Benign Diseases of the Breast
On this page you can read about:-
Nipple discharge, nipple retraction, breast pain and its treatment, non cancerous lumps in the breast eg cysts or firoadenomas, periductal mastitis, abscesses and HRT.
Nipple discharge is rarely a sign of anything serious provided there are no other symptoms such as blood staining, a lump, or permanent inversion of the nipple. There are several ducts coming to the surface on each nipple. Discharge frequently comes from several ducts at the same time.
These are all normal
Duct ectasia is a benign greenish fluid discharge from the nipple which is usually related to falling hormone levels, and in its self needs no treatment.
Intermittent discharge which is clear, yellow, creamy, greenish or brown is considered normal.
Red blood can also mean a harmless papilloma in a duct - which is also benign.
It is only if the discharge is red blood coloured that it needs further investigation by your doctor.
Bloody nipple discharge due to a cancer ringed in purple.
The best way of distinguishing red from brown discharge is to dab a little onto a white tissue and look at it under a good light.
Occasionally a woman may get such large amounts of discharge that it stains her clothes. There are ways of controlling this if it becomes a cosmetic problem and your doctor will be able to advise you.
If you get either persistent or blood stained discharge, you should see a doctor or Consultant Breast Surgeon and team
Pulling in of the nipple often happens when it is cold or for other reasons and usually lasts for a few minutes only. There are many women whose nipples have always been pulled in and some cannot breast feed because of it.
However it can also be a sign of breast cancer if it has happened quite recently.
Pulling in of the nipple is important especially if it is permanent and recent (progressing over a few weeks or months).It can occur for many harmless reasons as well as cancer. Indeed the usual reason is because a little inflammation has scarred a duct behind and this has pulled it in (duct ectasia or periductal mastitis).
If your nipple has changed shape, especially if it is associated with other symptoms such as a lump or blood stained nipple discharge, then it should be reported to your doctor or Consultant Breast Surgeon without delay as occasionally this is due to breast cancer. Most of the time however it isn't and a simple check up can reassure.
Breast pain is common - two out of three women suffer it at some time in their lives. Like any other breast problem, it can be worrying, but most breast pain can be treated and has nothing to do with cancer.
There are two types of breast pain: it may be related to the menstrual cycle (cyclical breast pain also known as hormonally mediated mastitis) or unrelated to your cycle (non-cyclical breast pain).
Cyclical breast pain
Breast tissue is influenced by the hormones which control your periods. From the time of ovulation, (generally halfway between periods,) the hormones (particularly progesterone) build up and then fall rapidly once the period starts. During this build up some women find the breast tissue is more sensitive even though their hormone levels are normal. This is the reason why in the few days leading up to the period many women feel discomfort in their breasts. Sometimes this can be severe enough to interfere with personal relationships, such as hugging partners and children.
Until recently, the cause of breast pain was something of a mystery. Most women with breast pain have normal levels of circulating hormones. It is now accepted that the problem is abnormal sensitivity of breast tissue to normal hormone levels. This increase in sensitivity is linked with the pattern of fatty acids in the blood stream. Fatty acids are substances present in all fats and oils which can affect the way the body responds to its own hormones. Women with breast pain have low levels of a fatty acid called gamolenic acid (GLA). Low levels of GLA are not caused by dietary deficiencies but by an inefficient conversion process in the body.
Treatment of cyclical breast pain
Make sure that your bra fits correctly. Go along to a specialist fitter to make sure it fits and supports you properly. Many large department stores have a specialist bra fitter who can advise you.
There is evidence that increased breast sensitivity is related to the balance between saturated and unsaturated fats, so adjusting your diet by reducing animal fats (such as butter, cream and fatty meat) and increasing your intake of fresh fruit and vegetables can be helpful.
Evening primrose oil is often recommended as a treatment for breast pain. The active component of evening primrose oil is gamma linolenic acid, a fatty acid that is thought to modulate hormone-receptor interaction in breast tissue.
Gamma linolenic acid (GLA) remains a well- tolerated natural dietary supplement.
A therapeutic dose of 1-2gms of Evening Primrose oil each day for a period of 1 month is required before benefit can be assessed. Improvement in severity of cyclical breast pain is see in around 30-40% of women. If symptoms are lessened, treatment should continue.
Hormonal treatments are used for pain refractory to more conservative therapy.
Danazol inhibits hormones, combining androgenic with anti-oestrogenic/anti-progestrogenic activity; but its action is probably through local effect on the breast tissue. Danazol has a rapid onset of action, but the side-effects of weight gain, hair growth and menstrual irregularity in 22% of patients limit its use. A starting dose of 100 mg twice daily should be prescribed until response is achieved; the dose is then reduced to 100 mg once a day. The need for continued treatment should be assessed after six months. Improvements in severity of cyclical and non-cyclical mastalgia are 80% and 40% respectively.
Tamoxifen is an anti cancer drug also used for severe breast pain, by the Consultant Specialist only. It is very effective in treating true breast pain if other treatments fail, but it has stronger side effects such as hot flushes, and rarely a risk of blood clots in the leg (DVT).It is used only by Consultant breast specialists and is for short term treatments eg 6 weeks to 6 months.
Non-cyclical Breast Pain (constant or intermittent breast pain occurring at different times in the cycle each month):
What causes non-cyclical breast pain.
Non-cyclical breast pain often comes from your ribs, or the muscle of your chest wall. Most muscle or joint pains settle more quickly if you rest the area. Unfortunately, the chest is constantly moving when you breath or cough and the muscles that move your shoulders attach to the ribs behind the breast. Resting this area is nearly impossible and this means that mild strains can become chronic and take a long time to settle.
Simple painkillers can help if the pain is troublesome - such as paracetamol or ibuprofen (brufen). Sometimes there is a trigger spot for the pain, and injection of this with local anaesthetic and a steroid may help.
Sometimes the joint between the front end of a rib and the breastbone can become inflamed and painful (Tietze's syndrome) and similar treatment is recommended. Once you know the cause, you may begin to recognise the sorts of activities which make the pain worse. If you can avoid these, it will help the area heal more quickly.
Is non-cyclical breast pain a sign of breast cancer?
Non-cyclical breast pain rarely indicates cancer unless there are other symptoms as well, such as the presence of a lump, nipple distortion, blood stained nipple discharge, general enlargement or dimpling of the skin of the breast. If you notice any of these in addition to the pain, then you should return to your doctor for further advice.
Fibrocystic change or Sclerosis adenosis
Fibrocystic changes occur during ovulation and just before menstruation. During these times, hormone level changes often cause the breast cells to retain fluid and develop into nodules or cysts (sacs filled with fluid), which feel like a lump when touched. The nodules or cysts can spread throughout the breast, may be located in one general area or simply appear as one or more large cysts. Having fibrocystic breasts does not place women at a higher or lower risk of developing breast cancer.
Diagnosis of Fibrocystic Breast Disease
Fibrocystic breast disease is usually diagnosed when a patient goes to her doctor for a checkup or seeks help for pain, tenderness or a lump that was probably discovered during breast self-examination. The doctor will examine the breasts and sometimes recommend a mammogram, an ultrasound exam and (rarely) a needle aspiration. Most of the time the diagnosis of fibrocystic breast characteristics does not require extensive testing.
Treatment of Fibrocystic Breast Disease
There are no specific treatments for fibrocystic breast disease, other than those to minimize discomfort. Doctors may recommend the following:
wear a firm bra that gives very good support for severe breast pain
avoid caffeine and chocolate
eliminate excessive dietary fat and limit salt intake
take pain relievers for combating pain
increase doses of vitamin E or Evening primrose oil.
Lumps in the Breast.
The vast majority of lumps in the breast are usually harmless benign lumps and not breast cancer. However all lumps should be reported to your Doctor.
Cysts (fluid filled lumps) of the breast are commonly found particularly between the ages of 40 and 60. It also can occur in those on the pill or hormone replacement therapy (HRT). Although often it is called fibrocystic disease, it is not a disease, but simply a sign of the changing hormone levels which occur naturally throughout life.
As the menopause approaches, the hormone levels fall and most of the milk producing part of the breast is replaced by fatty tissue. During this phase there is a tendency for cysts to form, often in several parts of the breast at the same time. Many more women get cysts than is realised because cysts are usually soft, painless and cannot be felt. It is only if they become inflamed because of a bruise that they become tense, hard and sometimes tender. Cysts are benign and have nothing to do with cancer.
Cysts do not turn into cancer. However cancer may mimick a cyst as it too can feel like a painless lump. This is why any lump should be reported to your doctor or Consultant Breast Surgeon so that a full examination can be carried out. If the lump proves to be a cyst, then you need worry no longer. Sometimes removing the fluid with a needle is required if the cyst is painful or to prove beyond doubt that it is not a solid lump.
If you have once had a cyst then you will be more likely to get cysts in the future, sometimes at other sites in the breast. However, once you go through the menopause, the cyst problem will disappear of its own accord except if you choose to use hormone replacement therapy (HRT). Unfortunately, HRT often makes a cyst forming tendency worse. This is not a reason for not using HRT if your symptoms of the menopause are troubling you, but you will have to accept this as a possible side effect.
As with all women, I suggest you get used to examining yourself and report to your own doctor if you notice anything new or unusual. If you do get another lump, it is most likely to be only another cyst. However, it is still important that you have it properly checked by your GP. Most cysts can be drained with a small needle and do not need removal.
breast cyst leaflet
Fibroadenoma's are caused by an over-development of fibrous tissue and glandular tissue in the breast and can vary in size. Some women can have several lumps. They feel like little marbles in the breast tissue and often seem to move about which has led to the term ("breast mouse"). They are usually painless. A lump is most likely to be fibroadenoma if you are under 30. Fibroadenomas are harmless and do not develop in to cancer but if they shown signs of abnormal cells on sampling they may need to be removed. Provided the surgeon has proved that a lump is a fibroadenoma by feel, ultrasound examination and by core biopsy, it is safe to leave the lump alone unless you wish to have it removed. They generally stay the same size, but if they do get larger or become uncomfortable it is simple to have them removed by doing a small operation under general anaesthetic usually as a day case (you do not have to stay in hospital over night), or by removing the lump under local anaesthetic using a mammotome which is a small biopsy needle which removes the lump piece by piece.
Periductal mastitis is inflammation around a breast duct. The breast fluid (yellow, green or clear) filling the duct occasionally attracts infection. The infection is usually very mild and caused by one of the bacteria which normally lives on the skin where it does no harm. Unfortunately within a breast duct filled with fluid, the bacteria can multiply and cause some inflammation. This causes non-cyclical breast pain, usually directly behind the nipple. The pain may be a mild aching, but often there is associated needle pain behind the nipple and spasms like the milk is being let down when breast feeding. The nipple may feel itchy.
Smoking is a significant cause of this type of inflammation and stopping is the best treatment.
This can be treated with a short course of antibiotics, usually Penicillin or Augmentin
Periductal Mastitis download
What causes breast abscess?
Breast abscess is most common while breast feeding, but can occur at other times as well. It can occasionally occur as a progression of periductal mastitis as described above. If the infection set up in the milk duct breaks out into the tissue of the breast, then an abscess will develope.
Breast abscesses cause a lot of pain in the breast, usually just behind the nipple. This is usually associated with a lump and reddening of the skin. The glands under the arm may become tender. Below is a periductal abscess treated with aspiration and antibiotics over two weeks,avoiding surgery.
A prompt course of antibiotics from your doctor may resolve the problem, but sometimes surgery is required to drain the abscess. If the antibiotics only partly treat the problem, then aspiration of the abscess with a needle may help.
Hormones and Breast Disease
The Pill and Hormone Replacement Therapy (HRT) and Their Effects on the Breast
Both the Pill (oral contraceptive) and HRT contain either the hormone oestrogen or progesterone or both. These are the normal female hormones which control breast development at the menarche, the normal menstrual cycle and enlargement of the breast in pregnancy and contribute to milk production when breast feeding.
The side effects which these medications cause are all as a result of these normal effects. It is normal to get some or all of the following particularly in the first few weeks after starting either the Pill or HRT.
Enlargement of the breasts.
Increased tenderness of the breast especially running up to the period time.
Increased lumpiness especially in the upper outer parts of the breast in the few days before the period starts.
There is evidence which proves that HRT causes a small rise in the risk of breast cancer, and you should not take HRT if you have had or suspect that you may have breast cancer as it may cause this disease to grow and spread more quickly. However, HRT taken for a short period of time (5 years) is unlikely to cause a significant risk of breast cancer and can be used safely after a discussion with your doctor.
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Rick Linforth Consultant Breast Surgeon
MD FRCS (Eng,ED) FRCS (Gen Surg)
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