Changes

April 2026 — reviewed. A literature search was conducted in April 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made. A new section on referral has been added. More emphasis was given to the lack of association between cyclical breast pain and breast cancer in the light of recent additional evidence and current national UK referral priorities and policies.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate diagnosis of cyclical breast pain.
• Offer appropriate treatment in primary care.
• Refer appropriately to a breast specialist.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Cyclical breast pain is related to the menstrual cycle, with symptoms usually starting during the luteal phase, within 2 weeks before the menses, and improving at the onset of the menstrual period. It often occurs at the same time each month and is most commonly bilateral and diffuse in nature, although it may be unilateral and may often be worse in the upper outer quadrant.
• It may also be termed physiological breast pain.

[Cornell, 2020]  [Hubbard, 2020; Sivarajah, 2020; Li, 2021]

What causes cyclical breast pain?

• The exact cause of cyclical breast pain is not fully understood — as pain is related to the menstrual cycle, it is thought that hormonal changes affecting the breast tissue are involved, although the exact hormonal pathway involved has not been identified.
• Other contributing factors (such as caffeine intake, iodine deficiency, dietary fat intake, and smoking) have been suggested but have not been found to definitively cause symptoms.
• Breast cancer does not generally cause cyclical breast pain, and breast pain alone is not considered to be a symptom of breast cancer.

 [Groen, 2017; Hafiz, 2018; Cornell, 2020; Sivarajah, 2020; Dave, 2022; ABS, 2024]

How common is cyclical breast pain?

• Breast pain is a common symptom, and it is estimated that up to 70–80% of women experience it at some point in their lifetime [Sivarajah, 2020; Li, 2021; NHS Northern Cancer Alliance, 2025].
• Up to 11% of women experience severe pain [Salzman, 2019].
• Cyclical breast pain is the most common type of breast pain, accounting for around two-thirds of reported breast pain [Salzman, 2019; Sivarajah, 2020; Li, 2021].
• Women with breast pain account for up to 41% of those attending one-stop breast clinics in the UK [ABS, 2024]. As it has been shown that breast pain in isolation is not associated with a diagnosis of breast cancer, pathways are being developed in the UK for the management and referral of breast pain so that services for the diagnosis of breast cancer are not swamped and so that those with breast pain can be assessed and optimally managed [Dave, 2022; ABS, 2024; NHS England, 2024].

What is the prognosis?

• Cyclical breast pain resolves spontaneously in 20–30% of women, but recurs in up to 60%.
• Remission is usual during pregnancy and menopause.
• There may be an impact on quality of life as breast pain may impact work, sleep, sexual activity, sport, and mood, particularly where pain is severe.
• The risk of finding breast cancer in a person with breast pain is no more than (indeed lower than in one large study) the incidence in the screened population, and no association has been found between cyclical breast pain and risk of breast cancer. Reassurance relating to this alone can reduce symptoms.

[Salzman, 2019; Cornell, 2020]  [Sivarajah, 2020; Dave, 2022; NHS Northern Cancer Alliance, 2025]

How should I diagnose cyclical breast pain?

• Take a history asking about:
  • Onset, severity, location, radiation, and duration of pain.
  • Relationship of pain to menstrual cycle, physical activity, or recent trauma.
  • Associated features, such as skin or nipple changes or a lump.
  • Family history of breast cancer.
  • Other risk factors for breast cancer (for example, alcohol intake, weight, level of physical activity, parity, age, and history of breastfeeding).
  • The possibility of pregnancy.
  • Medication.
• Perform an examination to identify signs suggestive of other conditions, such as:
  • Breast cancer — for example, an unexplained breast lump or thickening; suspicious skin changes; discharge, retraction, or other concerning nipple changes; or axillary lump.
  • Infection — for example, localized breast swelling, redness, warmth, and pain; associated systemic symptoms such as fever.
  • Extra-mammary causes of breast pain — for example, rash due to shingles, or chest wall tenderness suggesting musculoskeletal causes, best assessed by additional examination with the patient lying on each side to allow the breast to fall away from the chest wall.
  • For more information on assessment and management, see the CKS topics on Breast cancer - recognition and referral and Mastitis and breast abscess.
• Exclude pregnancy where indicated by history.
• Consider a diagnosis of cyclical breast pain when a woman with a normal breast examination describes pain that:
  • Usually starts during the luteal phase of the cycle (within 2 weeks before menses), increases until menstruation begins, and improves after menses. 
  • Is dull, heavy, or aching in nature. 
  • Is usually bilateral.
  • May be poorly localized or diffuse.
  • May be worse in the upper outer quadrant(s) and may and extend to the axilla.
• Consider the use of a breast pain diary to aid diagnosis.
  • Advise the woman to complete this daily for at least 2 cycles to assess the severity and timing of breast pain.
• If the woman is experiencing additional physical and/or psychological premenstrual symptoms, consider a diagnosis of premenstrual syndrome.
  • For more information, see the CKS topic on Premenstrual syndrome.
• Do not arrange imaging in a woman with symptoms of cyclical breast pain only and a normal examination.

What else might it be?

Other causes of breast pain include:

• Hormonal medication causing cyclical or non-cyclical breast pain (hormonal contraceptives and hormone replacement therapy).
• Non-cyclical breast pain due to:
  
  • Pregnancy.
  • Lactation.
  • Mastitis.
  • Trauma.
  • Fibrocystic disease.
  • Medication. In addition to contraceptives and hormone replacement therapy, breast pain may be a side effect of other medications, including selective serotonin reuptake inhibitors (SSRIs), amitriptyline, haloperidol, spironolactone, digoxin, metronidazole and ketoconazole.
  • Poorly fitting or unsupportive bras.
  • Larger cup size.
  • Stretching of Cooper's ligaments.
  • Malignancy.
  • Fat necrosis.
  • Diabetic mastopathy.
  • Mondor's disease (superficial thrombophlebitis)
• Extra-mammary conditions, for example:
  • Musculoskeletal conditions, such as costochondritis, soft tissue injury, rib or vertebral fracture.
  • Fibromyalgia.
  • Herpes zoster.
  • Referred pain from cardiac, gastrointestinal conditions (such as ischaemic heart disease, peptic ulcer, gallstones, or gastro-oesophageal reflux).

Scenario: Management

From age 12 years onwards (Female).

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of cyclical breast pain.

Search dates

May 2021 - April 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Mastodynia/
• mastodynia.tw.
• mastalgia.tw.
• breast pain$.tw.
• cyclical breast pain.tw. 
• 'breast pain' adj3 (cyclical or idiopathic or mastalgia).ti,ab. 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.