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The ABC of benign breast disease

Benign breast disease tends to take a back seat to breast cancer.

AARON NDHLUNI
General surgeon, Kingsbury, Vincent Pallotti and Groote Schuur hospitals, Cape Town
Aaron Ndhluni is a general surgeon with an interest in breast diseases.
E-mail: aaronn@surgcare.co.za

Benign breast disease is common, although the incidence is sparsely Fibrocystic disease, more accurately called fibrocystic changes
documented in the literature and is probably quite underestimated. (Fig. 1), is commonly seen in the breast. The term describes
The main reason is that it is regarded as unimportant, with far pathological changes seen under the microscope and should not be
more attention being focused on breast cancer. However, benign used to describe clinical findings. The histological changes include
breast disease is far more common than breast cancer. There is varying amounts of fibrosis and cysts. It is generally accepted that
now increasing interest because patients demand investigation and approximately 90% of women have fibrocystic changes, and that
treatment of their symptoms. these are more pronounced in women of reproductive age. For
many women such changes are normal, without an identifiable
cause.
Symptoms of benign breast disease
Fibrocystic breast disease does not increase the risk of developing
The clinical presentation of benign breast diseases includes one or
breast cancer.
more of the following symptoms:
• breast lump
• swelling or thickening
• erythema
• pain
• nipple discharge or nipple change.
Aberrations of normal development and involution (fibrocystic
disease), breast pain and nipple discharges are common, and these
will be reviewed.

Benign breast disease is far


more common than breast
cancer.
Fig. 1. Fibrocystic changes.
Aberrations of normal development
and involution (ANDI) Breast pain (mastalgia)
Breast pain is by far the most common reason for referral of
Many so-called diseases of the breast are now regarded more
patients to a breast clinic or specialist surgeons, and accounts for
accurately as aberrations of normal development and involution.
up to 50% of the patients seen. Nomenclature contributes to the
The vast majority of premenopausal women experience a degree
problem, with various terms such as mastodynia, mastitis and
of breast discomfort and nodularity prior to menstruation. In the
fibrocystic disease being used. Mastalgia is the most commonly
majority of cases this amounts to little more than an inconvenience
used and the most widely accepted term. Mild premenstrual
and as such is regarded as a normal physiological process. Some
breast pain is very common and affects most women at some time
women, however, present with severe distressing symptoms. The
or another. Mastalgia is an amplification of usual breast pain,
predominant symptoms are breast pain, breast lumps and lumpiness
presenting with greater frequency and severity. It is important to
and feeling of fullness in the breasts. Nipple discharge that is often
stress that mastalgia is a symptom and does not imply any specific
greenish-brown in colour and breast cysts are also common. In
pathological process any more than pain in other sites of the body.
the past this was described as fibrocystic disease. Unfortunately
there is poor correlation between the breast symptoms and the
histological features. In some cases there is no specific histological
Aetiology of mastalgia
abnormality. Various aetiological factors have been implicated for mastalgia:
• hyperoestrogenism

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B enign breast disease

• abnormal fluid retention The reason for many referrals by general in cola, tea, and coffee), chocolate, and dairy
practitioners is anxiety and fear of breast products. Relief may not be immediate, but
• abnormal prolactin secretion
cancer on the part of the patient, the parent symptoms generally improve within 3 - 4
• excessive caffeine ingestion or her doctor. It is therefore important not months.
only to treat the symptoms but also to allay
• inadequate essential fatty acid intake Evening primrose oil (a mixture of linoleic
any fears that may exist. It is imperative to
and linolenic acid) has been shown to be
• psychoneurosis emphasise that mastalgia does not imply any
effective in patients with cyclical mastalgia.
neoplastic process.
• medication (Table I) It is regarded by most patients as a natural
Mastalgia that seems to be related to homeopathic substance whose only
• age at first live birth
menstrual cycle changes is usually mild, and significant side-effect is nausea.
• nulliparity reassurance of its benign nature may be all
Danazol is an antigonadotropin agent that
that is necessary, along with firm brassiere
• breast feeding. may be used as a second-line agent (after
support and, possibly, the use of mild
evening primrose oil) to manage adult
A vast majority of clinical studies have failed analgesics. Underlying precipitating factors,
women with severe refractory mastalgia at a
to demonstrate significant differences in such as marijuana or other drug use, should
dose of 200 - 400 mg daily. It has no proven
levels of serum progesterone, oestradiol or be eliminated. Some patients benefit from
benefit in adolescent girls. It has a number of
prolactin among women who have breast avoidance of methylxanthines (i.e. caffeine
potential adverse reactions, including weight
pain and those who do not. There is a weak
causal relationship with some drugs.
Table I. Medication associated with mastalgia
Mastalgia may be related to infection,
malignancy, or extramammary conditions Common
such as muskuloskeletal chest wall pain
Oral contraceptives
(Tietze syndrome or costochondritis),
cervical spine disease, cardiac disease, or Hormone replacement therapy
others. Therefore a careful assessment is Antidepressants
necessary to identify the underlying cause Digoxin
of the pain. A primary breast cancer should
Methyldopa
be ruled out because it is the leading cancer
among women. Spironolactone
Chlorpromazine
Other
Fibrocystic breast
Amphetamines
disease does not Anabolic steroids
increase the risk Busulfan (and other chemotherapeutic agents)
of developing Cimetidine
Clomiphene
breast cancer. Corticosteroids
Insulin
There are two distinct types of mastalgia –
cyclical and non-cyclical. Cyclical mastalgia Isoniazid (and other antituberculosis drugs)
is breast pain with a definite association Ketoconazole
with the menstrual cycle, while non-cyclical Marijuana
mastalgia is unrelated to the monthly
Reserpine
cycle. Because of the cyclical relationship
to the menstrual cycle, cyclical mastalgia is Spironolactone
generally found in premenopausal women, Testosterone
with the commonest age of presentation Tricyclic antidepressants
being 15 - 40 years. This pain is frequently,
but not always, bilateral. Non-cyclical
mastalgia, on the other hand, occurs in
both pre- and postmenopausal women. It Table II. Medication used to treat mastalgia
has a more chronic presentation and tends
to be unilateral. Sometimes the pain is Simple analgesia
well localised. Non-cyclical mastalgia has Non-steroidal anti-inflammatory drugs
a higher relationship with extramammary Evening primrose oil
causes.
Vitamin E
Treatment of mastalgia Flaxseed
When a woman presents with mastalgia, a Magnesium
thorough history and physical examination Oral contraceptives
are necessary to rule out any underlying Danazol
pathology. Mammography, breast ultra-
sound or breast biopsy may be warranted Tamoxiphen
for diagnostic purposes. Bromocriptine

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B enign breast disease

gain, acne, amenorrhoea, masculinisation than a millimeter thick) is introduced


with hirsutism, voice change, reduction Table III. Causes of nipple into the duct itself and manipulated to
in breast size and teratogenicity. When discharge look at the lining of the duct system. No
treating mastalgia one should therefore incision is made. This enables detection of
always remember the classic dictum: ‘first Physiological small tumours, intraduct papillomas and
do no harm’. Galactorrhoea some other benign changes. A normal
ductoscopy has high reassurance value.
Other treatment modalities include oral Mammary duct ectasia
contraceptives which may improve (or Intraduct papilloma When there is blood-stained discharge,
worsen) breast pain; bromocriptine; microdochotomy (excision of the
Carcinoma
vitamin E supplementation (600 IU/d) offending duct) should be performed.
which has anecdotal, but no research- Purulent discharge from breast abscess The commonest finding is an intraduct
based, support for improvement; vitamin Drugs (e.g. ranitidine, phenothiazines, papilloma. Copious spontaneous dis-
E cream application; flaxseed; and topical oral contraceptives) charge should also be managed in a similar
non-steroidal anti-inflammatory gel. manner. However, in most patients
It is important to ascertain whether reassurance with careful follow-up is all
Secretions the nipple discharge is blood-stained, that is indicated.
spontaneous, unilateral or bilateral, or
(discharge) from from a single duct. If there is an associated
Further reading
 ughes et al.
1. H Aberrations of normal
the nipple are not lump, then the investigation thereof development and involution (ANDI): a
becomes paramount and the discharge new perspective on pathogenesis and
unusual, or even secondary. The presence of blood and nomenclature of benign breast disorders.
Lancet 1987; ii: 1316-1319.
necessarily a drainage from a single duct indicates a
 ughes et al. Benign Disorders and Diseases of
2. H
potentially serious cause.
sign of disease. the Breast: Concepts and Clinical Management.
Physiological nipple discharge and London: Bailliere Tindall, 1989.
galactorrhoea (secretion of milk not 3. M
 iltenburg DM, Speights VO. Benign breast
Surgery has virtually no role in the related to pregnancy or lactation) are by disease. Obstet Gynecol Clin North Am 2008;
treatment of mastalgia although there is far the most common. In older women, 35(2): 285-300.
some success in excision of focal areas of mammary duct ectasia is commoner.  reydanus DE et al. Breast disorders in
4. G
mastalgia when associated with a localised However, the most important causes are children and adolescents. Prim Care Clin
lump as part of ANDI. Occasionally Office Pract 2006; 33: 455-502.
intraduct papilloma (benign) and very
patients with a long history of unresponsive rarely breast cancer. 5. M
 illet AV, Dirbas FM. Clinical management
mastalgia demand consideration of of breast pain: a review. Obstet Gynecol Surv
mastectomy to release them from their 2002; 57(7): 451-461.
discomfort. This should be avoided.  osolowich V, Saettler E, Szuck B, et al.
6. R
In most patients Mastalgia. J Obstet Gynaecol Can 2006;
28(1):49-71.
Nipple discharge reassurance with 7. M
 eisner AL, Fekrazad H, Royce ME. Breast

Nipple discharge is a common presenting


careful follow- disease: benign and malignant. Med Clin N
Am 2008; 92: 1115-1141.
symptom. Patients with nipple discharge up is all that is 8. M
 ansel RE, Wisbey JR, Hughes LE. Controlled
often fear cancer, and the discharge may trial of antigonadotrophin danazol in painful
cause annoyance and social embarrassment. indicated. nodular benign breast disease. Lancet 1982; 1:
Since the breast is a gland, secretions 928-931.
(discharge) from the nipple are not unusual, Management of nipple discharge 9. S anten RJ, Mansel R. Benign breast disorders.
nor even necessarily a sign of disease. Nipple N Engl J Med 2005; 353: 275-285.
Investigation with cytology and radiology
discharge comes in a variety of colours and has poor yield and is disappointing. 10. B each RK. Galactorrhoea (nipple discharge)
in adolescent girls. In: Berman S, ed. Pediatric
textures. Possible causes of nipple discharge
Some centres perform ductoscopy. This Decision Making, 4th ed. Philadelphia:
are listed in Table III. Mosby, 2003: p.32.
is where a tiny fibre-optic scope (less

In a nutshell
• Breast pain and nipple discharge are common presenting symptoms.
• Aetiological factors for mastalgia are poorly understood.
• Allaying anxiety and fears about breast cancer is important.
• Surgery plays a very small role in the treatment of mastalgia.
• The vast majority of nipple discharges are physiological.
• Blood-stained, single-duct, spontaneous discharge is worrisome.
• Cytology and radiology have a poor yield in nipple discharge.

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