Mastalgia History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today about the pain you have been experiencing in your breast(s). I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presenting, for example, “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE), to pick up on later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

Examples of open questions here would be: “How would you describe this pain?” or “Have you noticed any other symptoms alongside the breast pain?” Examples of closed questions include: “Is the pain a sharp pain?” or  “Have you noticed any breast lumps?”

When taking a pain history, it is useful to use the SOCRATES mnemonic to structure your questioning:

• Site – where in the breast is the pain? Is it unilateral or bilateral? Is the pain generalised within the breast, e.g., cyclical mastalgia, or breast pain related to hormonal change including pregnancy or hormonal medication? Or, is the pain in a localised area of the breast, e.g., mastitis or breast abscess?
• Onset – when did the pain start and did anything happen at the time which could have triggered the pain? How long has it been going on for? 
• Character – what type of pain is the patient experiencing? E.g., sharp, stabbing, aching, burning, etc. Patients usually describe pain from hormonal change or cyclical mastalgia as an aching heaviness; whereas pain caused by mastitis may be described as sharp and neuralgia associated with varicella zoster virus is typically a burning pain.
• Radiation – does the pain travel anywhere else from the main site? E.g., Through to the back.
• Associated symptoms – has the patient experienced any other symptoms alongside the pain? E.g., malaise (mastitis, breast abscess, varicella zoster virus), or pre-menstrual symptoms (cyclical mastalgia)? Associated symptoms may also help you pick up referred causes of breast pain, e.g., belching and acidic taste may indicate gastro-oesophageal reflux and respiratory symptoms may indicate pleurisy.
• Timing – what is the time-course of the pain? How long does it last? Is it worse at a particular time of day? Is it constant or intermittent?
• Exacerbating & relieving factors – what, if anything (e.g., analgesia) makes the pain better? Does anything make the pain worse? 
• Severity – on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, how would the patient rate the severity of their pain?

System-specific History

After establishing further history of the breast pain, you need to gather any relevant system-specific information. In the case of mastalgia, the system in question is the breast. Try to think of symptoms which may present alongside breast pain and ask about these. 

It is important to not only ask about these symptoms, but to think about why their presence or absence is important in narrowing down the differential diagnosis. 

For example, in the absence of breast lumps or changes to the skin or nipple, most patients presenting with mastalgia can be reassured that sinister pathology e.g., breast cancer is not likely to be the underlying cause of their symptoms and no onward referral is required. The presence of these associated symptoms however, would make a diagnosis of malignancy more likely and make you consider referral to breast clinic for further assessment. 

Breast system symptoms to ask about include but are not limited to:

• Association with menstrual cycle – has the patient noticed that mastalgia is cyclical? Breast pain can be a pre-menstrual syndrome symptom alongside headache, mood changes, bloating, etc. Cyclical mastalgia tends to occur in the luteal phase, or the two weeks prior to menstruation and improve with the onset of menstruation.
• Breast lumps – it is very important to know if the patient has noted any lumps on self-examination and to examine every patient presenting with mastalgia. If a lump is present is it smooth, mobile and fluctuant in keeping with a breast cyst, or irregular, fixed, and hard, raising concern for malignancy?
• Skin changes – skin changes including puckering, tethering, thickening, dimpling or peau d’orange appearance are all concerning for malignancy and warrant further assessment. 
• Nipple changes – has the patient (or anyone else) noticed any nipple changes e.g., inversion which is not normal for them?
• Nipple discharge – nipple discharge may be a symptom of an underlying breast condition, e.g., mammary duct ectasia, intraductal papilloma. Production of breast milk from the nipples not associated with pregnancy or breastfeeding is called galactorrhoea and likely requires further investigation.
• Breastfeeding – is the pain associated with breastfeeding? Lactational mastitis is an important differential to consider, as well as the safety of certain prescribed medications for breast conditions if the patient is breastfeeding.
• Supportive underwear – enquire about the patient’s underwear, if it is supportive and if they have been measured and fitted for underwear of the correct size. Wearing unsupportive or incorrectly sized underwear can contribute to mastalgia, and correcting this is part of the management guidelines for cyclical breast pain.

Red Flags

It is important to ask about symptoms that may lead you to consider more sinister causes of breast pain in the differential diagnosis, which may require more urgent investigation and management, e.g., malignancy.

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information because they might find these symptoms concerning or may not have the same insight into their significance as you do. 

Red flags to screen for when taking a history of mastalgia include:

• Weight loss – could indicate malignancy.
• Breast lumps – any patient over the age of 30 presenting with a breast lump should be referred via a suspected cancer pathway to rule out breast malignancy.
• Axillary lump – a referral for suspected cancer should be considered for all patients over the age of 30 presenting with a lump in the axilla that has no clear explanation, to rule out breast malignancy.

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed out. However, it is key to think about which systems are relevant to review so that your questions remain relevant to the presenting complaint.

Relevant systems to review when taking a history of breast pain include:

• Musculoskeletal – could the mastalgia be referred pain with a musculoskeletal cause e.g., from the neck in cervical radiculopathy, or from the shoulder? Does the patient have costochondritis?
• Dermatological – has the patient developed a painful rash which is presenting as mastalgia? Causes of painful rashes which may affect the breast include intertrigo, or candida skin infection in the inframammary fold(s), and shingles.

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing this pain?”
• Concerns – “Is there anything that is worrying you about this breast pain?” “Have you read or Googled anything about your symptoms that has worried you?”
• Expectations – “Was there anything specifically you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of mastalgia, for example, a patient has previously been told they have gallstones and has developed pain just underneath the right breast. Don’t forget to ask about prior similar episodes of this presenting complaint.

Ask about previous surgery the patient may have undergone, especially if it will help to rule in/out a differential diagnosis, for example, a patient has presented with symptoms including breast tenderness possibly consistent with pregnancy but they have had a hysterectomy.

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer e.g., over-the-counter medications, herbal or alternative remedies, contraception, HRT, or injections such as B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis. For example, the patient who presents with bilateral breast pain and has recently started the combined oral contraceptive pill may be experiencing a drug side effect.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, other than their presenting complaint.

• Who do they live with? Does anyone else at home have the same symptoms, e.g., shingles? Do they have a social support network they could depend on if they were to receive a life-changing or life-limiting diagnosis? 
• Do they work? Do they need time off work for infection control, e.g., shingles? Does their work involve a lot of heavy lifting or manual labour, which may increase the risk of musculoskeletal pain presenting as mastalgia? (E.g., costochondritis, shoulder pain).
• Do they drive? Does their condition affect their ability to drive or to attend appointments?
• Have they had contact with someone with similar symptoms, or do they need to avoid contact with immunocompromised individuals?
• Have they recently returned from travelling abroad?
• Do they smoke? Smoking is associated with increased risks of malignancy and breast abscess.
• Do they drink alcohol? Alcohol can worsen symptoms of GORD, which can present as mastalgia. 
• Do they use recreational drugs?

Family History

Does anyone in the family have any breast conditions, e.g., breast cancer? Patients may ask you if they are at increased risk of breast cancer if they have a positive family history of the condition. It is worth familiarising yourself with the criteria that constitute increased risk of familial breast cancer and may prompt discussion regarding referral for genetic counselling.

Do any other health conditions run in the family?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests or further investigation and imaging.

Last updated May 2025

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