A Specialist's Guide to Breast Health

When we think about breast health, we tend to focus on one thing: finding a lump. While breast lumps are indeed important, they are only one part of a much broader picture. In my practice, I examine breasts as part of every well-woman check, because I believe breast care should sit alongside other preventive health measures such as cervical screening and routine blood work. I trained in breast examination at the AP-HP in Paris, specifically at the Breast Diseases Centre at St Louis Hospital, where I gained experience in the full spectrum of breast pathology — from common benign conditions to complex malignancies. That training shaped how I approach breast health today: methodically, thoroughly, and with a commitment to explaining findings clearly so that my patients leave the consultation feeling informed rather than frightened.

What changes should prompt a consultation?

You should see a specialist if you notice any of the following:

• A new lump or thickening in the breast or armpit
• A change in the size, shape, or appearance of a breast
• Skin changes: dimpling, puckering, redness, or an “orange peel” texture
• Nipple changes: new inversion, crusting, discharge (especially if bloodstained or occurring from one side only)
• Persistent breast pain that does not follow a cyclical pattern

I want to emphasise that this list is not intended to cause alarm. The vast majority of breast changes turn out to be benign. What matters is that you do not sit at home worrying — any new or persistent change deserves a professional assessment so we can either reassure you quickly or, in the rare case that further investigation is needed, act without delay.

What I check during a clinical breast examination

A clinical breast examination is a structured, systematic assessment that I perform as part of my breast health consultations and during comprehensive well-woman appointments. I examine both breasts and the axillary (armpit) lymph nodes with the patient sitting upright and then lying down. I am looking for asymmetry, skin changes, nipple abnormalities, and any palpable masses or areas of thickening.

When I find a lump, I assess its size, shape, consistency, mobility, and tenderness. Most lumps I encounter in clinical practice are benign — cysts, fibroadenomas, or areas of fibrocystic change. A benign lump typically feels smooth, well-defined, and mobile. Concerning features include a hard, irregular mass that feels fixed to surrounding tissue, skin tethering, or associated lymphadenopathy in the axilla. However, clinical examination alone cannot definitively distinguish between benign and malignant lesions, which is why I always arrange appropriate imaging when there is any uncertainty whatsoever.

Breast screening: age-specific recommendations

Breast screening in the UK operates on a population level through the NHS Breast Screening Programme, which invites women aged 50 to 71 for mammography every three years. Some areas are trialling an extension to include women from age 47 to 73, though this has not yet been rolled out nationally. If you are over 71, you can still request a mammogram every three years by contacting your local screening unit — many women are unaware of this.

For women under 50, routine mammographic screening is not offered on the NHS unless you are at higher risk. If you have a significant family history of breast cancer — for example, a first-degree relative diagnosed before the age of 50, or multiple affected relatives — you may be eligible for enhanced surveillance through a family history clinic. This can include annual mammography or MRI starting at a younger age, depending on your estimated lifetime risk.

Private screening offers an alternative for women who want imaging outside the NHS programme. In my practice, I arrange diagnostic breast ultrasound and refer for mammography when clinically indicated. I find that private screening is particularly valued by women with dense breast tissue (which is more common in younger women and can make mammographic interpretation more difficult), those with a family history who want more frequent monitoring, and women who simply want the reassurance of a comprehensive breast assessment at a time that suits them.

Not all breast changes are cancer

Most breast symptoms have benign causes. Fibroadenomas (non-cancerous lumps), fibrocystic changes, cysts, and hormonal breast pain are all extremely common and usually require only monitoring or simple management.

However, it is always better to have a change assessed and be reassured than to delay and worry. A clinical breast examination, combined with imaging when appropriate, can usually provide a clear answer quickly.

The triple assessment pathway: what happens after a referral

If your GP refers you urgently for a breast change, you will typically be seen within two weeks at a breast clinic under the two-week-wait pathway. The standard approach in the UK is called triple assessment, and it is designed to give a definitive answer, usually in a single visit. It consists of three components:

1. Clinical examination: The breast specialist examines both breasts and axillary lymph nodes systematically, assessing any palpable abnormality
2. Imaging: For women under 40, ultrasound is typically the first-line investigation because younger breast tissue is denser and less suited to mammography. For women over 40, mammography is standard, often combined with ultrasound. MRI may be used in specific circumstances, such as for women with breast implants or those at very high genetic risk
3. Biopsy: If a suspicious area is identified on examination or imaging, a tissue sample is taken. This is usually a core needle biopsy performed under ultrasound guidance with local anaesthetic. It takes only a few minutes and, while it can be uncomfortable, most women tolerate it well. Fine needle aspiration (FNA) may be used for cysts or lymph nodes

I find that knowing what to expect takes away much of the anxiety. Most women leave the clinic the same day with reassurance. If a biopsy is performed, results typically come within one to two weeks and are discussed at a multidisciplinary team meeting before being communicated to you. If the result is benign, you are discharged back to routine care. If further treatment is needed, a clear plan is put in place without delay.

Fibroadenomas in younger women

I see many women in their twenties and thirties who are understandably frightened by a lump that has appeared seemingly overnight. In the majority of cases, these are fibroadenomas — smooth, firm, benign lumps made of glandular and connective tissue. They feel rubbery and move easily under the skin, which is why they are sometimes called “breast mice.” Fibroadenomas are hormone-sensitive, so they can grow during pregnancy or while taking the oral contraceptive pill, and they often shrink after menopause. Most do not need removal. I arrange ultrasound to confirm the diagnosis and, if there is any uncertainty, a core biopsy. Once we are confident it is a fibroadenoma, monitoring is all that is required unless it is growing rapidly or causing discomfort.

Breast awareness, not monthly self-exam

The NHS now recommends a simpler message than structured monthly self-examination: know your normal. Get familiar with how your breasts look and feel at different times of the month — in the shower, getting dressed, or lying in bed. There is no special technique required. The goal is simply that if something changes, you notice it early and seek assessment. This approach has been shown to be just as effective as rigid monthly checking, without generating the anxiety that a structured regime can create.

Cyclical breast pain: what’s normal?

Many women experience breast tenderness that fluctuates with their menstrual cycle. This is related to hormonal changes — specifically, oestrogen and progesterone stimulate breast tissue in the luteal phase — and is typically felt in both breasts, most prominently in the week before a period. While uncomfortable, cyclical breast pain is not a sign of cancer.

Management options include:

• A well-fitted, supportive bra — a professional fitting can make a real difference, and I always suggest wearing a soft sports bra at night if pain is disrupting sleep
• Reducing caffeine intake, which some women find genuinely helpful
• Evening primrose oil (gamolenic acid), taken daily over two to three months — the evidence is modest but some of my patients swear by it
• Simple analgesia such as ibuprofen gel applied directly to the breast
• In persistent severe cases, prescription medications such as danazol or tamoxifen can be considered, though these carry side effects and are rarely needed

When breast pain is concerning

Most breast pain is benign. That said, I always want to hear about pain that is non-cyclical — meaning it does not follow your menstrual pattern — or pain that is localised to one specific spot in one breast. Breast cancer itself rarely presents with pain alone, but persistent focal pain deserves assessment to rule out an underlying cause. If you are unsure whether your pain is cyclical, keeping a brief diary for two to three months is a simple and effective way to find out.

Breast health and HRT: understanding the evidence

One of the most common questions I receive — and one I address in detail in my HRT myths article — is about the relationship between HRT and breast cancer risk. The evidence is nuanced, and I believe women deserve to understand the data rather than be left with vague fears.

The key points from the current evidence are as follows. Combined HRT (oestrogen plus progestogen) is associated with a small increase in breast cancer risk that becomes apparent after approximately five years of use. To put this in absolute terms: for every 1,000 women aged 50 to 59 taking combined HRT for five years, approximately four additional cases of breast cancer would be expected beyond the background rate. This is a meaningful increase, but it is modest — comparable to the increased risk associated with drinking two glasses of wine per day or being obese.

Oestrogen-only HRT, used by women who have had a hysterectomy, carries little to no increased breast cancer risk and may even be associated with a reduced risk in some studies. The type of progestogen also matters: micronised progesterone (body-identical progesterone) appears to carry a lower risk than older synthetic progestogens, though long-term data are still accumulating.

Current guidance from the British Menopause Society emphasises that for most women, the benefits of HRT for menopausal symptoms outweigh the risks when started within 10 years of menopause. The decision should be individualised, taking into account the severity of your symptoms, your baseline breast cancer risk, your family history, and your personal preferences. I always discuss both absolute and relative risk with my patients, because relative risk figures can sound alarming when taken out of context. Having a thorough discussion of your individual risk factors with a specialist who understands both breast health and menopause is essential for making an informed decision.