Breast Symptoms (Lump, Pain, Discharge)

A unified approach to the three common breast presentations in general practice — a lump, pain (mastalgia), and nipple discharge. The individual benign diagnoses (cyst, fibroadenoma, fibrocystic change, duct ectasia, papilloma, fat necrosis) are covered on Benign breast conditions; malignancy, screening and Paget disease on Breast cancer & screening; and Mastitis & breastfeeding problems separately.

The single most important principle: any discrete breast lump, and any suspicious symptom, is assessed by the triple test until cancer is excluded.

The triple test

The triple test combines three components; a lump is only “benign” if all three concur. Any discordant or abnormal component → refer to a breast surgeon.

1. Clinical assessment — history + examination.
2. Imaging — ultrasound and/or mammography, chosen by age (below).
3. Non-excisional biopsy — core biopsy (preferred, preserves tissue architecture) or FNA cytology.

The triple test has ~99.6% sensitivity for breast cancer; an abnormality at any stage prompts referral.

Choosing imaging by age

Situation	First imaging
Age <35, pregnant or lactating	Ultrasound first (dense tissue; good for benign lesions). Add mammography if USS is suspicious, malignant, indeterminate, or discordant with clinical findings.
Age ≥35	Mammography + ultrasound (complementary).
Suspicious mammogram/USS	Add ultrasound of the ipsilateral axilla.

Core biopsy is preferred over FNA. Reserve FNA for simple cysts (or a fibroadenoma confidently identified by an experienced service).

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Breast lump

Treat every discrete lump as cancer until proven otherwise. Cancer is the most common cause of a breast lump over the age of 50.

Red flags (refer directly to a breast surgeon)

• Hard, irregular lump
• Skin dimpling/puckering or oedema (peau d’orange)
• Nipple distortion/retraction, or nipple eczema (Paget disease)
• New bloody or single-duct nipple discharge
• Post-menopausal woman with a new lump

Examination

• The axillary tail houses ~58% of malignancies — examine it deliberately.
• Examine with arms by the side and raised above the head; use tangential light to bring out skin puckering or peau d’orange.
• Palpate axillary and supraclavicular nodes.

The Cancer Australia investigation pathway (summary)

• No discrete lesion / findings consistent with hormonal change → review in 6–8 weeks (just after a period); mammogram only if due for routine screening. If the finding has resolved, exit the pathway.
• A discrete lump, or anything clinically suspicious → imaging (age-appropriate, above) → cytology/core biopsy as indicated:
  • Simple cyst → FNA. Straw/dark-green fluid with the lump fully resolving → reassure (send fluid to cytology only if diagnostic uncertainty). Bloody fluid, or a residual lump after aspiration → breast surgeon.
  • Solid lesion, complex cyst, or indeterminate/suspicious imaging → core biopsy. Benign and concordant → reassure; anything atypical, suspicious, inadequate, or discordant → breast surgeon.

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Breast pain (mastalgia)

Pain accounts for ~50% of breast presentations in general practice, and is the presenting symptom of breast cancer only ~10% of the time — about 1 in 200 women presenting with breast pain have breast cancer. Reassurance (after excluding red flags) is the mainstay.

Cyclical vs non-cyclical mastalgia

	Cyclical	Non-cyclical
Typical age	30–40 (peak 35); rare after menopause	Early 40s (median ~41)
Pattern	Bilateral (often one side worse), upper outer quadrant; builds pre-menstrually, eases with menses	Bilateral & diffuse or localised; continuous or intermittent, no clear cycle relationship; often no identifiable pathological basis
Examination	Breasts may be diffusely nodular/lumpy	May be diffusely nodular/lumpy

Investigation: imaging is not usually required. Arrange imaging (mammography ≥40, ± targeted USS of a localised tender area) only if there are cancer-suspicious features — a lump, skin dimpling/distortion, nipple change, bloody/single-duct discharge, or repeated presentations about the same problem. USS is unhelpful for diffusely tender or post-menopausal breasts.

Management (both types)

• Reassurance that painful breasts are not usually a symptom of cancer.
• Well-fitted supportive (sports/non-underwire) bra.
• Topical NSAIDs (e.g. diclofenac gel) are the most effective analgesia.
• Review or adjust hormonal therapy (stop, reduce dose, or switch) where the MHT/COC may be contributing.
• Evening primrose oil ≥3 g/day — weak/placebo-level evidence but low-harm and often helpful; trial for ~4 months before judging effect.
• If severe/distressing and no response after 3–4 months → refer for second-line specialist options (tamoxifen, danazol, bromocriptine).

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Nipple discharge

The key discriminators are spontaneous vs expression-only, unilateral single-duct vs bilateral multi-duct, and bloody/serous vs other. Spontaneous, unilateral, single-duct, or bloody/serous discharge — and any discharge in a woman over 60 — needs imaging and referral.

Drug causes of galactorrhoea: antipsychotics (chlorpromazine, risperidone), metoclopramide, oestrogens (COC), opioids, cocaine.

By discharge colour

Colour	Likely causes
Blood-stained	Intraductal papilloma (most common), intraductal carcinoma, fibrocystic change
Green–grey	Fibrocystic change, mammary duct ectasia
Yellow	Cyst, intraductal carcinoma, abscess (pus)
Milky white (galactorrhoea)	Lactation ± galactocele, prolactinoma, drugs

If galactorrhoea: check a pregnancy test, prolactin and TSH.

Pathway

• Bilateral, and/or only on expression, non-bloody → reassure, advise to stop expressing (expression itself perpetuates it), mammogram if due, review in 2–3 months.
• Unilateral spontaneous, bloody or serous, single-duct, or age >60 → mammography
  • ultrasound → refer to a breast surgeon.