Cyclical breast changes and pain are common complaints. Half of all women complaining of premenstrual syndrome have breast pain, unless they come from Asian countries like Japan where the incidence is very much lower. The pain can be associated with lumps, breast enlargement, nipple soreness, a sense of warmth or burning, increased ‘ropiness’ when the breast is palpated, and soreness or congestion into the armpit. The symptoms may effect one or both breasts. Lumpiness or structural changes can also occur without any pain; however, the most common symptoms are pain and lumpiness in the upper, outer quadrant of both breasts, which occurs in the luteal phase of the cycle.
Disease or normal changes?
When examined, individual women’s breasts show a wide variation in nodularity and other structural changes which occur as a result of normal cyclical effects of oestrogen and progesterone. Oestrogen is ‘proliferative’, or makes cells in the breast grow in size and number. Progesterone changes the cells which line the ducts so that they become ‘secretory’ and able to produce milk if pregnancy occurs. The blood supply to the breast is also enhanced by progesterone and this leads to a greater amount of fluid build-up in the breast tissue because some of the fluid in the blood vessels seeps into the surrounding tissues.
During the period, there is a time of relative cellular dormancy when the proliferative glandular tissue stimulated by both oestrogen and progesterone involutes. For reasons which are not entirely clear, this process of involution can be incomplete, leading to breast changes which range from palpable breast lumps to microscopic changes in the breast tissue.
Fibrocystic breast disease was once the term used to describe these findings and is sometimes still used as a diagnosis. Fibrocystic breast disease technically means ‘fibrous and cystic breast changes’, but many women who have been given this diagnosis have breast changes which fall within the normal range of cyclic proliferation and involution already described. Additionally, some women with breast pain have neither of these changes, while women who do have fibrous and cystic changes might have little or no pain.
Terms such as benign mammary hyperplasia, mammary dysplasia and benign cystic hyperplasia, which technically only apply to those changes detected microscopically, are also sometimes used.
Understandably, this leads to a lot of confusion and concern as many women equate these types of diagnoses with malignancy. Medically, the favoured term is ‘aberrations of normal development and involution’ (ANDI); however, to avoid confusion and unnecessary concern, many practitioners will use simple terms such as cyclical breast pain, mastalgia or non-specific breast lumpiness to describe to the woman the benign changes which occur before her period.
Diagnosis of Cyclical Breast Complaints
A woman might visit her practitioner after discovering a discrete lump or generalised breast lumpiness; with a complaint of cyclic or persistent breast pain; or a combination of these problems. The possibility of cancer can be a major concern for a woman who discovers breast lumps, but many women simply want some sort of treatment for bothersome pain and are convinced that their problem is ‘just hormonal’. For a diagnosis of a purely cyclic and benign complaint to be given, however, all other possible causes of the symptoms must be first excluded.
Diagnosis usually proceeds down a fairly well-worn path. When a woman has a symptom of breast pain only, her breasts should be examined after the period to rule out the possibility of breast lumps. Many women palpate their breasts when they experience discomfort — before the period — precisely the time when non-cyclical changes are most difficult to find.
When women have breast lumpiness, referral for a breast examination should be arranged after the period if the problem has not been resolved. All breast changes which persist after the period — even if they have the characteristic ‘hormonal’ pattern of worsening premenstrually — need thorough evaluation. The current myth that lumps that are painful, or symptoms that worsen premenstrually, will not be cancerous, is incorrect. Up to 10 per cent of women with cyclical breast changes may also have cancer.
There is absolutely no problem in waiting until after the period to re-examine breasts, even when breast cancer is a distinct possibility, because all changes take many months to develop. It is much easier to find breast changes when palpating breasts in the post-menstrual phase, and there is less likelihood of making an inaccurate diagnosis.
When a woman or practitioner feels a woman’s breasts, they might find either generalised lumpiness, a dominant lump, or an area of thickening which is quite different to the rest of the breast tissue.
A dominant lump or area of thickening might be:
• Cancer, which is often an immobile, hardened, non-discrete area.
• A well-defined breast lump, which might be a fibroadenoma, a cyst or a lipoma.
• A less well-defined area of thickening or lumpiness.
The discovery of a dominant lump suggests the need for referral to a breast clinic or specialist to rule out the possibility of breast cancer. On average, one in every five breast lumps discovered is malignant, and the incidence of malignancy increases with age.
Investigations for these findings are fairly routine:
• mammogram and/or ultrasound
• needle aspiration and histology
• lumpectomy and biopsy.
More commonly, breast changes will be cyclical and present as a generalised lumpiness of the breast, which represents a normal variation of hormonal activity in the breast. These changes may require no further investigation apart from regular monitoring.
Some of the best results clinically and experimentally have been associated with dietary change involving reduced fat intake. Fats to avoid include saturated fats such as those found in full-cream dairy products and meat; and those from coconut, avocado and peanuts. A group of women who were counselled to reduce dietary fat intake and substitute kilojoules with complex carbohydrates were shown to have substantial reductions in breast swelling and tenderness.
Because oestrogens can increase the pro-inflammatory (series 2) prostaglandins, oestrogen modulation may be useful. Increased fibre improves oestrogen clearance, and the cabbage family vegetables improve liver conjugation of oestrogens. A diet which contains very little fat, is high in fibre, contains large amounts of phyto-oestrogens, vegetables, grains and legumes is our recommendation. Depending on complicance, dietary intervention may be the best and only intervention needed.
Avoiding methylxanthines (caffeine, theobromine and theophylline) in tea, coffee, cocoa and cola drinks also leads to dramatic improvements in many cases. Exercise also reduces breast pain and regular exercise throughout the cycle is beneficial.