Breast presentations and diagnosis
Breast pain (mastalgia)
Overview and approach
Mastalgia is commonly benign; classify cyclical, non-cyclical and extramammary pain without dismissing associated suspicious findings.
- Breast pain is a rare presentation of breast cancer. With a normal examination and imaging, risk is similar to a woman without pain, and reassurance usually suffices. Up to 70% of women experience it at some time.
- Cancer Australia lists unilateral breast pain as a symptom for triple-test assessment in the GP guide (1).
Assessment and clinical features
Ask location/duration, cycle, pregnancy/lactation, medicines/hormones, trauma, mass, discharge and skin changes; consented breast/axillary and chest-wall examination.
- Cyclical (about 2/3): week before menses, often bilateral, upper outer quadrants. Causes: fibrocystic change, OCP, postmenopausal hormone therapy.
- Non-cyclical (about 1/3): constant or intermittent, more often unilateral and variable; more likely breast or chest-wall lesion. Causes: large pendulous breasts, HRT, caffeine, smoking, high-fat diet; solitary cyst (rapid onset); duct ectasia (fever, local pain, subareolar nodule); mastitis/abscess; inflammatory breast cancer (tender firm enlarged warm breast, peau d'orange, often no fever).
- Extramammary: the breast is supplied by intercostal nerves T3-T5. Causes: pectoralis injury, costochondritis (2nd-5th junctions), Tietze syndrome, cervical radiculopathy (burning pain), trauma (seat belt, partner violence), intercostal neuralgia, gallbladder or ischaemic heart disease, post-thoracotomy syndrome.
Differentials and investigations
Imaging depends on age, focality, examination and local breast pathway; consider cyst, infection, chest-wall disease and referred cardiac/other pain.
- A mass, skin change or bloody nipple discharge in any woman needs mammography with or without ultrasound and clinical evaluation to exclude cancer (1).
Management and follow-up
After appropriate assessment, reassurance, supportive bra and suitable analgesia; review medicines and arrange follow-up. Evidence for evening primrose oil is limited; specialist hormonal therapy is not routine junior-doctor prescribing.
- First line: reassurance, support, over-the-counter analgesics, review hormonal medicines; caffeine and smoking cessation and evening primrose oil are harmless but unproven; trial about 6 months.
- Second line (specialist): tamoxifen preferred over danazol for 1-3 months in refractory pain; off-label.
Red flags and clinical pearls
New lump, bloody discharge, skin tethering/inversion, persistent focal symptoms or unresolved inflammation needs breast assessment; fever/systemic illness suggests infection, while acute concerning chest pain needs its own emergency pathway.
- Consider cardiac and gallbladder causes in older or at-risk patients.
Last updated from Sen’s notes on 9 October 2026.