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Common breast problems

Most breast problems are the result of benign conditions, but any persistent change warrants evaluation. In women, four very common problems are breast pain, breast cysts, fibroadenomas, and nipple discharge. The following summaries describe these conditions, with recommendations for evaluation and management.

Breast pain

Most women experience breast pain at some point in their lives. Breast pain may be related to:

  • Hormone effect on fibrocystic breast tissue, the most common cause of pain
  • Injury
  • Infection
  • Breast cancer (though this is very rarely associated with breast pain)

The term “fibrocystic disease” has historically been used to describe breast pain in women, with or without generalized lumpiness. But this is NOT a disease, and represents the type of pain that may occur when normal breast tissue responds to hormonal changes. We now like to use the term “fibrocystic change” to describe this common symptom in women. It may occur during the menstrual cycle, pregnancy, perimenopause and when starting or changing birth control pills or hormone therapy.

When patients with fibrocystic change undergo ultrasound of the breasts, cysts can often be seen. Cysts are sacks of fluid which seem to cause tenderness, either as they fill with the fluid, or sometimes as the cysts spontaneously empty of fluid. Patients may have either tiny “micro-cysts” and/or larger cysts that occasionally can be felt on physical exam or breast self exam. Pain may or may not be associated with cysts. When present, the breast pain tends to be chronic, but intermittent, often cyclical, and may be generalized or focal.

Most pain will subside with time. If you experience persistent, non-cyclic pain, you should consult your physician. The following treatments may be helpful in reducing breast pain. We have no medical research to confirm the effectiveness of these treatments, but they seem to work for some women, and you may want to try them out for yourself.

  • Wear a sport or support bra
  • Take an over-the-counter pain medicine
  • Decrease your daily salt intake
  • Reduce or avoid caffeine, found in coffee, many soft drinks, and chocolate. This will not have an immediate effect and it may take 6-8 weeks to notice a change.

Remember: Any time a lump is felt, you should have it checked, whether there is pain or not.

Breast cysts

Simple pockets of fluid in the breast are referred to as breast cysts. Many normal women develop breast cysts at some point during their life. They can occur at any time from puberty well into post-menopausal years. You may have only one or several, in one or both breasts.

Most cysts cannot be felt. Some cysts are first discovered on mammography. However, some are large enough to be felt, and they may change size rapidly. Cysts can become very tender; usually the soreness fluctuates, and often improves on its own. Cysts are almost always benign processes, but a new lump questioned on mammogram, physical exam, or breast self exam should be evaluated with “additional views” mammography and then ultrasound. Those tests can determine if it can be diagnosed as a benign “simple cyst”. Sometimes, mammography and ultrasound cannot absolutely confirm the diagnosis of “simple cyst”, and the cyst may need to be aspirated in the office for further evaluation.

Remember that you cannot be sure if a new breast lump is a cyst by the way it feels, so it is important to report any new or persistent breast lump to your doctor.

Fibroadenomas

Fibroadenomas are the second most common cause of a benign (non-cancerous) breast mass or lump, with cysts being the most common. They are composed of a combination of fibrous and glandular tissue. The exact cause is unknown, but they are formed by an overgrowth of these two normal types of tissue found in the breast.

Fibroadenomas are most commonly seen in women younger than 40 years old, but can be seen at nearly any age. They are sometimes found in teenagers. They are not the result of diet, exercise or medication, though they may be sensitive to hormones. Because of this sensitivity to hormones, they can enlarge during pregnancy and breastfeeding.

Fibroadenomas usually present as a lump you can feel. They may be found incidentally on a mammogram. They are usually moveable and painless, although some discomfort can be present. Many women have only one fibroadenoma, however, a significant number of women have several in one or both breasts. Even if you have a history of one or more fibroadenomas, any new lump should be brought to your doctor's attention and evaluated.

If you or your doctor find a lump in your breast, mammography and/or ultrasound will be used to evaluate it. If it demonstrates benign (non-cancerous) characteristics, it may just be followed to be sure it remains stable. Otherwise, it may need to be biopsied in the office with special needle devices using ultrasound guidance, thus avoiding surgery. It should be removed if it enlarges, or if you are comfortable with needle biopsy or follow-up.

Remember, most changes or lumps you find in your breast will not be breast cancer, but it is important that you have any change evaluated.

Nipple discharge

Discharge from the nipple can be alarming, but many normal women do have some discharge that can be expressed (squeezed) from the nipple. A 1987 study at a Boston hospital actually found 83% of women had discharge that could be expressed. These included women who were old, young, mothers, non-mothers, previously pregnant and never pregnant.

Luckily, most discharge from the breast is nothing to be alarmed about. In general, discharges that occur in both breasts at the same time are due to hormonal cause. If a woman is not breast feeding, milky discharge is known as galactorrhea. This occurs because something is increasing the prolactin levels in the body. This can be related to the pituitary gland in the brain, or other hormonal problems. Also, certain medications can increase prolactin levels in the body, including birth control pills, certain antihypertensive or blood pressure medications, or major tranquilizers.

Concern is raised about a nipple discharge when it: occurs spontaneously (without squeezing), persists, comes from a single duct, involves only one breast, and looks bloody or clear colored. If you notice any of these changes, you should call your doctor because these findings are sometimes a sign of cancer.

When nipple discharge is not bloody or clear, but rather appears yellow, green, or brown, this is less worrisome and breast cancer is considered less likely. Occasionally, the discharged liquid may be smeared on a microscopic slide or otherwise tested to evaluate for the presence of abnormal cells or blood that the naked eye cannot detect. If negative, and the discharge is present only when expressed, the patient may be instructed to refrain from expressing the discharge for several weeks. Often, the amount of discharge may decrease, or the discharge will resolve spontaneously without further treatment.

In summary, nipple discharge is a relatively common occurrence among women at certain points in their lives and usually is not worrisome unless the discharge is from one breast, from a single duct, spontaneous, and bloody or clear in color. If any of these signs are present, you should contact your physician for further evaluation.

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