Fibrocystic condition of the breast

Definition

Fibrocystic condition of the breast is a term that may refer to a variety of symptoms: breast lumpiness or tenderness, microscopic breast tissue, and/or the x-ray or ultrasound picture of the breast. It has been called a "wastebasket" diagnosis because a wide range of vaguely defined benign breast conditions may be labeled as fibrocystic condition. It is not a cancer, and the majority of types of fibrocystic conditions do not increase the risk of breast cancer .

Description

There is no such thing as a normal or typical female breast. Breasts come in all shapes and sizes, with varying textures from smooth to extremely lumpy. The tissues of the female breast change in response to hormone levels, normal aging, nursing (lactation), weight fluctuations, and injury. To further complicate matters, the breast has several types of tissue; each of these tissue types may respond differently to changes in body chemistry.

Fibrocystic breast condition may be called fibrocystic disease, although it is clearly not a single, specific disease process. Variations or changes in the way the breast feels or looks on x ray may cause the condition to be called "fibrocystic change." Other names have been used to refer to this imprecise and ill-defined term: mammary dysplasia, mastopathy, chronic cystic mastitis, indurative mastopathy, mastalgia, lumpy breasts, or physiologic nodularity.

Estimates vary, but 40-90% of all women have some evidence of "fibrocystic" condition, change, or disease. It is most common among women between the ages 30 and 50, but may be seen at other ages.

Causes and symptoms

Fibrocystic condition of the breast refers to technical findings on diagnostic testing (signs); however, this discussion focuses on symptoms that may fall under the general category of the fibrocystic condition. First, a brief review of the structure and function of the breast may be useful.

The breast is not supposed to be a soft, smooth organ. It is actually a type of sweat gland. Milk, the breasts' version of sweat, is secreted when the breast receives appropriate hormonal and environmental stimulation.

The normal breast contains milk glands, with their accompanying ducts, or pipelines, for transporting the milk. These complex structures may not only alter in size, but can increase or decrease in number as needed. Fibrous connective tissue, fatty tissue, nerves, blood and lymph vessels, and lymph nodes, with their different shapes and textures, lie among the ever-changing milk glands. It is no wonder that a woman's breasts may not feel uniform in texture and that the "lumpiness" may wax and wane.

The fibrocystic condition refers to the tenderness, enlargement, and/or changing "lumpiness" that many women encounter just before or during their menstrual periods. At this time, female hormones are preparing the breasts for pregnancy, by stimulating the milk-producing cells, and storing fluid. Each breast may contain as much as three to six teaspoons of excess fluid. Swelling, with increased sensitivity or pain, may result. If pregnancy does not occur, the body reabsorbs the fluid, and the engorgement and discomfort are relieved.

Symptoms of fibrocystic breast condition range from mildly annoying in some women to extremely painful in others. The severity of discomfort may vary from month to month in the same woman. Although sometimes distressing, this experience is the body's normal response to routine hormonal changes.

This cycle of breast sensitivity, pain and/or enlargement, can also result from medications. Some hormone replacement therapies (estrogen and progesterone) used for postmenopausal women can produce these effects. Other medications, primarily, but not exclusively those with hormones may also provoke these symptoms.

Breast pain unrelated to hormone shifts is called "noncyclic" pain. "Trigger-zone breast pain" is a term that may also be used to describe this area-specific pain. This type of pain may be continuous, or it may be felt intermittently. Trauma, such as a blow to the chest area, a prior breast biopsy , or sensitivity to certain medications may also underlie this type of pain. Fibrocystic condition of the breast may be cited as the cause of otherwise unexplained breast pain.

Lumps, apart from those clearly associated with hormone cycles, may also be placed under the heading of fibrocystic condition. These lumps stand out from enlarged general breast tissue. Although noncancerous lumps may occur, the obvious concern with such lumps is cancer.

Noncancerous breast lumps include:

• Adenosis. This condition refers to the enlargement of breast lobules, which contain a greater number of glands than usual. If a group of lobules are found near each other, the affected area may be large enough to be felt.
• Cysts. These are fluid-filled sacs in the breast and probably develop as ducts that become clogged with old cells in the process of normal emptying and filling. Cysts usually feel soft and round or oval. However a cyst deep within the breast may feel hard, as it pushes up against firmer breast tissue. A woman with a cyst may experience pain, especially if it increases in size before her menstrual cycle, as is often the case. Women between the age of 30 and 50 are most likely to develop cysts.
• Epithelial hyperplasia. Also called proliferative breast disease, this condition refers to an overgrowth of cells lining either the ducts or the lobules.
• Fibroadenomas. These are tumors that form in the tissues outside the milk ducts. The cause of fibroadenomas is unknown. They generally feel smooth and firm, with a somewhat rubber-like texture. Typically a fibroadenoma is not attached to surrounding tissue and moves slightly when touched. They are most commonly found in adolescents and women in their early twenties but can occur at any age.
• Fibrosis. Sometimes one area of breast tissue persistently feels thicker or more prominent than the rest of the breast. This feeling may be caused by old hardened scar tissue and/or dead fat tissue as a result of surgery or trauma. Often the cause of this type of breast tissue is unknown.
• Miscellaneous disorders. A number of other benign (noncancerous) breast problems may be placed under the heading of "fibrocystic condition." These problems include disorders that may lead to breast inflammation (mastitis), infection, and/or nipple discharge.

Atypical ductal hyperplasia

The condition known as atypical ductal hyperplasia (ADH) is a condition in which the cells lining the milk ducts of the breast are growing abnormally. This condition may appear as spots of calcium, or calcifications, on the mammogram. A biopsy removed from the breast would confirm the diagnosis. Atypical ductal hyperplasia is not a cancer. In most women, this condition will cause no problems. However, for some women, especially women with family histories of breast cancer, the risk of developing breast cancer is increased. (One study with over 3, 000 female participants indicated that about 20% of the participants with atypical hyperplasia and a family history of breast cancer developed breast cancer, as compared to the 8% of participants who developed the disease with atypical hyperplasia and no family history of breast cancer.) For women with ADH and a family history of breast cancer, more frequent mammograms and closer monitoring may be required.

Diagnosis

Breast cancer is the most common concern of women who feel a breast lump or experience an abnormal breast symptom. For peace of mind, and to rule out any possibility of cancer, any newly discovered breast lumps should be brought to the attention of a family physician or an obstetrician-gynecologist. He or she will obtain a history and conduct thorough physical examination of the area. Depending on the findings on physical examination, the patient is usually referred for tests. The most common of these tests include:

• Mammography . A mammogram is an x-ray examination of the breasts. The two major types of abnormalities doctors look for are masses and calcifications; either abnormality may be benign or malignant. The size, shape, and edges of these masses help doctors determine whether or not cancer is present. Sometimes, however, this test may be difficult to interpret, however, due to dense breast tissue.
• Ultrasonography. If a suspicious lump is detected during mammography, an ultrasound (the use of high-frequency sound waves to outline the shape of various organs and tissues in the body) is useful (although not definitive) in distinguishing benign from cancerous growths.
• Ductography. A ductogram (also called a galactogram) is a test that is sometimes useful in evaluating nipple discharge. A very fine tube is threaded into the opening of the duct onto the nipple. A small amount of dye is injected, outlining the shape of the duct on an x ray, and indicates whether or not there is a mass in the duct.
• Biopsy. If a lump cannot be proven benign by mammography and ultrasound, a breast biopsy may be considered. Usually a tissue sample is removed through a needle (fine-needle aspiration biopsy, or FNAB) to obtain a sample of the lump. The sample is examined under the microscope by a pathologist, and a detailed diagnosis regarding the type of benign lesion or cancer is established. In some cases, however, FNAB may not provide a clear diagnosis, and another type of biopsy (such as a surgical biopsy, core-needle biopsy, or other stereotactic biopsy methods—such as the Mammotome or Advanced Breast Biopsy Instrument) may be required.

Other breast conditions such as inflammation or infection are usually recognized on the basis of suspicious history, breastfeeding, or characteristic symptoms such as pain, redness, and swelling. A positive response to appropriate therapies often confirms the diagnosis.

Treatment

Once a specific disorder within the broad category of fibrocystic condition is identified, treatment can be prescribed. There are a number of treatment options for women with a lump that has been diagnosed as benign. If it is not causing a great deal of pain, the growth may be left in the breast. However, some women may choose to have a lump such as a fibroadenoma surgically removed, especially if it is large. Another option to relieve the discomfort of a painful benign lump is to have the cyst suctioned, or drained. If there is any uncertainty regarding diagnosis, the fluid may be sent to the lab for analysis.

Symptoms of cycle breast sensitivity and engorgement may also be treated with diet, medication, and/or physical modifications. For example,

• Although there is no scientific data to support this claim, many women have reported relief of symptoms when caffeine was reduced or eliminated from their diets. Decreasing salt before and during the period when breasts are most sensitive may also ease swelling and discomfort. Low-fat diets and elimination of dairy products also appear to decrease soreness for some women. However, it may take several months to realize the effects of these various treatments.
• Over-the-counter analgesics such as acetaminophen (Tylenol) or ibuprofen (Advil) may be recommended. In some cases, treatment with prescription drugs such as hormones or hormone blockers may prove successful. Oral contraceptives may also be prescribed.
• Warm soaks or ice packs may provide comfort. A well-fitted support bra can minimize physical movement and do much to relieve breast discomfort. Breast massage may promote removal of excess fluid from tissues and alleviate symptoms. Massaging the breast with castor oil, straight or infused with herbs or essential oils, can help reduce and dissipate fibroadenomas as well as keep women in touch with changes in their breast tissue.
• Infections are often treated with warm compresses and antibiotics . Lactating women are encouraged to continue breastfeeding because it promotes drainage and healing. However, a serious infection may progress to form an abscess that may need surgical drainage.
• Some studies of alternative or complementary treatments, although controversial, have indicated that vitamins A, B complex and E, and mineral supplements may reduce the risk of developing fibrocystic condition of the breast. Evening primrose oil (Oenothera biennis ), flaxseed oil, and fish oils have been reported to be effective in relieving cyclic breast pain for some women.

Prognosis

Most benign breast conditions carry no increased risk for the development of breast cancer. However, a small percentage of biopsies uncover overgrowth of tissue in a particular pattern in some women; this pattern indicates a 15-20% increased risk of breast cancer over the next 20 years. Strict attention to early detection measures, such as annual mammograms, is especially important for these women.

Prevention

There is no proven method of preventing the various manifestations of fibrocystic condition from occurring. Some alternative health care practitioners believe that eliminating foods high in methyl xanthines (primarily coffee and chocolate) can decrease or reverse fibrocystic breast changes.

Resources

BOOKS

Goldmann, David R., and David A. Horowitz, eds. The American College of Physicians Home Medical Guide: Breast Problems. New York: Dorling Kindersley, 2000.

Kneece, Judy C. Finding a Lump In Your Breast. Columbia, SC: EduCare Publishing, 1996.

Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book, 3rd rev. ed. Reading, MA.: Addison-Wesley, 2000.

Singer, Sydney Ross. Get It Off! Understanding the Cause of Breast Pain, Cysts, and Cancer. Pahoa, HI: ISCD Press, 2000.

PERIODICALS

"Benign Conditions." Harvard Women's Health Watch 5 (May 1998): 4-5.

Duijm, Lucien E.M., et al. "Value of Breast Imaging in Women With Painful Breasts: Observational Follow Up Study." British Medical Journal 317 (November 1998): 1492-1495.

Horner, N.K. and J.W. Lampe. "Potential Mechanisms of Diet Therapy for Fibrocystic Breast Conditions Show Inadequate Evidence of Effectiveness." Journal of the American Dietetic Association 100 (November 2000):1368-1380.

Mannello, F., M. Malatesta, and G. Gazzanelli. "Breast Cancer in Women With Palpable Breast Cysts." Lancet 354 (August 1999): 677-678.

Morrow, Monica. "The Evaluation of Common Breast Problems." American Family Physician 61 (April 15, 2000): 2371-2378, 2385.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329. 1-800-ACS-2345 <http://www.cancer.org>

American College of Obstetricians and Gynecologists. 40912th St., S.W., P.O. Box 96920, Washington, DC 20090-6920. <http://www.acog.org>

Cancer Information Service (CIS). 9000 Rockville Pike, Building 31, Suite 10A18, Bethesda, MD 20892. Phone: 1-800-4-CANCER. Free telephone service provided by the National Cancer Institute.

OTHER

National Cancer Institute. Understanding Breast Changes: A Health Guide for All Women. 10 July 2001 <http://rex.nci.nih.gov/MAMMOG_WEB/PUBS_POSTERS/UNDRSTNDNG/UNDER_STANDING_CHANGE.html>.

Ellen S. Weber

Genevieve Slomski, Ph.D.

KEY TERMS

Advanced Breast Biopsy Instrument (ABBI)

— Uses a rotating circular knife and thin heated electrical wire to remove a large cylinder of abnormal breast tissue.

Lobules

—A small lobe or subdivision of a lobe (often on a gland) that may be seen on the surface of the gland by bumps or bulges.

Lymph nodes

—Rounded, encapsulated bodies consisting of an accumulation of lymphatic tissue.

Mammotome

—A method for removing breast biopsies using suction to draw tissue into an opening in the side of a cylinder inserted into the breast tissue. A rotating knife then cuts tissue samples from the rest of the breast; also known as a vacuum-assisted biopsy.

Stereotactic biopsy

—A biopsy taken by precisely locating areas of abnormal growth through the use of delicate instruments.

QUESTIONS TO ASK THE DOCTOR

• How common is this condition?
• Do cysts show up on mammography?
• Can fibrocystic condition of the breast lead to cancer?
• How can I tell the difference between cysts and cancer when I perform my breast self-exam?
• Can I do anything to prevent this condition?
• What are my treatment options?
• Will I have this condition forever?

Fibrocystic Condition of the Breast

Definition

Fibrocystic condition of the breast is a term that may refer to a variety of symptoms: breast lumpiness or tenderness, microscopic breast tissue, and/or the x ray or ultrasound picture of the breast. It has been called a "wastebasket" diagnosis because a wide range of vaguely defined benign breast conditions may be labeled as fibrocystic condition. It is not a cancer, and the majority of types of fibrocystic conditions do not increase the risk of breast cancer.

Description

There is no such thing as a normal or typical female breast. Breasts come in all shapes and sizes, with varying textures from smooth to extremely lumpy. The tissues of the female breast change in response to hormone levels, normal aging, nursing (lactation), weight fluctuations, and injury. To further complicate matters, the breast has several types of tissue; each of these tissue types may respond differently to changes in body chemistry.

Fibrocystic breast condition may be called fibrocystic disease, although it is clearly not a single, specific disease process. Variations or changes in the way the breast feels or looks on x ray may cause the condition to be called "fibrocystic change." Other names have been used to refer to this imprecise and ill-defined term: mammary dysplasia, mastopathy, chronic cystic mastitis, indurative mastopathy, mastalgia, lumpy breasts, or physiologic nodularity.

Estimates vary, but 40-90% of all women have some evidence of "fibrocystic" condition, change, or disease. It is most common among women between the ages 30 and 50, but may be seen at other ages.

Causes and symptoms

Fibrocystic condition of the breast refers to technical findings on diagnostic testing (signs); however, this discussion focuses on symptoms that may fall under the general category of the fibrocystic condition. First, a brief review of the structure and function of the breast may be useful.

The breast is not supposed to be a soft, smooth organ. It is actually a type of sweat gland. Milk, the breasts' version of sweat, is secreted when the breast receives appropriate hormonal and environmental stimulation.

The normal breast contains milk glands, with their accompanying ducts, or pipelines, for transporting the milk. These complex structures may not only alter in size, but can increase or decrease in number as needed. Fibrous connective tissue, fatty tissue, nerves, blood and lymph vessels, and lymph nodes, with their different shapes and textures, lie among the ever-changing milk glands. It is no wonder that a woman's breasts may not feel uniform in texture and that the "lumpiness" may wax and wane.

The fibrocystic condition refers to the tenderness, enlargement, and/or changing "lumpiness" that many women encounter just before or during their menstrual periods. At this time, female hormones are preparing the breasts for pregnancy, by stimulating the milk-producing cells, and storing fluid. Each breast may contain as much as three to six teaspoons of excess fluid. Swelling, with increased sensitivity or pain, may result. If pregnancy does not occur, the body reabsorbs the fluid, and the engorgement and discomfort are relieved.

Symptoms of fibrocystic breast condition range from mildly annoying in some women to extremely painful in others. The severity of discomfort may vary from month to month in the same woman. Although sometimes distressing, this experience is the body's normal response to routine hormonal changes.

This cycle of breast sensitivity, pain and/or enlargement, can also result from medications. Some hormone replacement therapies (estrogen and progesterone) used for postmenopausal women can produce these effects. Other medications, primarily, but not exclusively those with hormones may also provoke these symptoms.

Breast pain unrelated to hormone shifts is called "noncyclic" pain. "Trigger-zone breast pain" is a term that may also be used to describe this area-specific pain. This type of pain may be continuous, or it may be felt intermittently. Trauma, such as a blow to the chest area, a prior breast biopsy, or sensitivity to certain medications may also underlie this type of pain. Fibrocystic condition of the breast may be cited as the cause of otherwise unexplained breast pain.

Lumps, apart from those clearly associated with hormone cycles, may also be placed under the heading of fibrocystic condition. These lumps stand out from enlarged general breast tissue. Although noncancerous lumps may occur, the obvious concern with such lumps is cancer.

Noncancerous breast lumps include:

• Adenosis. This condition refers to the enlargement of breast lobules, which contain a greater number of glands than usual. If a group of lobules are found near each other, the affected area may be large enough to be felt.
• Cysts. These are fluid-filled sacs in the breast and probably develop as ducts that become clogged with old cells in the process of normal emptying and filling. Cysts usually feel soft and round or oval. However a cyst deep within the breast may feel hard, as it pushes up against firmer breast tissue. A woman with a cyst may experience pain, especially if it increases in size before her menstrual cycle, as is often the case. Women between the age of 30 and 50 are most likely to develop cysts.
• Epithelial hyperplasia. Also called proliferative breast disease, this condition refers to an overgrowth of cells lining either the ducts or the lobules.
• Fibroadenomas. These are tumors that form in the tissues outside the milk ducts. The cause of fibroadenomas is unknown. They generally feel smooth and firm, with a somewhat rubber-like texture. Typically a fibroadenoma is not attached to surrounding tissue and moves slightly when touched. They are most commonly found in adolescents and women in their early twenties but can occur at any age.
• Fibrosis. Sometimes one area of breast tissue persistently feels thicker or more prominent than the rest of the breast. This feeling may be caused by old hardened scar tissue and/or dead fat tissue as a result of surgery or trauma. Often the cause of this type of breast tissue is unknown.
• Miscellaneous disorders. A number of other benign (noncancerous) breast problems may be placed under the heading of "fibrocystic condition." These problems include disorders that may lead to breast inflammation (mastitis), infection, and/or nipple discharge.

Atypical ductal hyperplasia

The condition known as atypical ductal hyperplasia (ADH) is a condition in which the cells lining the milk ducts of the breast are growing abnormally. This condition may appear as spots of calcium salts, or calcifications, on the mammogram. A biopsy removed from the breast would confirm the diagnosis. Atypical ductal hyperplasia is not a cancer. In most women, this condition will cause no problems. However, for some women, especially women with family histories of breast cancer, the risk of developing breast cancer is increased. (One study with over 3,000 female participants indicated that about 20% of the participants with atypical hyperplasia and a family history of breast cancer developed breast cancer, as compared to the 8% of participants who developed the disease with atypical hyperplasia and no family history of breast cancer.) For women with ADH and a family history of breast cancer, more frequent mammograms and closer monitoring may be required.

Diagnosis

Breast cancer is the most common concern of women who feel a breast lump or experience an abnormal breast symptom. For peace of mind, and to rule out any possibility of cancer, any newly discovered breast lumps should be brought to the attention of a family physician or an obstetrician-gynecologist. He or she will obtain a history and conduct thorough physical examination of the area. Depending on the findings on physical examination, the patient is usually referred for tests. The most common of these tests include:

• Mammography. A mammogram is an x-ray examination of the breasts. The two major types of abnormalities doctors look for are masses and calcifications; either abnormality may be benign or malignant. The size, shape, and edges of these masses help doctors determine whether or not cancer is present. Sometimes, however, this test may be difficult to interpret, however, due to dense breast tissue.
• Ultrasonography. If a suspicious lump is detected during mammography, an ultrasound (the use of high-frequency sound waves to outline the shape of various organs and tissues in the body) is useful (although not definitive) in distinguishing benign from cancerous growths.
• Ductography. A ductogram (also called a galactogram) is a test that is sometimes useful in evaluating nipple discharge. A very fine tube is threaded into the opening of the duct onto the nipple. A small amount of dye is injected, outlining the shape of the duct on an x ray, and indicates whether or not there is a mass in the duct.
• Biopsy. If a lump cannot be proven benign by mammography and ultrasound, a breast biopsy may be considered. Usually a tissue sample is removed through a needle (fine-needle aspiration biopsy, or FNAB) to obtain a sample of the lump. The sample is examined under the microscope by a pathologist, and a detailed diagnosis regarding the type of benign lesion or cancer is established. In some cases, however, FNAB may not provide a clear diagnosis, and another type of biopsy (such as a surgical biopsy, core-needle biopsy, or other stereotactic biopsy methods—such as the Mammotome or Advanced Breast Biopsy Instrument) may be required.

Other breast conditions such as inflammation or infection are usually recognized on the basis of suspicious history, breastfeeding, or characteristic symptoms such as pain, redness, and swelling. A positive response to appropriate therapies often confirms the diagnosis.

Treatment

Once a specific disorder within the broad category of fibrocystic condition is identified, treatment can be prescribed. There are a number of treatment options for women with a lump that has been diagnosed as benign. If it is not causing a great deal of pain, the growth may be left in the breast. However, some women may choose to have a lump such as a fibroadenoma surgically removed, especially if it is large. Another option to relieve the discomfort of a painful benign lump is to have the cyst suctioned, or drained. If there is any uncertainty regarding diagnosis, the fluid may be sent to the lab for analysis.

KEY TERMS

Advanced Breast Biopsy Instrument (ABBI)— Uses a rotating circular knife and thin heated electrical wire to remove a large cylinder of abnormal breast tissue.

Lobules— A small lobe or subdivision of a lobe (often on a gland) that may be seen on the surface of the gland by bumps or bulges.

Lymph nodes— Rounded, encapsulated bodies consisting of an accumulation of lymphatic tissue.

Mammotome— A method for removing breast biopsies using suction to draw tissue into an opening in the side of a cylinder inserted into the breast tissue. A rotating knife then cuts tissue samples from the rest of the breast; also known as a vacuum-assisted biopsy

Stereotactic biopsy— A biopsy taken by precisely locating areas of abnormal growth through the use of delicate instruments.

Symptoms of cycle breast sensitivity and engorgement may also be treated with diet, medication, and/or physical modifications. For example,

• Although there is no scientific data to support this claim, many women have reported relief of symptoms when caffeine was reduced or eliminated from their diets. Decreasing salt before and during the period when breasts are most sensitive may also ease swelling and discomfort. Low-fat diets and elimination of dairy products also appear to decrease soreness for some women. However, it may take several months to realize the effects of these various treatments.
• Over-the-counter analgesics such as acetaminophen (Tylenol) or ibuprofen (Advil) may be recommended. In some cases, treatment with prescription drugs such as hormones or hormone blockers may prove successful. Oral contraceptives may also be prescribed.

• Warm soaks or ice packs may provide comfort. A well-fitted support bra can minimize physical movement and do much to relieve breast discomfort. Breast massage may promote removal of excess fluid from tissues and alleviate symptoms. Massaging the breast with castor oil, straight or infused with herbs or essential oils, can help reduce and dissipate fibroadenomas as well as keep women in touch with changes in their breast tissue.
• Infections are often treated with warm compresses and antibiotics. Lactating women are encouraged to continue breastfeeding because it promotes drainage and healing. However, a serious infection may progress to form an abscess that may need surgical drainage.
• Some studies of alternative or complementary treatments, although controversial, have indicated that vitamins A, B complex and E, and mineral supplements may reduce the risk of developing fibrocystic condition of the breast. Evening primrose oil (Oenothera biennis ), flaxseed oil, and fish oils have been reported to be effective in relieving cyclic breast pain for some women.

Prognosis

Most benign breast conditions carry no increased risk for the development of breast cancer. However, a small percentage of biopsies uncover overgrowth of tissue in a particular pattern in some women; this pattern indicates a 15-20% increased risk of breast cancer over the next 20 years. Strict attention to early detection measures, such as annual mammograms, is especially important for these women.

Prevention

There is no proven method of preventing the various manifestations of fibrocystic condition from occurring. Some alternative health care practitioners believe that eliminating foods high in methyl xanthines (primarily coffee and chocolate) can decrease or reverse fibrocystic breast changes.

Resources

BOOKS

Goldmann, David R., and David A. Horowitz, editors. The American College of Physicians Home Medical Guide: Breast Problems. New York: Dorling Kindersley, 2000.

Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book. 3rd ed., revised. Reading, MA.: Addison-Wesley, 2000.

Singer, Sydney Ross. Get It Off! Understanding the Cause of Breast Pain, Cysts, and Cancer. Pahoa, HI: ISCD Press, 2000.

PERIODICALS

Horner, N.K., and J.W. Lampe. "Potential Mechanisms of Diet Therapy for Fibrocystic Breast Conditions Show Inadequate Evidence of Effectiveness." Journal of the American Dietetic Association 100 (November 2000): 1368-1380.

Mannello, F., M. Malatesta, and G. Gazzanelli. "Breast Cancer in Women With Palpable Breast Cysts." Lancet 354 (August 1999): 677-678.

Morrow, Monica. "The Evaluation of Common Breast Problems." American Family Physician 61 (April 15, 2000): 2371-2378, 2385.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329. 1-800-ACS-2345. 〈http://www.cancer.org〉.

American College of Obstetricians and Gynecologists. 409 12th St., S.W., P.O. Box 96920, Washington, DC 20090-6920. 〈http://www.acog.org〉.

Cancer Information Service (CIS). 9000 Rockville Pike, Building 31, Suite 10A18, Bethesda, MD 20892. 1-800-4-CANCER. 〈http://wwwicic.nci.nih.gov〉.

OTHER

National Cancer Institute. Understanding Breast Changes: A Health Guide for All Women. July 10, 2001. 〈http://rex.nci.nih.gov/MAMMOG_WEB/PUBS_POSTERS/UNDRSTNDNG/UNDER_STANDING_CHANGE.html〉.

Fibrocystic breast disease

Definition

Fibrocystic breast disease is a general term that refers to a variety of symptoms and diagnoses, including breast lumpiness, tenderness, and a wide range of vaguely-defined benign breast conditions. The term is also used diagnostically to describe the appearance of breast tissues viewed under the microscope, on x-ray film, or on ultrasound equipment.

Description

There is no such thing as a typical or normal female breast. Breasts come in all shapes and sizes, with varying textures from smooth to extremely lumpy. The tissues of the female breast change in response to hormone levels, normal aging , nursing (lactation), weight shifts, and injury. To further complicate matters, the breast has several types of tissue, each of which may respond differently to changes in body chemistry.

Fibrocystic breast disease is clearly not a single, specific disease process. Variations or changes in the way the breast feels or looks on an x ray may cause the condition to be called "fibrocystic change." Other names have been used to refer to this imprecise and ill-defined term: mammary dysplasia, mastopathy, chronic cystic mastitis, indurative mastopathy, mastalgia, lumpy breasts, or physiologic nodularity.

Estimates vary, but 40–90% of all women have some evidence of fibrocystic condition, change, or disease. It is most common among women ages 30–50, but may be seen at other ages.

Causes & symptoms

Fibrocystic condition refers to technical findings. This discussion will focus on symptoms a woman experiences,

which may fall under the general category of the fibrocystic condition.

The breast is not a soft, smooth, pulpy organ. It is actually a type of sweat gland. Milk, the breasts' version of sweat, is secreted when the breast receives appropriate hormonal and environmental stimulation.

The normal breast contains milk glands, with their accompanying ducts, or pipelines, for transporting the milk. These complex structures may not only alter in size, but can increase or decrease in number as needed. Fibrous connective tissue, fatty tissue, nerves, blood and lymph vessels, and lymph nodes, with their different shapes and textures, lie among the ever-changing milk glands. This explains why a woman's breasts may not feel uniform in texture, and why "lumpiness" may wax and wane.

Fibrocystic condition is the tenderness, enlargement, and/or changing lumpiness that many women encounter just before or during their menstrual periods. At this time, female hormones are preparing the breasts for pregnancy , by stimulating the milk-producing cells and storing fluid. Each breast may contain as much as three to six teaspoons of excess liquid. Swelling, with increased sensitivity or pain , may result. If pregnancy does not occur, the body reabsorbs the fluid, and the engorgement and discomfort are relieved.

These symptoms range from mildly annoying in some women to extremely painful in others. The severity of the sensations may vary from month to month in the same woman. Although sometimes distressing, this experience is the body's normal response to routine hormonal changes.

This cycle of breast sensitivity, pain, and/or enlargement can also result from medications. Some hormone replacement therapies used for post-menopausal women can produce these effects. Other medications, primarily, but not exclusively, those with hormones, may also provoke these symptoms.

Breast pain unrelated to hormone shifts is called "noncyclic" pain. This area-specific pain is also called "trigger-zone breast pain," and it may be continuous, or may be felt intermittently. Trauma, such as a blow to the area, or a breast biopsy performed several years before, or sensitivity to certain medications may also underlie this type of pain. Fibrocystic condition may be cited as the cause of otherwise unexplained breast pain.

Lumps, apart from those clearly associated with hormone cycles, may also be placed under the heading of fibrocystic condition. These lumps stand out from enlarged general breast tissue. The obvious concern with such lumps is cancer , although noncancerous lumps also occur. Two noncancerous types, fibroadenomas and cysts, are discussed here.

Fibroadenomas are tumors which form in the tissues outside the milk ducts. The cause of fibroadenomas is unknown. They generally feel smooth and firm, with a somewhat rubber-like texture. Typically a fibroadenoma is not attached to surrounding tissue, and will move slightly when touched. They are most commonly found in adolescents and women in their early 20s but can arise at any age.

Cysts are fluid-filled sacs in the breast. They probably develop as ducts become clogged with old cells in the process of normal emptying and filling. Cysts usually feel soft and round or oval. However, a cyst deep within the breast may feel hard, as it pushes up against firmer breast tissue. A woman with a cyst may experience pain, especially if it increases in size before her menstrual cycle, as many do. Women age 30–50 are most likely to develop cysts.

Sometimes one area of breast tissue persistently feels thicker or more prominent than the rest of the breast. This may be caused by hardened scar tissue and/or dead fat tissue from surgery or trauma. Often the cause of such tissue is unknown.

A number of other breast problems which are benign or noncancerous may be placed under the heading of fibrocystic condition. These include disorders which may lead to breast inflammation (mastitis), infection, nipple discharge, dilated milk ducts, milk-filled cyst, wart-like growth in the duct, and excess growth of fibrous tissue around the glands.

Diagnosis

Breast cancer is the concern in most cases of an abnormal breast symptom. A newly discovered breast lump should be brought to the attention of a family physician or an obstetrician-gynecologist. A physical examination of the area is usually performed. Depending on the findings, the patient may be referred for tests.

The most common tests are mammography and breast ultrasound. A cyst may be definitively diagnosed by ultrasound. To relieve the discomfort, the patient may choose to have the cyst suctioned, or drained. If there is any question as to the fluid diagnosis, the fluid is sent for analysis.

If a lump cannot be proven benign by mammography and ultrasound, a breast biopsy may be considered. Tissue is removed through a needle to obtain a sample of the lump. The sample is examined under the microscope by a pathologist, and a detailed diagnosis regarding the type of benign lesion or cancer is established.

A ductogram evaluates nipple discharge. A very fine tube is threaded into the duct, dye is injected, and the area is looked at for diagnosis. Other breast conditions such as inflammation or infection are usually recognized on the basis of suspicious history, such as breast-feeding and characteristic symptoms such as pain, redness, and swelling. A positive response to appropriate therapies will support the diagnosis.

Treatment

Warm soaks, heating pads, or ice packs may provide comfort. A well-fitted support bra worn day and night can minimize physical movement and do much to relieve breast discomfort. Breast massage may promote removal of excess fluid from tissues and alleviate symptoms. Massaging the breast with castor oil , straight or infused with herbs or diluted essential oils , can help reduce and dissipate fibroadenomas as well as keep women in touch with changes in their breasts.

Many women have reported relief of symptoms when caffeine was reduced or eliminated from their diets . Decreasing salt intake before and during the period when breasts are most sensitive may also ease swelling and discomfort. Vitamins A, B complex, and E and selenium supplements have been reported to be helpful. Because fat promotes estrogen production, and estrogen is thought to be linked to breast tenderness, low-fat diets and elimination of dairy products also seem to decrease soreness for some women. Restricting salt intake may also help reduce fluid retention and lessen breast pain. It may take several months to realize the effects of these various treatments.

Evening primrose oil (Oenothera biennis ), flax oil, and fish oils have been reported to be effective in relieving cyclic breast pain for some women. In addition, a focus on liver cleansing is important to assist the body in conjugation and elimination of excess estrogens. The herb chaste tree (Vitex angus-castus ) can be used to help relieve symptoms of premenstrual syndrome (PMS), including breast tenderness.

A Chinese herbalist may recommend Herba cum Radice Asari with Radix Angelicae Sinensis and Flos Carthami Tinctorii for painful breast lumps, or Rhizoma Cyperi Rotundi with Radix Bupleuri and Fructus Trichosanthis for breast masses that swell around the time of menstruation .

Allopathic treatment

A lump that has been proven benign can be left in the breast. Some women may choose to have a lump such as a fibroadenoma surgically removed, especially if it is large. Infections are treated with warm compresses and antibiotics. Lactating women are encouraged to continue breastfeeding, as it promotes drainage and healing. A serious infection may progress to form an abscess which may need surgical drainage.

Once a specific disorder within the broad category of fibrocystic condition is identified, treatment can be prescribed. Symptoms of cyclical breast sensitivity and engorgement may be treated with diet, medication, and/or physical modifications.

Over-the-counter analgesics (pain relievers) such as acetaminophen (Tylenol) or ibuprofen (Advil) may be recommended. In some cases, treatment with hormones or hormone blockers may prove successful. Birth control pills may be prescribed.

Expected results

Most benign breast conditions carry no increased risk for the development of breast cancer. However, a small percentage of biopsies will uncover overgrowth of tissue in a particular pattern in some women that indicates a 15–20% risk of developing breast cancer over the next 20 years. Strict attention to early detection measures, such as annual mammograms, is especially important for these women.

Prevention

No way has yet been proven to prevent the various manifestations of fibrocystic condition from occurring. Some alternative practitioners believe that elimination of foods high in methylxanthines (primarily coffee and chocolate) can decrease or reverse fibrocystic breast changes.

Resources

BOOKS

Kneece, Judy C. Finding a Lump In Your Breast. Columbia, SC: EduCare Publishing, 1996.

Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book. 2nd ed. Reading, MA: Addison-Wesley, 1995.

PERIODICALS

"Benign Conditions." Harvard Women's Health Watch 5 (May 1998): 4–5.

Paula Ford-Martin