GPAtlas🧭 When to suspect
Suspect cyclical breast pain (cyclical mastalgia) in a woman of reproductive age whose breast discomfort follows a consistent, predictable pattern tied to the menstrual cycle. The pain is characteristically dull, heavy or aching, usually bilateral and diffuse, maximal in the luteal phase (the week or two before menstruation) and resolving with the onset of the period.
Mastalgia is experienced by up to 70% of women at some point, and around two-thirds of true breast pain is cyclical. It is a hormonally driven, benign symptom: cyclical pain resolves spontaneously in 20–30% of women but recurs in around 60%. The two clinical priorities in primary care are simple – confirm the cyclical pattern (a breast-pain diary is the most useful tool) and exclude the red flags that warrant a suspected-cancer referral. Importantly, breast pain alone – with a normal examination and no lump or other concerning sign – is not associated with breast cancer and is not, by itself, a reason for urgent referral.
| Pattern | Characteristic features |
|---|---|
| Cyclical (≈ two-thirds) | Bilateral, diffuse, heavy/aching; worse premenstrually (luteal phase) and relieved by menses; typical onset around the 30s; hormonally driven. |
| Non-cyclical (≈ one-third) | No relationship to the cycle; often unilateral and localised; later onset (~40s); causes include large/pendulous breasts, cysts, duct ectasia, trauma, previous surgery, mastitis. |
| Extramammary / chest wall | Pain arising outside breast tissue – costochondritis, muscular strain, rib pathology (reproduced on chest-wall palpation); also consider referred cardiac, pleuritic or upper-GI pain. |
Raise suspicion of a non-cyclical or sinister cause when pain is new, focal, unilateral and persistent, particularly in a postmenopausal woman, or where it accompanies a lump, skin change, or nipple change.
Source: NICE NG12 · BJGP 2020
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