Breast Pain

Overview

The Modernising Patient Pathway Programme (MPPP) Symptomatic Breast Specialty Delivery Group (SDG) has been established to support and explore innovative approaches to the delivery of symptomatic breast services across NHS Scotland.

Through the development of Once for Scotland approaches to delivery of patient care, there is a strong focus on identifying opportunities to further develop clinical pathways. This aims to reduce unwarranted variation in the quality of care and to improve waiting times for non-urgent breast services. Specialty Delivery Groups play a key role in this work by engaging clinical leadership and fully utilising their roles across NHS Scotland.

The development of a Breast Pain Pathway has been progressed through the MPPP SDG, reflecting a common theme identified during engagement with colleagues across NHS Scotland.

The recommendations outlined have not followed the standard SIGN development process and are instead based on available guidance and expert consensus. Peer review has also been undertaken to provide appropriate quality assurance.

This guidance will be reviewed and updated as new evidence emerges.

Patient Guidance

The Breast Services pathways for Scotland seek to promote equitable, safe, and timely access to assessment and care for all patients presenting with breast related symptoms, including breast pain, nipple discharge, axillary or skin lumps, and gynaecomastia. Pathway access and clinical decision‑making should be based on the presenting symptom, underlying breast tissue, and individual clinical risk, ensuring that no patient is unintentionally disadvantaged.

These symptomatic pathways apply to all patients, including trans and gender‑diverse individuals. Referral, investigation, and management should be guided by the nature of the presenting symptom, relevant anatomy, prior medical or surgical history (including any gender-affirming treatment), and clinical risk factors, rather than gender identity alone. The aim is to ensure that patients with breast symptoms are directed to the most appropriate diagnostic pathway without delay.

Patients who have residual breast tissue, regardless of gender identity, should be referred through standard symptomatic breast pathways when they present with breast symptoms. Those who have had chest or breast surgery may still require referral if symptoms arise in remaining breast tissue, the chest wall, axilla, or skin.

In light of the Supreme Court ruling on the definition of biological sex within the Equality Act 2010, services should recognise that biological sex may remain a relevant determinant for certain aspects of investigation, clinical management, or accommodation within breast services. Where this is the case, any alternative arrangements should be proportionate, clinically justified, and handled sensitively, ensuring patient dignity while maintaining safety and pathway clarity.

A common theme during these meetings has been a focus on the referral of breast pain to secondary care services. A consensus was formed around two principles that:

1. There has been an increasing medicalisation of the symptom of breast pain, despite this being usually an entirely normal physiological process. Breast pain is the main factor in around 15% of all symptomatic breast clinic referrals leading to over investigation.
2. Almost all people who are referred with breast/axillary pain have chest wall pain unrelated to the breast itself.

The Modernising Patient Pathway Programme Symptomatic Breast Group was tasked to discuss current and proposed practice and to develop recommendations for the management of people with breast pain. It is important to note that these recommendations are for patients with breast pain only and with no other worrying symptoms or signs on presentation (details of such signs and symptoms are provided in the NICE CKS).^1,2

The recommendations fall into three groups:

1.   Imaging for Breast Pain

• Currently there is a widespread difference between, and within, Scottish breast units with regard to imaging patients with breast pain; with some imaging no patients, some all patients and some using it as an opportunity for screening.

We suggest that:

• There is no indication for imaging patients with breast pain in the absence of any other symptoms or signs
• If patients have missed screening appointments they should be directed to the appropriate screening pathway to be included within a fully quality-assured programme, and opportunistic screening within symptomatic practice is not recommended
• If units wish to image patients with breast pain it may be worth auditing this pathway to see if the incidence of cancers differs from an age-matched screening population.

2.  Referral to Secondary Care

We suggest that patients with symptoms of breast pain, whether pre- or postmenopausal, can be reassured that this a normal process, usually settles of its own accord and are directed to symptomatic relief advice. Ideally, this reassurance would be provided through public messaging on NHS and third-sector platforms without necessitating a need to be seen in primary care.³

Patients who are referred to secondary care should:

• have intractable severe unifocal postmenopausal breast (not chest wall or axillary) pain
• have had 3 months’ trial of conservative advice management
• appreciate that further management options, apart from analgesia, are very limited.

The very small number of patients with breast pain requiring referrals to secondary care do not necessarily need to be managed in rapid access clinics but instead could be given:

• written advice which is also shared with their GP
• a telephone/Near me appointment with specialist nurses
• an appointment in a low risk/benign clinic.

3.   Management of Patients with Breast Pain within Primary Care

1. Patients experiencing breast or chest wall pain can be strongly reassured that in the absence of any other symptoms or findings that this is normal, usually self limiting and not linked with malignancy.
2. Most postmenopausal breast pain is actually chest wall in origin and patients can be reassured accordingly.
3. Conservative management advice should include a well-fitted supportive bra and regular use of topical NSAIDs massaged into the symptomatic area on the chest wall.

1. National Institute for Health and Care Excellence (NICE). Breast pain – cyclical: diagnosis [Internet]. London: NICE; 2024 [cited 2026 May]. Available from: https://cks.nice.org.uk/topics/breast-pain-cyclical/diagnosis/diagnosis

2. National Institute for Health and Care Excellence (NICE). Breast pain – cyclical: differential diagnosis [Internet]. London: NICE; 2024 [cited 2026 May]. Available from: https://cks.nice.org.uk/topics/breast-pain-cyclical/diagnosis/differential-diagnosis/ 

3. NHS Inform. Breast cancer in women – symptoms [Internet]. NHS Scotland; 2026 [cited 2026 May]. Available from: https://www.nhsinform.scot/illnesses-and-conditions/cancer/cancer-types-in-adults/breast-cancer-female#symptoms-of-breast-cancer 

4. Association of Breast Surgery. Position statement on breast pain [Internet]. London: ABS; 2024 [cited 2026 May]. Available from: https://associationofbreastsurgery.org.uk/media/qvhdb0p2/breast-pain-statement-final-february-2024.pdf 

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