Revised and edited by Christopher M. Cirino, DO – By Daniela Dominguez.
The article that follows is an update on an important women’s health topic: fibrocystic breasts. Breast changes are common and seen in fifty percent of women. The breasts contain the mammary glands, responsible for lactation. The tissue is receptive to hormonal changes as levels ebb and flow. While the lesions are uncomfortable, they are benign. Nevertheless, some forms do increase the risk of developing cancer. If you have fibrocystic breasts, know that there are options to address them and even ways to naturally reduce severity and treat them.
A 36-year-old reports to her doctor for increasing swelling of her right breast. She has a history of fibrocystic breasts and reports swelling and pain of her right breast over the course of the last several months. She notes that she tends to have increased pain right before her periods begin.
At the office, an exam revealed swelling and a cyst-like firmness on the right lower breast quadrant. Transillumination confirmed a large cyst. The patient consented to a therapeutic cyst aspiration. The doctor removed approximately 60ml of yellow-green-colored fluid with a complete collapse of the cyst. The discomfort subsided promptly. She was referred for a mammogram and breast ultrasound for further clarification.
Here are seven frequently asked questions about fibrocystic breasts:
Table of Contents
Are fibrocystic breasts a disease process?
No (and Yes). Fibrocystic breast changers were previously known as fibrocystic breast disease. They are a group of benign breast lesions and are not considered pathological processes. The prevalence in women of reproductive age is as high as 30% to 60%; usually the women are between the ages of thirty and fifty.5
The exact cause is unknown. The prevailing theory suggests the breast tissue’s exaggerated response to hormones and growth factors.4 Several risk factors for fibrocystic breast changes seem to support this, including its association with oral contraceptive hormones, primarily estrogen and polycystic ovarian syndrome.
A more challenging question is whether the changes of fibrocystic breasts all represent one mechanism. It is possible that the changes exist along a spectrum, with increasing association to breast cancer risk with more severe changes.
Is There Any Role of Health and Diet in Preventing Fibrocystic Breast Disease?
The reader should note that this section is denser (no pun intended) in hypothesis and studies than other sections.
Fibrocystic breasts are commonly seen in healthy women. Studies have been limited in establishing a clear link between diet and fibrocystic breast changes. Dietary causality to health concerns is difficult to establish. The lack of clarity may be more associated to challenges in study design and longitudinal evaluation. Nevertheless, a case can be made that diet plays a role in fibrocystic breast changes.
In this section, I will review three food and drink sources, applying the theory of estrogen excess and dysfunction to evaluate for biological plausibility.
The body uses hormones and enzymes to metabolize food molecules and store and mobilize adipose stores. A diet high in processed foods increases adipose stores via insulin’s activity. Adipose tissue can generate estrogen and increase levels in the bloodstream.
It is conceivable that greater adipose tissue in obesity leads to higher estrogen levels in the body, increasing breast density. One study showed a correlation between fibrocystic breast changes and higher percent body fat. Accordingly in this population, there may be a higher risk of breast cancer.
It is not surprising that obesity increases the risk of cancer, including breast, because it is characterized by insulin resistance and higher levels of insulin, a growth factor. Conversely, lifestyle factors, including exercise and a plant-based diet, may be responsible for preventing 25 to 30% of cases of breast cancer.
Moderate alcohol intake increases the risk of breast cancer. Alcohol consumed at an earlier age (18-22 years) was found to increase the rate of proliferative benign breast densities. Studies consistently show higher levels of estrogen (up to 300% higher) in women who ingest alcohol.
Multiple earlier studies do not support a correlation between caffeine intake and fibrocystic breast changes (Levinson, 1986, Boyle, 1984). If we look for any biological plausibility of the estrogen theory, interestingly studies do show alterations in estrogen levels. However, the levels seem to vary by subject background and type of caffeinated beverage consumed; moderate levels (200mg) of caffeine reduced estrogen concentrations in white women, and soda and green tea increased estrogen in all groups, Asia, Caucasian, and African American groups.
Do fibrocystic breast changes increase the risk of cancer?
First of all, the finding of fibrocystic breast changes does not equate to cancer. The changes in fibrocystic breasts exist along a spectrum. The breast changes include small and large cysts, increased tissue growth, and scarring changes.
Fibrocystic breast changes classify as non-proliferative (simple breast cysts), proliferative without atypia (ductal hyperplasia, intraductal papilloma, sclerosing adenosis, radial scars, and fibroadenomas), and proliferative with atypia (atypical hyperplasia).
The classification shows that some benign fibrocystic breast changes have a risk of transforming into a malignancy. A study of 677 surgical specimens of the breast showed a 17% coexistence between cancer and fibrocystic changes. Non-proliferative breast lesions do not increase the risk of breast cancer.
Proliferative lesions have a chance of progressing to breast cancer. The risk varies based on cellular findings: two times (relative risk of 1.88) without atypia and four times (relative risk of 4.24) with atypia.1-3 Therefore, finding these lesions represents an indication for ongoing screening for malignancy. Here is an article from Your Health Forum on breast cancer screening.
Remember that risk does not mean diagnosis. Clarifying the difference while underscoring the need for screening can reduce patient anxiety and support collaboration.
|Type of Fibrocystic Breast Changes|
With Atypia (atypical hyperplasia)
How can someone tell if they have fibrocystic breast changes?
Fibrocystic breast changes often have lumpy or ropey texture. There may be nodular areas along with nipple tenderness. Sometimes a dominant mass (more often in the upper outer quadrants) can be present. Nipple discharge occurs less commonly.
The symptoms tend to increase during the menstrual cycle or can intensify in postmenopausal women if they initiate estrogen hormone therapy.6 If you notice any new changes, consult a physician who will do a thorough physical examination and arrange for imaging. 7
Several findings suggest a breast lesion is likely benign: a tender, round, regular, and well-defined shape of the nodule or mass; elastic consistency; and easily mobile. A non-tender, irregular mass with skin retractions alerts the clinician of the possibility of breast cancer.8
An exaggerated response of the breast tissue to hormones and growth factors leads to breast pain, tenderness, and nodularity. It often presents as premenstrual cyclic breast pain (mastalgia), with pain and tenderness to touch.
Imaging usually follows a careful physical examination. Women younger than forty typically start with ultrasound, while women older than forty undergo mammography. 10-11 Ultrasound and mammogram characteristics inform the physician whether the nodule or mass is more likely to be benign. Radiologists or surgeons perform a biopsy if the mass shows suspicion of malignancy.
Is follow-up required?
The American College of Obstetricians and Gynecologists recommends breast self-awareness, regular clinical breast exams (physical examination by a physician) every 1-3 years for all women ages 25 to 39 and annually for women over 40 years. Yearly mammograms begin at the age of 40.12
The follow-up plan will depend on the age and type of fibrocystic breast change. Most women require reassurance that there is no risk of breast cancer and will continue routine evaluation.
Is there a Treatment for Fibrocystic Breasts?
As stated, fibrocystic breast changes are characterized by symptoms related to the menstrual cycle, especially breast pain and fullness. Therefore, the treatment is focused on reducing those symptoms.
The use of a supportive bra gives a sense of more comfort to women. 14
Over-the-counter pain medications like non-steroidal anti-inflammatory drugs can reduce breast pain (mastalgia.) There is some improvement in pain from reducing the intake of coffee, chocolate, or energizing beverages (methylxanthines). 15
If there are cysts, aspiration of palpable or painful cysts can be part of the treatment. Cysts often recur, so repeating aspiration is only done if the cysts cause pain. 16
There may be a further need for pharmacological treatment, especially if the pain limits daily activities. After instituting medical therapy, doses can gradually decrease after three to six months of treatment.
Metformin, a common medication for diabetes mellitus, was found to decrease clinical symptoms of fibrocystic breast changes compared to a placebo group. In a different study in non-diabetic women with breast cancer, metformin led to hormonal changes, decreasing levels of estrogen (supporting biologic plausibility).
Danazol (Danocrine) is the only drug approved by the USA Food and Drugs administration for breast pain. However, there are androgenic side effects like masculine pattern hair growth, loss of hair, deepening of the voice, bulking, and acne.
Bromocriptine stops prolactin production and is better than not using a medication. However, it can also produce side effects like lightheadedness, diarrhea, and vomiting.
Tamoxifen reduces breast pain in 70% of affected women with cyclic mastalgia. Side effects include hot flashes and vaginal dryness.
When should I be concerned?
There are suspicious changes in women with fibrocystic breast changes that can alert of a more serious problem. Progression of growth in a dominant mass, persistent or a bloody nipple discharge, any suspicious mammographic changes or lesions indicate the need for further evaluation, including a biopsy.13
Overall, about one-half of women develop fibrocystic breast changes. It is important to assess any areas of one’s lifestyle that can strengthened, including diet, stress management, and physical activity. A collaborative approach with a primary care doctor can ensure that these findings are appropriately screened and followed-up.
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- Is `fibrocystic disease’ of the breast precancerous? Arch Pathol Lab Med 1986;110:171-173
- Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med 2005;353:229-237
- Shaaban AM, Sloane JP, West CR, et al. Histopathologic types of benign breast lesions and the risk of breast cancer: case-control study. Am J Surg Pathol 2002;26:421-430
- Potten CS, Watson RJ, Williams GT, et al. The effect of age and menstrual cycle upon proliferative activity of the normal human breast. Br J Cancer 1988;58:163-170
- Hughes LE, Mansel RE, Webster DJ. Aberrations of normal development and involution (ANDI): a new perspective on pathogenesis and nomenclature of benign breast disorders. Lancet 1987;2:1316-1319
- Goehring C, Morabia A. Epidemiology of benign breast disease, with special attention to histologic types. Epidemiol Rev 1997;19:310-327
- Barton MB, Harris R, Fletcher SW. Does this patient have breast cancer? JAMA 1999;282:1270-1280
- Dent DM, Hacking EA, Wilkie W. Benign breast disease: clinical classification and disease distribution. Br J Clin Pract 1988;42:Suppl:69-71
- Boneti C., Arentz C., Klimberg V.S.: Scapulothoracic bursitis as a significant cause of breast and chest wall pain: underrecognized and undertreated. Ann Surg Oncol 2010; 17: pp. 321-324.
- Wolfe JN, Saftlas AF, Salane M. Mammographic parenchymal patterns and quantitative evaluation of mammographic densities: a case-control study. AJR Am J Roentgenol 1987;148:1087-1092
- Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology 2002;225:176-181
- American College of Obstetritians and Gynecologysts. Breast Cancer Risk Assessment and Screening in Average-Risk Women. Number 179. July 2017
- Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med 2005;353:229-237
- Wilson MC, Sellwood RA. Therapeutic value of a supporting brassiere in mastodynia. Br Med J 1976;2:90-90
- Millet AV, Dirbas FM. Clinical management of breast pain: a review. Obstet Gynecol Surv 2002;57:451-461
- Costantini L, Bucchi L, Dogliotti L, et al. Cohort study of women with aspirated gross cysts of the breast — an update. In: Mansel RE, ed. Recent developments in the study of benign breast disease. London: Parthenon, 1993:227-39.
- Mauvais-Jarvis P. Mastodynia and fibrocystic disease. Curr Ther Endocrinol Metab 1988;3:280-284
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