Fibrocystic Breasts And Breast Pain
Benign breast conditions are a common finding in clinical practice, with fibrocystic breast changes and fibroadenomas occurring in 60% to 90% of all women. The hallmark of fibrocystic breast changes is that the cysts fluctuate in size and shape, may entirely disappear and reappear cyclically, and are associated with hormonal changes in the menstrual cycle. Women with this condition describe their breasts as feeling lumpy, “ropey,” and tender. The changes occur bilaterally. Fibroadenomas are mobile, solid, firm, rubbery masses that typically occur singly, and are not usually painful. They are second only to fibrocystic changes as the most common of the benign breast conditions, and are commonly found in women in their 20s. Breast tenderness that accompanies the menstrual cycle is known as cystic mastalgia.’ Cyclic mastalgia may be associated with other premenstrual complaints. The terms benign breast disorder and benign breast disease are unfortunate misnomers, as they are neither a disorder nor disease. In only a small percentage of cases are the atypical ductal and lobular hyperplasias associated with increased risk of breast carcinoma. Practitioners consulting with women for fibrocystic breast changes and other findings must be sensitive to a patient’s increased anxiety about finding a breast lump, and provide clear information and calming reassurance both during the exam and while the patient awaits tests results if any were deemed necessary.
Fibrocystic breast changes are an exaggerated response to cyclic ovarian hormones. The etiology of fibroadenomas and cyclic mastalgia may also be hormonal, though in some cases, the cause of a fibroadenoma may be unclear. When this occurs in women over 30, removal of the mass is generally recommended.
Diagnosis And Differential Diagnosis
There are two primary aims when arriving at a diagnosis of fibrocystic breasts. The first is to rule out breast cancer, and the second is to determine if benign breast symptoms warrant treatment. A careful history, physical exam, and cancer risk assessment are indicated (Clinical Features of Benign Breast Changes and Table Risk for Development of Breast Cancer by Type of Benign Breast Disease). A thorough breast exam is best performed after the menses, as examination prior to menses (when the pain is actually likely to be most acute) can obscure problematic lumps caused by normal breast tissue proliferation and nodularity from normal hormonal changes. If a suspicion of breast cancer remains after the history and physical, further diagnostic tests should be performed as appropriate. Diagnosis of fibrocystic breasts can be made on the basis of cancer exclusion. For women experiencing symptoms including pain, tenderness, swelling, inflammation, or nipple discharge, the comprehensive history and physical can be used to determine if the problem is cyclic or noncyclic in nature and whether it is associated with other signs and symptoms, including fever or premenstrual mood swings. It is also important to gently move aside the breast tissue and examine the chest wall and muscle to determine whether breast pain or muscle pain is the proper diagnosis. Depending on the associated signs and symptoms, a diagnosis, including breast infection, muscle sprain / strain, premenstrual syndrome, or noncyclic mastalgia can be determined.
Clinical Features of Benign Breast Changes
Breast tenderness and swelling
Breast pain (mastalgia)
• Gross cysts
• Fibroadenomas Nipple discharge Breast infections
• Lactational or postpartum mastitis
• Acute mastitis associated with macrocystic breasts
• Chronic subareolar abscess
Risk for Development of Breast Cancer by Type of Benign Breast Disease
|Histologic Pattern||Approximate Relative Risk Of Developing Breast Carcinoma||Proportion Of Benign Lesions*|
|Nonproliferative changes||No increased risk||70%|
|Proliferative disease without atypical hyperplasia||Twofold increased risk||27%|
|Proliferative disease with:||3%-4%|
|Atypical hyperplasia||Fivefold increased risk|
|Atypical lobular hyperplasia||Fivefold increased risk|
|Atypical ductal hyperplasia||Twofold increased risk|
|Proliferative disease with atypia and family history**||11 -fold increased risk||3%-4%|
*As determined by biopsy
**Family history limited to mother, daughter, or sister with breast cancer
Conventional treatment for fibrocystic breasts includes encouraging women to wear loose fitting brassieres, decreased caffeine consumption, and smoking cessation, and a pharmacologic focus on hormonal modulation, including oral contraceptives (OCs), prolactin antagonists, and antiestrogen agents as well as diuretics for moderate premenstrual mastalgia; and analgesics such as ibuprofen, salicylates, and acetaminophen for pain. Hormonal therapies often carry unwanted side effects, including weight gain, lipid profile changes, depression, and abnormal bleeding. Although oral contraceptives reduce symptoms in up to 90% of women, symptoms return upon discontinuation. Danazol, which suppresses the pituitary ovarian axis by inhibiting the output of both follicle-stimulating hormone and luteinizing hormone from the pituitary gland, is also used for mastalgia. Its side effects include virilization, muscle cramps, CPK elevations, and liver damage. Bromocriptine is also used for breast pain and nodularity but has several common side effects, including nausea, giddiness, and postural hypotension. Reduction in dietary fat intake has been shown to reduce cyclic mastalgia.
It is important to evaluate whether women with breast pain are exercising appropriately and properly. Some women who believe that they are experiencing breast pain or tenderness are instead having chest wall pain, often resulting from inappropriate or overexercise, especially strength-building exercises that emphasize the pectoral muscles. No studies have examined the impact of any type of exercise on the symptoms or nodularity of fibrocystic breasts. Consequently, it is difficult to know what duration, type, or frequency of exercise would most benefit women with fibrocystic breasts.
Inadequate support of the breasts is thought to lead to suspensory ligament strain, which may cause or contribute to pain and tenderness. No randomized controlled studies have examined breast support and its relationship to breast pain.
No studies have examined the effect of stress, anxiety, depression, or sleep disturbances on fibrocystic symptoms. However, many other pain syndromes, including fibromyalgia and vulvar pain, are closely associated with levels of “distress” in a woman’s life. No randomized clinical trials have been conducted using acupuncture for fibrocystic breast symptoms; however, several open label trials have found that up to 95% of women’s mastalgia was improved after acupuncture treatment.
Treatment Summary For Fibrocystic Breasts And Breast Pain
• Reduce endogenous and exogenous estrogen load through dietary modification, reduction in environmental exposure, and botanical modulation of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian axis and biotransformation of hormones. Examples of herbal actions to accomplish this include adaptogens, hormonal modulators, cholagogues, and aperients.
• Use SERMS to competitively bind estrogen receptors.
• Relieve excess congestion in breast tissue via stimulation of local lymphatic drainage with lymphatics as well as diuretics to help eliminate excess fluids.
• Use topical applications for symptomatic pain relief and to stimulate local circulation and lymphatic flow.
• Avoid the use of caffeinated products, including coffee, black tea, chocolate, and caffeinated sodas.
• Supplement with vitamins E and B6.
• Make certain that exercise is appropriate and not causing chest wall pain or strain.
• Make sure that the patient wears adequate breast support and appropriately sized brassieres.
• Acupuncture may be beneficial for relieving symptoms of fibrocystic breasts.