raynaud's phenomenon of the nipple. Breastfeeding Medicine. 2020;15(11):686-688. https://doi.org/610.1089/bfm.2020.0198.

Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2022;18:17455057221087865.

Douglas PS. Does the Academy of Breastfeeding Medicine Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary. International Breastfeeding Journal. 2023;18:Article no. 51 https://doi.org/10.1186/s13006-13023-00588-13008.

Hoffman T, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening and tests - a systematic review. JAMA Internal Medicine. 2015;175(2):274-286.

Hoffman T, Del Mar C. Clinicians' expectations of the benefits and harms of treatments, screening, and tests - a systematic review. JAMA Internal Medicine. 2017;177(3):407-419.