Mastalgia Algorithm

Safety

Screen for red flags — exclude breast cancer & serious pathology first

Done — red flags excluded

Before exploring cyclical vs non-cyclical pain, rule out these life-threatening and urgent diagnoses. Any red flag mandates same-day or urgent action.

New discrete lump Hard, irregular, painless or painful mass → Suspected cancer: breast clinic (NICE NG12 — urgent breast referral)

Skin changes Peau d'orange, skin tethering, dimpling, ulceration (any age) → Consider suspected cancer referral: breast clinic (NICE NG12; includes inflammatory breast cancer)

Nipple changes Discharge, retraction or other concerning change in one nipple age 50+ (e.g. new inversion, eczematous change unresponsive to treatment — Paget's disease, spontaneous unilateral bloody discharge) → Suspected cancer: breast clinic

Axillary lump Unexplained axillary lump age 30+ — assess persistence, hardness, fixation, progressive enlargement, associated breast findings, local infection or recent vaccination → Consider suspected cancer referral: breast clinic (NICE NG12)

Mastitis with systemic illness, spreading cellulitis or suspected abscess → Same-day assessment; suspected abscess needs urgent breast/ultrasound assessment and drainage, not repeated empirical antibiotics. Persistent, recurrent or atypical non-lactational mastitis → breast service (differentials include inflammatory breast cancer, granulomatous mastitis, periductal mastitis, infection)

Breast pain alone, normal examination Very rarely due to breast cancer. Manage initially in primary care with explanation, support, appropriate analgesia and review → Consider non-urgent breast referral if pain is persistent, focal, unexplained, significantly affects quality of life or fails to respond to initial treatment. Refer urgently if a mass or other suspicious sign develops.

Breast pain + an unexplained lump Age 30+, with or without pain → Suspected cancer: breast clinic (NICE NG12); under 30 → generally non-urgent referral, but urgent if hard, fixed, enlarging or otherwise clinically suspicious

Previous or known breast cancer + new bone pain New persistent focal bone pain, back pain, neurological symptoms or systemic features → Urgent oncology assessment via the patient's cancer pathway — contact the acute oncology team the same day; Emergency for suspected pathological fracture, spinal cord compression or acute neurological compromise. Without a breast-cancer diagnosis, breast pain plus nonspecific back pain is not in itself evidence of metastatic disease.

Breast pain alone with a normal examination is very rarely due to breast cancer, and there is no evidence that mammography discriminates for cancer in this group, but missing a concurrent lump while focusing on pain is a significant safety failure. Under NICE NG12, an unexplained breast lump at age 30 and over, with or without pain, needs a suspected cancer pathway referral. Inflammatory breast cancer (IBC) is particularly dangerous — it mimics mastitis and carries a worse prognosis than early-stage disease. Post-menopausal or unilateral pain alone does not automatically meet a suspected cancer referral criterion; review and consider non-urgent referral if persistent. RCGP SCA examiners will specifically test whether candidates can risk-stratify breast presentations without missing red flags.

Diagnose

Classify the mastalgia — cyclical vs non-cyclical vs chest wall

Done — type classified

Use a structured history — pregnancy, lactation, menstrual relationship, duration, focality, severity, any lump, discharge, skin/nipple change, axillary symptoms and previous breast cancer. A breast pain diary (Cardiff Breast Pain Chart) over up to two cycles can help where the relationship to menstruation is unclear, but is not required in every patient.

Pain diary

If the menstrual relationship is unclear, a Cardiff Breast Pain Chart for up to two cycles — patient marks daily severity (0–3) and relation to periods. Not required in every patient.

Menstrual relationship

Ask: "Does the pain follow your cycle? Does it start 1–2 weeks before your period and ease when it starts?" Cyclical pain typically builds in luteal phase and resolves with menstruation.

Location & character

Cyclical: diffuse, bilateral, upper outer quadrant, heavy/aching. Non-cyclical: unilateral, focal, burning or sharp. Chest wall: reproducible with pressure on costochondral junctions. Pain location alone is not a reliable indicator of malignancy.

Duration

Cyclical: onset 20s–40s, perimenopausal peak. Non-cyclical: any age. After the menopause the absence of menstruation makes cyclical classification less useful; examine carefully and review.

Medication review

Check for HRT, OCP, SSRIs, antipsychotics, digoxin, methyldopa, spironolactone, cimetidine — all can cause mastalgia as a side effect. Ask about herbal remedies (evening primrose, phytoestrogens).

Caffeine / diet

Caffeine and dietary fat — evidence of benefit from reduction is weak; may be discussed as an optional self-management trial.

The Cardiff Breast Pain Chart was developed specifically for primary care and is validated for guiding treatment decisions. Cyclical mastalgia often settles spontaneously, and recording symptoms can itself reduce anxiety. Non-cyclical pain has a more varied aetiology (breast, chest-wall, cervical, shoulder, medication-related or neuropathic) and needs careful clinical reassessment rather than routine imaging. Misclassifying chest wall pain (Tietze's syndrome, costochondritis) as breast pain leads to unnecessary breast referrals.

Diagnose

Phenotype the mastalgia — subtype diagnosis drives management

Done — subtype identified

Once red flags excluded and diary reviewed, classify into one of four subtypes:

Cyclical mastalgia

Bilateral, upper-outer quadrant, starts 7–14 days pre-menstrually, resolves with period. Age 20–40s. Usually physiological — exaggerated progesterone/prolactin sensitivity. Often no underlying pathology. Usually benign

Non-cyclical mastalgia

No relationship to cycle. Unilateral, often focal, sharp or burning. Does not necessarily indicate breast pathology — may be chest-wall, cervical, shoulder, medication-related or neuropathic. Breast causes: duct ectasia, periductal mastitis, macrocyst, post-surgical change, Mondor's disease (superficial thrombophlebitis). Needs further assessment

Chest wall / musculoskeletal

Costochondritis (Tietze's), intercostal muscle strain, cervical radiculopathy, rib stress fracture. Reproduced by pressing on costochondral junction — not the breast itself. Manage as MSK pain in primary care

Drug-induced

HRT (oestrogen-dominant), combined OCP, SSRIs (esp. sertraline), antipsychotics (↑ prolactin), digoxin, spironolactone. Review medication list in every case. Review with shared decision-making

Severity grading

Mild: a few days per cycle, little effect on daily life — reassurance + lifestyle. Moderate: more days per cycle or more troublesome — consider topical NSAIDs. Severe: affects sleep, work or daily function — treat first line and refer routinely to the breast clinic if not responding after 3 months (Step 6). Use the pain diary to grade severity.

Subtype classification is the pivot point for the entire management pathway. Cyclical mastalgia often responds to explanation, reassurance and simple measures. Non-cyclical mastalgia responds less predictably and should prompt reconsideration of chest-wall and musculoskeletal causes rather than routine imaging. Drug-related mastalgia should be addressed by shared review of the medicine, not automatic withdrawal. Treating chest wall pain with breast-directed therapy is ineffective and delays appropriate musculoskeletal management. The severity grading ensures proportionate escalation — avoiding unnecessary systemic hormonal therapy in mild cases.

Diagnose

Targeted breast examination — what to look for and what it means

Done — examination completed

Offer a chaperone. Examine in two positions: sitting (arms by sides then arms raised) and lying (arms behind head). Document findings explicitly in notes.

Inspection — sitting

Look for skin changes (peau d'orange, erythema, oedema), asymmetry, nipple changes (inversion, eczematous change, discharge). Dimpling with arm raise is a concerning sign (not diagnostic of malignancy) → consider a suspected cancer pathway referral (NICE NG12). Normal finding: symmetrical contour, no skin changes.

Palpation — quadrants

Systematically palpate all four quadrants + axillary tail + subareolar. Discrete lump: note size, consistency (soft/firm/hard), mobility, fixation to skin or muscle → suspected cancer pathway referral if any uncertainty. Diffuse nodularity = fibrocystic change (benign). Focal tenderness without mass — reassuring if matches pain site.

Nipple discharge

Do not routinely express the nipple — manipulation can itself produce discharge and may be uncomfortable. Ask whether discharge is spontaneous or only occurs after expression. Document whether it is unilateral or bilateral, single-duct or multi-duct, and its colour. Bilateral, multi-duct, clear/milky = usually physiological or drug-related. Spontaneous unilateral bloody or serous discharge is concerning → refer according to local breast pathways (suspected cancer pathway if age 50+). Persistent galactorrhoea → check prolactin, TSH, medications.

Axillae

Palpate for lymphadenopathy. Size alone is not a reliable criterion — assess persistence, hardness, fixation, progressive enlargement, associated breast findings, local infection or recent vaccination. Unexplained axillary lump age 30+ → consider a suspected cancer pathway referral (NICE NG12). Soft, tender, mobile nodes = reactive (infection, recent vaccination). Normal: no palpable nodes or soft small nodes.

Chest wall

Press firmly on costochondral junctions (2nd–5th). Reproduces the pain exactly = chest wall origin (Tietze's/costochondritis). Press over breast — no reproduction. Document clearly to guide management.

Extramammary causes

Examine the shoulder, cervical and thoracic spine, and ask about upper-limb and nerve-root symptoms.

Supraclavicular fossa

Palpate supraclavicular nodes — enlarged hard nodes with breast pain → suspected cancer pathway referral to the breast clinic (possible nodal spread).

Bra fit assessment

Ask about bra type and size. Poorly fitting bra (especially underwired) is a common, under-recognised cause of non-cyclical breast pain — particularly in women with large breasts. Simple intervention with significant impact.

Clinical breast examination is not a screening tool, but it is essential in any mastalgia presentation to exclude concurrent pathology. The chest wall compression test (pressing on costochondral junctions) has high specificity for musculoskeletal aetiology — a positive test changes management completely, avoiding unnecessary breast imaging and systemic treatment. A well-fitting supportive bra may help, particularly for larger breasts or activity-related pain.

Diagnose

Targeted investigations — when to test and when NOT to

Done — investigations considered

Most cyclical mastalgia with normal examination requires no investigations in primary care. Investigate to exclude specific causes:

Breast imaging

Do not routinely request mammography for breast pain alone with a normal examination — there is no evidence that mammography discriminates for breast cancer in this group. Do not delay a clinically indicated breast referral to obtain primary-care imaging. Refer a suspicious mass or other concerning sign to the breast service for clinical and triple assessment; the imaging modality is selected by the breast service according to age, examination and pregnancy/lactation status (ultrasound is often preferred in younger patients, but mammography may still be used where indicated). Imaging via breast clinic

Serum prolactin

Not for bilateral mastalgia alone. Check if persistent galactorrhoea, amenorrhoea or menstrual disturbance, symptoms of pituitary disease, medication exposure likely to raise prolactin (antipsychotics, metoclopramide, domperidone, methyldopa) or unexplained hypogonadism. Use the local laboratory reference range. If elevated, repeat under appropriate conditions and review medicines before arranging pituitary imaging. Serum prolactin

TFTs

Hypothyroidism can cause diffuse mastalgia and galactorrhoea. Check TSH if galactorrhoea, menstrual disturbance, clinical suspicion of thyroid disease or unexplained hyperprolactinaemia — not a routine test for uncomplicated cyclical mastalgia. TSH

Pregnancy test

Breast pain is common in early pregnancy. Check urine hCG where pregnancy is possible and the history is uncertain. Breast pain in pregnancy or lactation needs a separate assessment pathway, especially with a persistent lump, focal inflammatory change or failure to respond to usual measures. Urine hCG

Hormonal profile

Do NOT routinely check oestrogen, progesterone, or LH/FSH for typical cyclical mastalgia — unhelpful and not evidence-based. Check FSH/LH only if assessing for perimenopause when this is clinically relevant. Avoid routine hormone panels

Do NOT order

Routine FBC, CRP, liver function for mastalgia — not indicated without specific clinical concern. Avoid over-investigating benign cyclical breast pain, which increases patient anxiety and generates unnecessary follow-up. Avoid unnecessary bloods

Association of Breast Surgery guidelines emphasise that investigations should be proportionate and targeted. Over-investigation of typical cyclical mastalgia creates health anxiety, nocebo effects, and false-positive cascades. The breast clinic (triple assessment: clinical exam + imaging + biopsy if needed) is better placed to perform and interpret breast imaging than primary care ordering mammograms ad hoc. Prolactin and TFTs address specific treatable causes — normal prolactin excludes pituitary-driven galactorrhoea and guides management. Pregnancy is the single most important and easily missed non-breast cause of mastalgia in women of reproductive age.

Refer

Referral criteria — who needs specialist breast clinic input

Done — referral decision made

Most mastalgia is managed entirely in primary care. Use these criteria to decide urgency:

999

None for mastalgia alone. If septic shock from breast abscess → 999. Suspected pathological fracture with severe pain, deformity or neurovascular compromise, or suspected spinal cord compression → 999/emergency.

Same day

Mastitis with systemic illness, spreading cellulitis or suspected abscess — suspected abscess needs urgent breast/ultrasound assessment and drainage, not repeated empirical antibiotic courses. Non-lactational mastitis not improving after 48 hrs → reassess (not an automatic diagnosis of malignancy); persistent, recurrent or atypical → breast service to exclude inflammatory breast cancer.

Suspected cancer: breast clinic

Unexplained breast lump age 30+, with or without pain (discrete hard/fixed lump: urgent at any age). Discharge, retraction or other concerning change in one nipple age 50+ (including nipple eczema not responding to topical treatment — exclude Paget's). Consider referral for skin changes suggestive of breast cancer (dimpling, peau d'orange, ulceration) at any age, or an unexplained axillary lump age 30+. Clinical uncertainty about a discrete or suspicious finding.

Consider non-urgent breast clinic

Post-menopausal or persistent focal non-cyclical pain with a normal examination — review, and consider non-urgent referral if persistent, unexplained or affecting quality of life. Urgent referral if any breast, nipple or axillary abnormality develops.

Routine breast clinic

Severe cyclical mastalgia affecting quality of life or sleep and not responding to 3 months of first-line primary care treatment (specialist breast/menopause assessment). Confirmed macrocyst causing pain. Recurrent cysts.

Primary care only

Typical cyclical mastalgia + normal examination. Confirmed chest wall pain (MSK pathway). Drug-induced mastalgia (manage by medication review). Mild–moderate mastalgia responding to lifestyle + topical NSAIDs.

NICE NG12 sets the suspected cancer pathway referral thresholds: an unexplained breast lump at 30 and over, with or without pain; discharge, retraction or other change in one nipple at 50 and over; and consider referral for skin change suggestive of cancer, or an unexplained axillary lump at 30 and over. The Association of Breast Surgery guidelines explicitly support primary care management of typical cyclical mastalgia without referral — this is appropriate stewardship of breast clinic capacity. NICE notes that in people presenting solely with breast pain and no palpable abnormality, there is no evidence that mammography discriminates for breast cancer and routine imaging is not recommended. Post-menopausal or unilateral pain alone does not automatically meet a suspected cancer criterion — review, and consider non-urgent referral if persistent or unexplained.

Treat

Pharmacological treatment ladder — start low, escalate methodically

Done — treatment initiated

Begin treatment after red flags excluded, type classified, and lifestyle interventions initiated. Cyclical and non-cyclical mastalgia may respond differently:

First line — by mastalgia type:

Cyclical mastalgia

Topical NSAID 1st line

After explanation, reassurance and a supportive bra: topical NSAID (e.g. diclofenac gel) if required — dose and duration per product information and local formulary, subject to contraindications. Minimal systemic absorption. Preferred over oral NSAIDs.

Non-cyclical mastalgia

Topical NSAID 1st line

Topical NSAID to the focal pain site (per product information/local formulary). Less predictable response than cyclical — arrange review. If no response, reconsider chest-wall and musculoskeletal causes, review medication and pregnancy status, and consider non-urgent breast referral if persistent or unexplained.

Drug-induced

Medication review 1st line

Review temporal relationship, dose and preparation. Discuss risks and benefits with the patient and, where necessary, the menopause or breast specialist. Do not change effective HRT or contraception without considering symptom control, pregnancy risk, bleeding pattern and contraceptive requirements. Do not switch an effective antidepressant or antipsychotic solely because of mastalgia without shared decision-making and consideration of relapse risk. In current or previous breast cancer, do not alter endocrine therapy in primary care without specialist input. Document rationale.

Chest wall pain

Oral NSAID + physio 1st line

Topical NSAID, or oral ibuprofen with food used cautiously (pregnancy, renal disease, peptic ulcer disease, cardiovascular disease, anticoagulants, older age, asthma or previous NSAID reaction) + local heat. Consider local steroid injection (triamcinolone + lidocaine, dose per NICE/SPC) into costochondral junction if persistent — highly effective for Tietze's. Refer physio if recurrent.

Escalation — persistent or severe cyclical mastalgia (specialist steps are not a routine primary-care ladder):

Step 1Explanation + reassurance + supportive bra (pain diary if cycle relationship unclear). Start here for mild symptoms.

Step 2Topical NSAID — dose and duration per product information/local formulary. First pharmacological step. Simple analgesia where appropriate.

Step 3Evening primrose oil (EPO) — not routinely recommended because evidence of benefit is limited or absent (UK prescription licences for gamolenic acid products were withdrawn in 2002 for lack of efficacy evidence). If a patient chooses to try an OTC supplement, discuss uncertain benefit, interactions and adverse effects.

Step 4Tamoxifen — specialist initiated only, after specialist assessment. Specialist May be effective for severe, persistent mastalgia. Off-label for mastalgia in the UK. Discuss thromboembolic risk; consider endometrial and menstrual adverse effects; avoid in pregnancy and ensure appropriate non-hormonal contraception; shortest effective duration. Do not prescribe routinely in primary care.

Step 5Danazol — specialist only; not a routine step. Specialist Androgen with anti-gonadotrophic effect. Androgenic adverse effects (weight gain, acne, hirsutism, voice changes) and important contraindications. Effective contraception required. Do not start simply because topical treatment has failed.

Step 6Bromocriptine — not routinely recommended for ordinary mastalgia. Specialist Dopamine agonist — generally reserved for a specialist indication such as confirmed hyperprolactinaemia. Side effects: nausea, dizziness, hypotension. Do not start simply because topical treatment has failed.

Next steps: see Benign breast disorders · Mastitis and breast abscess · Breast cancer

Evidence base for each step:
Topical NSAID: minimal systemic absorption — preferred over oral NSAIDs for focal breast or chest-wall pain; follow product information for dose and duration.
Evening primrose oil, vitamin E and vitamin B6: current evidence does not demonstrate meaningful benefit — not routinely recommended.
Tamoxifen: may be effective for severe, persistent mastalgia; off-label for mastalgia in the UK; thromboembolic, endometrial and menstrual adverse effects; specialist-led only.
Danazol: androgenic adverse effects commonly cause discontinuation; specialist-led only.
RCGP examiners expect trainees to know that GCSB (goserelin/GNRH analogues) are NOT routinely used for mastalgia in primary care — these are third-line specialist options.

Lifestyle

Non-pharmacological interventions — optional self-management with realistic expectations

Done — lifestyle advice given

Supportive underwear, general physical activity, weight management where appropriate and stress management are reasonable. Dietary changes can be offered as optional, time-limited self-management trials with realistic expectations, not mandatory treatment:

👙 Correct bra fitting Well-fitting, supportive bra (consider sports bra during activity or flares), particularly for larger breasts or activity-related pain. Avoid underwired bras during exacerbations.

☕ Caffeine reduction Evidence that reducing caffeine reliably treats mastalgia is weak. If the patient wishes, offer an optional, time-limited trial of reduced caffeine with realistic expectations.

🥗 Dietary fat reduction Evidence that reducing dietary fat reliably treats mastalgia is limited. Can be offered as an optional self-management trial; healthy eating may also benefit weight and cardiovascular risk.

🏃 Regular aerobic exercise General physical activity is reasonable for overall health and wellbeing; wear a supportive bra during exercise.

📓 Pain diary (Cardiff Chart) Up to two cycles if the relationship to menstruation is unclear. Tracking pain can reduce anxiety by contextualising the symptom pattern.

🌿 Evening primrose oil Not routinely recommended because evidence of benefit is limited or absent (no longer a licensed medicine in the UK since 2002). If a patient chooses to try an OTC supplement, discuss uncertain benefit, interactions and adverse effects.

💊 Vitamin E / B6 Should not be routinely recommended — evidence of benefit is limited or absent. Chronic high-dose pyridoxine (B6) can cause peripheral neuropathy; high-dose vitamin E also has potential harms and no established role in mastalgia. If a patient chooses to try a supplement, discuss uncertain benefit, interactions and adverse effects.

🧘 Stress management Stress amplifies pain perception. CBT, mindfulness, yoga all have RCT evidence for chronic pain reduction. Consider referral to NHS Talking Therapies or self-referral to wellbeing service if anxiety component prominent.

⚖️ Weight management Weight management where appropriate, for general health. Refer to tier 2 weight management if appropriate.

Lifestyle interventions are under-prescribed for mastalgia and over-reliance on pharmacotherapy is common. Explanation, reassurance and a well-fitting supportive bra are the most defensible first steps. Claims that reducing caffeine or dietary fat reliably treats mastalgia are not well supported; offer these only as optional, time-limited trials with realistic expectations. Evening primrose oil, vitamin E and vitamin B6 are not routinely recommended.

Safety

Follow-up & safety-netting — when to return and when to escalate

Done — safety-netting provided

Safety-net every patient explicitly. Document that safety-netting advice was given in the notes.

2–4 weeks

If starting topical diclofenac or new medication — review tolerability, ensure correct application, check pain diary is being kept. Reassess if symptoms worsening.

6–8 weeks

Review pain diary at 2 completed cycles. Assess response to first-line treatment. If no improvement: check the diagnosis (chest wall, medicines, pregnancy) and adherence; continue first-line treatment to the 3-month review (specialist steps in Step 7 are not started in primary care). If improved: continue and plan 3-month discharge review.

3 months

Full review at 3 months. Has pain resolved, improved, or persisted? If resolved: discharge with safety-netting. If partially improved: continue current treatment for further 3 months. If no improvement: consider referral to breast clinic (routine).

6 months

If still on pharmacological treatment — consider stepping down or stopping to see if spontaneous resolution has occurred. Many women can stop treatment after 6 months; reassess need for continuation.

Annual

For women with ongoing cyclical mastalgia — annual breast awareness check. Remind patient of normal breast screening programme (mammographic screening from age 50 via NHS BSP). No additional surveillance needed for mastalgia alone.

999 if:

Breast abscess causing sepsis (high fever, rigors, haemodynamic compromise). Suspected pathological fracture with severe pain, deformity or neurovascular compromise, or suspected spinal cord compression, in known or suspected breast malignancy.

Same-day if:

New discrete palpable lump or new focal pain develops at any point during follow-up. Skin changes develop (dimpling, peau d'orange). New nipple inversion. Wound/abscess concern in post-surgical patient. Spontaneous unilateral bloodstained nipple discharge appears.

Return if:

Pain becomes unilateral, focal, and persistent (change in pattern). Pain no longer related to menstrual cycle. Menstrual irregularity on hormonal treatment. New symptoms develop (weight loss, bone pain, fatigue) — reassess and arrange cancer/orthopaedic evaluation according to context.

Discharge criteria

Pain resolved or mild and manageable with lifestyle measures alone. Normal examination at all visits. No new features of concern. Safety-netting understood and documented. Patient has breast screening info.

Safety-netting is a critical RCGP SCA competency domain and is frequently assessed. The key risk in mastalgia management is a change in symptom character that indicates new pathology developing — a cancer arising coincidentally in a woman already on the mastalgia pathway. Documented safety-netting protects both the patient and the practitioner. The 3-month review is important because: (1) most responders to first-line treatment show improvement by 3 months, (2) tamoxifen response is assessed at 3 months in breast clinic protocols. Pattern change (becoming non-cyclical, becoming focal, becoming unilateral) is the key alarm feature that warrants urgent reassessment — this must be explicitly communicated to the patient.