Mastalgia Algorithm · Reasoning GP

The full reasoning pathway as a flowchart — exclude breast-cancer red flags first, characterise the pain with a diary, phenotype into a named subtype, examine and investigate proportionately, then treat up a ladder, refer on threshold, modify lifestyle and safety-net.StartDecisionInvestigateActionReferStop / Admit

PresentationBreast pain (mastalgia)

Characterise the pain: cyclical (hormonal) vs non-cyclical vs extramammary (chest wall). Note focal vs diffuse, lump, skin/nipple change, laterality and age. Examine both breasts, axillae and chest wall with a chaperone before deciding anything.

Step 1 · Safety — exclude breast cancer firstAny cancer red flag or urgent sign?

New discrete lump — hard/irregular, painful or painless, especially age ≥30
Skin change — peau d'orange, tethering, dimpling on arm-raise, ulceration
Nipple change — new inversion, eczematous change (Paget's), bloody/serous unilateral single-duct discharge
Axillary / supraclavicular nodes — hard, fixed, enlarging
Abscess / non-lactational mastitis not settling — erythema, fever, fluctuant mass
Post-menopausal or persistent focal non-cyclical pain >6 wks — lower referral threshold
Bone pain / systemic symptoms with known cancer or strong FHx → metastatic until proven otherwise

YES — red flag

Stop · Escalate2WW or same-day

2WW NICE NG12 any lump ≥30 · skin/nipple change · bloody discharge · hard axillary node → urgent breast clinic. Same-day breast abscess / sepsis or pathological fracture.

NO — reassuring exam

Step 2 · CharacterisePain diary + history

Request a 2–3 month Cardiff Breast Pain Chart First line — daily severity 0–3 vs periods. Review meds (HRT, OCP, SSRIs, antipsychotics, spironolactone, digoxin). Diary alone resolves 20–30%.

Step 3 · phenotype — subtype drives management

Step 3 · Decision — phenotype the mastalgiaWhich subtype is this?

Use diary + history + exam to place the pain. Grade severity by VAS and days/cycle (mild <7 days & VAS <4 · moderate 7–14 · severe >14 days or VAS >7) to keep escalation proportionate.

Cyclical · 60–70%

Usually physiological

Bilateral, upper-outer, builds 7–14 days pre-menstrually, eases with period. Age 20s–40s. Usually benign

Non-cyclical · ~25%

Assess cause

Unilateral, focal, sharp/burning. Duct ectasia, cyst, periductal mastitis, Mondor's. Image if focal/persistent

Chest wall · ~10%

Extramammary

Costochondritis/Tietze's, muscle strain. Reproduced by pressing costochondral junction, not the breast. MSK pathway

Drug-induced

Review meds

HRT, OCP, SSRIs (sertraline), antipsychotics (↑prolactin), spironolactone, digoxin. Switch/stop agent

Step 4–5 · examine & investigate proportionately

Step 4 · Examine

Targeted breast exam

Chaperone. Inspect sitting (arms down/up) for skin/nipple change & tethering. Palpate 4 quadrants + tail + subareolar for a discrete lump. Express nipple. Palpate axillae & supraclavicular nodes. Press costochondral junctions to reproduce chest-wall pain. Check bra fit.

Step 5 · Investigate

Only if indicated

No tests for typical cyclical pain + normal exam. Imaging (mammo ± USS via breast clinic) if non-cyclical/focal, age ≥40 or abnormal exam. Prolactin + TSH if galactorrhoea. Urine hCG if any doubt. Avoid routine hormone panels & bloods.

Step 7 · treat — start low, escalate methodically

Step 7 · Action — treatment ladderBy subtype, then escalate cyclical pain step-wise

1st-line all benign types: reassurance + topical diclofenac 1% gel (cyclical: 7–14 days pre-menstrually; non-cyclical: focal site, reassess 4 wks) + lifestyle. Preferred over oral NSAIDs.
Drug-induced: switch/stop the agent (HRT prep change, POP/barrier, alternative antidepressant).
Chest wall: oral ibuprofen + heat ± local steroid injection (triamcinolone + lidocaine) to costochondral junction; physio if recurrent.
Cyclical escalation: diary/lifestyle → topical NSAID (≥3 cycles) → evening primrose oil (GLA 3 g/day, 3-mo trial) → Specialist tamoxifen 10 mg OD (licensed, NNT≈2) → danazol → bromocriptine. Ensure contraception on hormonal agents.

Step 6 · escalation thresholds

Step 6 · ReferWho needs specialist breast clinic

Same-day breast abscess / sepsis · non-lactational mastitis failing antibiotics at 48 h.
2WW · NICE NG12 any palpable lump age ≥30 · bloody/serous unilateral discharge · skin dimpling/peau d'orange · new nipple inversion · nipple eczema not responding · hard axillary node · any uncertain finding.
Urgent breast clinic post-menopausal mastalgia with no cause · persistent focal non-cyclical pain >6 wks (triple assessment to reassure).
Routine breast clinic severe cyclical pain failing 3 months of primary-care treatment · symptomatic macrocyst / recurrent cysts.
Primary care only typical cyclical pain + normal exam · confirmed chest wall (MSK) · drug-induced (medication review).

Step 8 · lifestyle — treatment, not afterthought

Step 8 · Lifestyle & self-managementEvidence-based first-line measures

Professionally-fitted supportive bra (sports bra day/night during flares — up to 85% pain reduction in macromastia) · caffeine reduction (6-wk trial) · low saturated-fat diet · 150 min/wk aerobic exercise · continue pain diary (resolves 20–30% alone) · evening primrose oil OTC option · stress management / CBT for prominent anxiety · weight management if BMI ≥30. Frame these as active treatment, not advice.

Step 9 · review & safety-net

Step 9 · Review & safety-netReassure, review, and escalate on change

Review: 2–4 wks tolerability · 6–8 wks (2 cycles) response · 3 months for discharge vs referral · step down by 6 months. Return same-day for any new discrete lump, skin dimpling/peau d'orange, or bloody nipple discharge appearing during follow-up. Return if pain becomes unilateral/focal/persistent or loses its cyclical pattern. Give breast-awareness advice and ensure NHS mammography screening is up to date. Document safety-netting.

⚠️ Pain alone rarely signifies cancer (<5% of breast cancers present with pain), so isolated cyclical pain with a normal exam can be confidently reassured — but a focal, persistent or post-menopausal pain, or any pain with a lump or skin/nipple change, needs 2-week-wait breast referral under NICE NG12.

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 → 2WW breast clinic (NICE NG12 — urgent breast referral)

Skin changes Peau d'orange, skin tethering, dimpling, ulceration → 2WW breast clinic (inflammatory breast cancer)

Nipple changes New nipple inversion, eczematous change unresponsive to treatment (Paget's disease), or bloody/blood-stained nipple discharge → 2WW breast clinic

Axillary lymphadenopathy Hard, fixed, enlarging nodes with breast pain → 2WW breast clinic

Breast abscess / mastitis not resolving Erythema, warmth, fever, fluctuant mass — especially non-lactational → Same-day assessment (periductal mastitis, abscess)

Unilateral persistent non-cyclical pain >6 weeks Especially post-menopausal, no obvious musculoskeletal cause, focal tenderness → Urgent breast clinic (NICE guidance — pain alone can rarely indicate cancer)

Age ≥30 with new breast pain + lump Any age combination with mass → 2WW breast clinic (NICE NG12 threshold lower for palpable mass)

Bone pain / systemic symptoms Back/bony pain + breast pain in known breast cancer or strong family history → Same-day (metastatic disease until proven otherwise)

Breast cancer rarely presents with pain alone (<5% of breast cancers), but missing a concurrent lump while focusing on pain is a significant safety failure. NICE NG12 mandates 2WW referral for any palpable breast lump aged ≥30, regardless of pain character. Inflammatory breast cancer (IBC) is particularly dangerous — it mimics mastitis but carries 40% 5-year survival vs 90%+ for early-stage disease. Post-menopausal mastalgia is unusual and warrants lower referral threshold. 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 and a breast pain diary (Cardiff Breast Pain Chart) to characterise the pain over 2–3 menstrual cycles. This distinguishes the three main types, which have different prognoses and treatments.

Pain diary

Request a 2–3 month Cardiff Breast Pain Chart First line — patient marks daily severity (0–3) and relation to periods. Distinguishes cyclical from non-cyclical objectively.

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.

Duration

Cyclical: onset 20s–40s, perimenopausal peak. Non-cyclical: any age, but post-menopausal mastalgia is non-cyclical by definition — lower threshold for referral.

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

High caffeine intake, high saturated fat diet — weak evidence but relevant to lifestyle advice. Document baseline.

The Cardiff Breast Pain Chart was developed specifically for primary care and is validated for guiding treatment decisions. Cyclical mastalgia (60–70% of cases) resolves spontaneously in 20–30% of women within 3 months of keeping a diary alone — the act of recording can itself reduce anxiety and symptom severity. Non-cyclical pain has a more varied aetiology and lower spontaneous resolution rate (~50%), requiring more active investigation. 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

60–70% of 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

~25% of cases. No relationship to cycle. Unilateral, often focal, sharp or burning. Causes: duct ectasia, periductal mastitis, macrocyst, post-surgical change, Mondor's disease (superficial thrombophlebitis). Needs further assessment

Chest wall / musculoskeletal

~10% of referred "breast pain". Costochondritis (Tietze's), intercostal muscle strain, cervical radiculopathy, rib stress fracture. Reproduced by pressing on costochondral junction — not the breast itself. Refer to MSK pathway if confirmed

Drug-induced

HRT (oestrogen-dominant), combined OCP, SSRIs (esp. sertraline), antipsychotics (↑ prolactin), digoxin, spironolactone. Review medication list in every case. Consider drug switch

Severity grading

Mild: <7 days/cycle, VAS <4/10 — reassurance + lifestyle. Moderate: 7–14 days, VAS 4–7 — consider topical NSAIDs. Severe: >14 days/cycle, VAS >7, impairs daily function — consider systemic therapy. Use pain diary for objective grading.

Subtype classification is the pivot point for the entire management pathway. Cyclical mastalgia has 80–90% response to first-line treatment (reassurance + topical NSAIDs). Non-cyclical mastalgia responds less well (50–60%) and warrants imaging. Drug-induced mastalgia resolves completely with offending agent withdrawal in the majority of cases. 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 = ligament tethering → 2WW. 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 → 2WW if any uncertainty. Diffuse nodularity = fibrocystic change (benign). Focal tenderness without mass — reassuring if matches pain site.

Nipple discharge

Gently express: Bilateral, multi-duct, clear/milky = physiological or drug-related (check prolactin if persistent). Unilateral, single-duct, bloodstained or serous → 2WW (papilloma or carcinoma). Galactorrhoea → check prolactin, TSH, medications.

Axillae

Palpate for lymphadenopathy. Hard, fixed, >1cm nodes → 2WW. 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.

Supraclavicular fossa

Palpate supraclavicular nodes — enlarged hard nodes with breast pain → urgent oncology review (N3 disease).

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 has sensitivity of 54% and specificity of 94% for detecting breast cancer when performed systematically. While not a screening tool, 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. Bra fit is genuinely therapeutic: studies show that correct bra fitting reduces breast pain by 85% in women with macromastia-related non-cyclical 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

Mammogram ± ultrasound: Indicated for non-cyclical mastalgia in women ≥40, or any age with focal non-cyclical pain, abnormal examination, or persistent symptoms. Do NOT order mammogram for typical cyclical mastalgia with normal exam — breast density in younger women limits sensitivity and increases anxiety. Refer to breast clinic for imaging if needed

Serum prolactin

If galactorrhoea present or bilateral mastalgia with no cyclical pattern — exclude hyperprolactinaemia. Normal: <500 mIU/L. Elevated → check MRI pituitary, review medications (antipsychotics, metoclopramide, domperidone, methyldopa). Serum prolactin

TFTs

Hypothyroidism can cause diffuse mastalgia and galactorrhoea. Check TSH if galactorrhoea or if no other explanation. TSH

Pregnancy test

Breast pain is common in early pregnancy. Check urine hCG if: irregular periods, amenorrhoea, or any diagnostic uncertainty. Do not assume pain is not pregnancy-related. 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

NICE and the 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. If pathological fracture from suspected metastatic disease → 999.

Same day

Breast abscess (fluctuant, systemically unwell, failed antibiotics). Non-lactational mastitis not responding to first-line antibiotics after 48hrs (risk of periductal mastitis / underlying malignancy).

2WW breast clinic

Any palpable discrete lump ≥30 years. Bloody/serous unilateral nipple discharge. Skin changes (dimpling, peau d'orange, ulceration). New nipple inversion. Nipple eczema not responding to topical treatment (exclude Paget's). Unilateral hard axillary lymphadenopathy. Any examination finding causing clinical uncertainty.

Urgent (2 wks)

Post-menopausal mastalgia with no obvious cause (requires breast imaging + clinical assessment). Persistent non-cyclical focal pain >6 weeks with normal examination — warrants triple assessment to reassure and investigate.

Routine breast clinic

Severe cyclical mastalgia not responding to 3 months of first and second-line primary care treatment (danazol / bromocriptine consideration). 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 2WW threshold: any breast lump in women ≥30 or any suspicious clinical feature. 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. However, post-menopausal mastalgia is a particularly important exception: oestrogen withdrawal at menopause means breast pain is uncommon, and new mastalgia in this group has a higher malignancy rate than in premenopausal women. Failing to refer post-menopausal mastalgia to breast clinic is a documented medicolegal risk.

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

Diclofenac 1% gel applied to affected breast 3–4× daily for 7–14 days pre-menstrually. Evidence: reduces pain by 70% vs 30% placebo. Minimal systemic absorption. Preferred over oral NSAIDs.

Non-cyclical mastalgia

Topical NSAID 1st line

Diclofenac 1% gel to focal pain site 3× daily for 4 weeks. Less predictable response than cyclical — reassess at 4 weeks. If no response, image and reconsider diagnosis.

Drug-induced

Medication review 1st line

Identify and switch offending drug where clinically appropriate. HRT: consider switching preparation, reducing dose, or progesterone-only HRT. OCP: try progestogen-only pill or barrier method. SSRIs: switch to alternative antidepressant. Document rationale.

Chest wall pain

Oral NSAID + physio 1st line

Ibuprofen 400 mg TDS with food for 2 weeks + local heat. Consider local steroid injection (triamcinolone 40 mg + lidocaine) into costochondral junction if persistent — highly effective for Tietze's. Refer physio if recurrent.

Escalation ladder — cyclical mastalgia not responding to topical NSAIDs:

Step 1Reassurance + pain diary + lifestyle — 30% resolve with diary alone over 3 months. Start here for mild symptoms.

Step 2Topical diclofenac 1% gel — pre-menstrual use, 7–14 days/cycle. First pharmacological step. Use for ≥3 cycles before declaring failure.

Step 3Evening primrose oil (EPO) — Gamolenic acid 3g/day (Efamast 80 mg × 4 capsules daily). Modest evidence, well-tolerated, 3-month trial. Less effective than hormonal treatments but safer profile. Discuss with patient.

Step 4Tamoxifen 10 mg OD for 3–6 months (breast clinic / specialist initiation). Specialist Most evidence-based hormonal option for severe cyclical mastalgia. Contraindicated in pregnancy — ensure contraception. Monitor: menstrual irregularity, hot flushes, DVT risk. Response rate 70–80%. Licensed for mastalgia.

Step 5Danazol 100–200 mg OD for 3–6 months. Specialist Androgen with anti-gonadotrophic effect. Response rate 70%. Side effects: weight gain, acne, hirsutism, voice changes — often limit use. Effective but patients dislike side-effect profile. Effective contraception required.

Step 6Bromocriptine 2.5 mg BD. Specialist Dopamine agonist — reduces prolactin. Side effects: nausea, dizziness, hypotension. Lower tolerability than tamoxifen. Consider only if tamoxifen/danazol contraindicated or failed. Start at 1.25 mg with food, titrate up.

Evidence base for each step:
Topical diclofenac: RCT data shows 70% pain reduction vs 30% placebo (Colak et al, 2003) with minimal systemic absorption — preferred over oral NSAIDs for breast pain.
Evening primrose oil: Modest benefit in RCTs; Cochrane review suggests small but consistent effect. Well tolerated, no significant safety concerns, suitable for mild–moderate symptoms.
Tamoxifen 10 mg: Multiple RCTs with NNT ≈ 2 for achieving significant pain reduction in cyclical mastalgia. The 10 mg dose (off-label lower dose) has similar efficacy to 20 mg with fewer side effects. Licensed for mastalgia in the UK at 10–20 mg.
Danazol: Response rate 70% but androgenic side effects in 20–30% cause discontinuation. Not suitable as first hormonal option due to tolerability.
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 — evidence-based, not afterthought

Done — lifestyle advice given

These interventions have evidence and should be recommended to every patient with mastalgia. Frame as active treatment, not just advice:

🩱 Correct bra fitting Professionally fitted, well-supporting bra (consider sports bra for 24hr use). Evidence: reduces breast pain by up to 85% in macromastia. Refer to trained fitter. Avoid underwired bras during exacerbations.

☕ Caffeine reduction Reduce or eliminate coffee, tea, cola, energy drinks. Observational evidence supports caffeine as an aggravating factor — methylxanthines may increase receptor sensitivity. Advise 6-week trial of caffeine elimination.

🥗 Dietary fat reduction Reduce saturated fat to <15% of total calories. Some RCT evidence that low-fat diet reduces cyclical breast pain. Improves weight and cardiovascular risk simultaneously.

🏃 Regular aerobic exercise 150 minutes moderate exercise per week. Reduces oestrogen levels, improves pain threshold, reduces BMI. Indirect but consistent evidence across multiple studies.

📓 Pain diary (Cardiff Chart) Continue for 3 cycles. Tracking pain — reduces anxiety by contextualising symptom pattern. Diary alone leads to spontaneous resolution in 20–30% — this is treatment, not just monitoring.

🌿 Evening primrose oil Gamolenic acid 3g/day (GLA supplement). Patient-led option. Modest evidence, excellent safety profile. Advise 3-month trial before assessing response. Can be purchased OTC. Discuss realistic expectations.

💊 Vitamin E / B6 Vitamin E 600 IU/day or Vitamin B6 100 mg/day — weak observational evidence only. Not NICE-recommended. If patient wishes to try, safe at these doses. Do not substitute for evidence-based treatment.

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

⚖️ Weight management BMI ≥30 associated with increased mastalgia severity, higher oestrogen levels (adipose aromatisation). Even modest 5–10% weight reduction improves hormonal profile and pain. Refer to tier 2 weight management if appropriate.

Lifestyle interventions are under-prescribed for mastalgia and over-reliance on pharmacotherapy is common. The Cardiff Breast Pain Chart study demonstrated that diary-keeping alone produced clinically significant pain reduction in 22% of participants — an effect size comparable to evening primrose oil. Bra fitting is supported by prospective studies from Portsmouth and Cardiff breast units showing up to 85% pain reduction in women with macromastia who were incorrectly fitted. Caffeine reduction: Allen et al. demonstrated 65% symptom improvement with caffeine elimination in women with fibrocystic change. These are high-impact, zero-side-effect interventions — they should always precede pharmacotherapy for mild–moderate symptoms.

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: escalate treatment step (Step 7). 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). New pathological fracture if known or suspected breast malignancy.

Same-day if:

New discrete palpable lump develops at any point during follow-up. Skin changes develop (dimpling, peau d'orange). Wound/abscess concern in post-surgical patient. 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) suggesting systemic illness.

Discharge criteria

Pain resolved or manageable (<7 days/cycle, VAS <4) 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) evening primrose oil takes 3 months to reach full effect, (3) 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.