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Benign Breast Conditions

The majority of patients seen in a breast surgical practice have complaints related to benign conditions. Most women seek medical advice for evaluation of breast lumps, breast pain, and discharge from the nipple, abnormal mammogram, and changes in the skin. Although in the majority of cases these conditions are not caused by breast cancer, it is of paramount importance to undergo medical evaluation to rule it out. Breast cancer is often first detected as an abnormality on a mammogram or an ultrasound before it is noticed by the patient or physician. A palpable breast cancer will usually present as a painless lump. Less than 5% of breast cancers present with breast pain. Breast cancer can also present with nipple discharge (in a minority of cases) or skin changes (redness, swelling, thickening) typically seen in inflammatory breast carcinoma. We will go over the most common benign breast conditions, their clinical presentation and briefly discuss the workup and treatment recommended.

Fibrocystic Changes: Fibrocystic changes refer to benign (non cancerous) changes in the breast. It was formerly known as fibrocystic breast disease. We now know it is not a disease, but rather a condition. The condition is also known as diffuse cystic mastopathy and mammary dysplasia. Over 60% of women have lumpy breasts and are affected by this condition. These lumps are usually located in the upper outer quadrant of the breast. Breast pain and tenderness are usually present in fibrocystic breasts. It primarily affects women under the age of 50 years and will usually resolve after menopause. Both breasts are commonly affected. The symptoms of pain range from mild breast tenderness and pain before the menstrual period to severe and constant breast pain. The breasts have multiple nodules and lumps throughout.
Fibrocystic changes affect the breast glandular tissue. The most important factor affecting this condition is the hormonal fluctuation during the female monthly cycle. Estrogen and progesterone hormones play an important role in this condition. Other hormones such as prolactin, insulin, and thyroid hormones also have an effect on the breast tissue. These hormones stimulate the growth of breast glandular tissue. These changes result in fullness and fluid retention of the breasts that resolve with the onset of menstruation. Women are often concerned about the possibility of breast cancer. Although fibrocystic change is a benign condition the clinical presentation of breast lumps can mimic the presentation of breast cancer.

Breast Pain: Breast pain is also known as mastalgia or mastodynia. Breast pain is a very common problem in women, mostly young women who are still having their period. Although cancer is a major concern for women it is rarely the cause of isolated breast pain. Only 3% to 5% of breast cancers can present with breast pain. There are two types of breast pain patterns. The first and the most common one is cyclical mastalgia. The pain is usually worse before the menses and improves once the period begins. It is believed to be caused by hormonal changes. Non-cyclical mastalgia usually occurs in women older than 40 and is constant and not associated with the menstrual cycle.


Causes of Breast Pain

•  Fibrocystic changes
•  Effects of hormones in breast tissue
•  Benign tumors
•  Cysts
•  Breast cancer
•  Pregnancy
•  Breast infections
•  Plugged milk duct
•  Thrombophlebits (Mondor’s disease)
•  Medications
•  Trauma
•  Dietary factors (methylxantines, fat intake)

Only 3% to 5% of breast cancers present with breast pain. Cyclical breast pain is associated with the menstrual period. It usually get worse just before the menses.


Management of Breast Pain

The patient should undergo a thorough evaluation to identify the cause of breast pain. There are conditions that are easily identified and can be treated with quick results. Symptomatic breast cysts can be aspirated. Large painful benign tumors can be removed. Breast abscesses should be treated with drainage. Breast infections are treated with antibiotics.
The treatment of breast pain secondary to fibrocystic changes can be very challenging in some cases. Breast pain may resolve spontaneously while 20% of patients respond with placebo treatment.

Elimination of Methylxanthines:
Chemicals classified as methylxanthines have been identified as a possible cause of pain secondary to fibrocystic changes. These chemicals are found in coffee, chocolate, tea, cola beverages, and asthma medication. There is conflicting data associating methylxanthines consumption with breast pain and tenderness. Some studies do show alleviation or complete resolution of pain after eliminating methylxanthines from the diet. Others do not support this association. We suggest a methylxanthine-restricted diet in view of its cost effectiveness and the fact that it has no side effects.

Low Dietary Fat:
Some studies have shown improvement or resolution of symptoms with a low-fat diet. Reduction of dietary fat may improve breast tenderness and pain.

Evening Primrose Oil:
Studies have shown that women with breast pain have lower levels of an essential fatty acid named gamma-linoleic acid and have a large proportion of saturated fats. Administration of essential fatty acids in the form of evening primrose oil (9% gamma-linoleic acid) can decrease the abnormal sensitivity of the breast tissue. Unfortunately, several large studies have shown no beneficial effect of evening primrose oil in the treatment of breast pain.


Endocrine Therapy

Danazol:
Danazol is a derivative of the male hormone testosterone. It blocks the action of estrogen and progesterone in the breast tissue and blocks the production of enzymes in the ovaries.
The use of this medication should be reserved only for cases of severe cyclical breast pain due to fibrocystic condition. Side effects include acne, oily hair, muscle cramps, nervousness, increased libido, hirsutism, hot flashes, amenorrhea, weight gain, voice change, fluid retention, depression, headaches and dyspareunia. These symptoms usually resolve with discontinuation of the medication. It is contraindicated in women with history of thromboembolic disease.

Luteinizin Hormone-Releasing Hormone Agonist (Lupron):
LHRH agonist work by blocking the hormone production in the ovaries. It has multiple side effects including hot flashes, depression, decreased libido, myasthenia, vaginal atrophy, bone loss, visual disorders, and hypertension. It should only be used for a short period of time and should be limitedto cases of severe pain.

Analgesics:
Nonsteroidal anti inflammatory medications may provide alleviation of pain symptoms. It should only be taken for a shot period of time.

Tamoxifen:
This is a medication used in the treatment of breast cancer. It is an agonist and antagonist of the hormone estrogen. The mechanism of action in reducing breast pain is by blocking the action of estrogen in the breast tissue. Tamoxifen has significant secondary effects and its use should be limited to the most severe cases of mastalgia. The secondary effects include increased incidence of uterine malignancies, pulmonary embolism, blood clots, stroke, abnormal vaginal bleeding or discharge, headaches, visual disturbances, fatigue, hot flashes, mood swings and night sweats.