Fibrocystic Breast Disease
Breast disorders are so common that Smith and Souba estimate that one of every two women will consult her physician about a breast disorder at some point in her life. Most patients who consult their physicians for breast problems do not have a malignancy of the breast.
Patients with a breast problem, however, should be evaluated and all methods available should be used to make a diagnosis. Therefore, the physician should be aware of all the benign conditions that may be encountered.
Clinically, the most useful classification system for benign breast disease is based on symptoms and physical findings. Six general categories are noted:
- Physiologic swelling and tenderness
- Nodularity; significant lumpiness, both cyclic and non-cyclic
- Mastalgia; severe pain, both cyclic and non-cyclic
- Dominant lumps; including gross lumps and fibroadenomas
- Nipple discharge; including intraductal papilloma and duct ectasia
- Infections and inflammation, including subareolar, abscesses, lactational mastitis, breast abscesses and Mondor's Disease
Swelling, breast pain, and nodularity are often grouped together and referred to as fibrocystic disease or changes. Aggregating these categories may be problematic as the various causes of these conditions may need to be isolated to determine the specific cause of the condition and the resultant treatment option to be undertaken. As examples, women on oral contraceptives or hormone replacement therapy may experience swelling and breast tenderness. By reducing or eliminating the estrogen replacement therapy, the breast pain or swelling may be reduced. In addition, breast pain may be caused by trauma, chest wall pain or by costochondritis. In any event, the underlying cause of the pain, nodularity or swelling may be treated more effectively.
Dominant lumps are generally clinically benign breast lesions that are distinct, persistent, and relatively unchanging. The lesions that are represented by these lumps include macrocysts, galactoceles, and fibroadenomas. These lumps generally do not respond to hormonal therapy that may be effective in treating nodularity or breast pain.
Fibroadenomas represent the most common benign solid tumor of the female breast.
They are typically seen in women in the third decade of life although they are sometimes seen in postmenopausal women. Fibroadenomas may be hormonally responsive and may change in size throughout the menstrual cycle.
Nipple discharge is produced due to a variety of conditions. Benign conditions include mammary duct ectasia, intraductal papilloma, and breast abscess. When there is multicolored discharge such as greenish or black in color, this is usually duct ectasia. It
is commonly found in pre-menopausal women who have had children. There is generally no treatment for this condition. Intraductal papilloma is usually seen when there is bloody nipple discharge. This must be investigated with surgery but is commonly found to be benign.
Treatment of benign conditions of the breast depend largely on the ability to successfully identify the specific disorder and to rule out malignancy. Once the condition is identified, the treatment will vary from surgery to medical treatment.
Breast pain is inadequately treated. Breast pain affects up to 70% of the female population and is the cause of 50% of referrals to a specialized breast clinic. Fibrocystic breast disease affects 50% of women between the ages of 30 and 50. It often has a significant impact on the quality of life of women suffering from the disorder. Breast pain may impair a woman's ability to work, participate in physical activity, or even embrace a loved one. It has a profound social, psychological, and economic impact on women and their families.
According to a published study, breast pain and fibrocystic breast disease negatively impact sexual
activity 33-48%, physical activity 29-36%, social activities 13-15%, and work by 6-15% (Journal of the American College of Surgery 1997, 185,466). In 15% of patients with breast
pain, the disorder is significant enough to warrant pharmacologic therapy.
The approach initially adopted to treat breast pain is reassurance along with a properly fitted brassiere. Dietary changes are encouraged and include the elimination of caffeine and chocolate. Women may also be advised to use over the counter analgesics and gamma lineolic acid.
Danazol, the only prescription product approved for the treatment of breast pain/fibrocystic breast disease is employed when breast pain is more severe. Danazol is highly effective in the treatment of breast pain although its side effects, which are androgenic in nature, limit use. Bromocriptine, although not approved for breast pain or fibrocystic breast disease, has also been used with moderate success in the treatment of breast pain, although nearly 33% of women using it experience severe side effects. These side effects include postural hypotension, headache, and nausea. Similarly, tamoxifen, an antiestrogen, is used to treat severe cases of breast pain. The long term safety of tamoxifen is the subject of much discussion and
its use is reserved for cases of breast pain refractory to other treatment modalities.
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