Common Breast Problems - Breast Health Part II
Breast problems are a common health worry for most women. While it can be frightening to discover a new breast problem, most breast problems are not caused by breast cancer. These issues are common in women of all ages, from adolescents to older women and are usually related to changes that occur with menstrual periods, pregnancy, and aging, or the case of a tight bra.
Breast development is the first sign of puberty in young girls. Usually, breasts begin as small, tender bumps under one or both nipples that will get bigger over the next few years. It is not unusual for one breast to be larger than the other or for one side to develop before the other. In adolescent boys during puberty, breast buds are common. They may last up to 2 years, but they tend to go away within the first year. Breast buds develop because of rapid changes in hormone levels.
The best way to monitor for changes in the breasts is to perform breast self-examination (BSE). This involves checking your breasts for lumps or changes on a routine basis. This is a healthy habit to develop. It should be done routinely and on a monthly basis preferably at the beginning of the menstrual period when the breasts are less tender and less swollen. Women who are breastfeeding should examine their breasts after completing a feeding. The breast self-examination should be done while standing and lying in different positions and while looking at your breasts in a mirror. Once you know what your breasts normally look and feel like, any new lump or change in appearance should be noticeable and should be brought to the attention of your doctor.
When having a routine visit with your doctor a clinical breast examination (CBE), will also be performed as part of your physical. During a CBE, your doctor will carefully feel your breasts and under your arms to check for lumps or other unusual changes. It may also be done at your routine gynecology visit. This is a good opportunity to talk about any questions you may have regarding your breasts. If there have been any changes in the shape or size of your breast, if you feel a lump, have noticed nipple discharge, or have breast pain please discuss this with your doctor.
Once you have reached a certain age, usually 40-50 years, a woman should start regular screening with a mammogram. Your doctor may suggest that you have a screening mammogram at a younger age if you have any risk factors for breast cancer. A mammogram is a low-dose x-ray exam of the breasts and allows for a more in-depth look at the breast tissue. It can often find problems that are too small for you or your doctor to feel. The results are recorded on x-ray film or directly into a computer for a doctor called a radiologist to examine. Every year and every time you have a mammogram, a comparison should be made to the previous one in order to look for changes. Breast changes will occur in almost all women. In fact, most of these changes are not cancer and are called “benign,” but only a doctor can know for sure. Breast changes can also be cyclical and happen monthly due to your menstrual period, so the best time to have your mammogram is right after your menses.
Most breast problems or changes are not caused by cancer. But breast self examination is not enough…. It is a combination of BSE, clinical breast examination by your doctor and mammography that have the best prognosis to prevent and catch breast cancer early.
In this blog, I will review some of the most common breast problems, including those that you or your physician may find. I will also try to explain how common breast problems are evaluated and treated. If you find a new breast problem, you should make an appointment with your doctor as soon as possible. Although breast problems are not usually an emergency, delaying the evaluation can potentially allow the problem to worsen. In some cases, this evaluation will be all that is needed. If your initial evaluation shows no sign of a problem but you remain concerned, further testing, follow-up over time, and/or referral to a breast specialist may be recommended.
COMMON BREAST PROBLEMS
1. Breast lump
a. Sacs filled with fluids -Breast cysts
b. Painless, movable, and firm round lumps (fibroadenomas)
c. Growths inside the ducts (intraductal papillomas)
d. Enlargement of lymph nodes in the breast
2. Breast pain or tenderness (mastalgia)
3. Nipple discharge, Nipple rash, Inverted nipple
4. Breast skin changes
5. Generalized Breast Lumpiness- Fibrocystic Breast Disease
6. Breast trauma-Damaged fatty tissue (fat necrosis).
7. Breast infections (mastitis) (breast abcesses)
8. Breast enlargement in men (gynecomastia)
THE BREAST LUMP
When a woman finds a breast ‘lump’, the first thing to do is to make sure it is not a problem related to breast cancer. The earlier breast cancer is detected, the more easily and successfully it can be treated. However, it is important to remember that 80-85% of all breast lumps are benign, especially in women under age 40.
There are many causes for lumps in the breast. These range from normal changes in your body to abnormal breast disease. Breast lumps are either benign (noncancerous) or malignant (cancerous). Some lumps are age-dependent; some have a clear relationship with the menstrual cycle, where the breasts may have a lumpy or granular feeling to the breast tissue right before the period.
If and when you find a breast lump, signs of a potentially cancerous breast lump may include:
1. A painless lump that is firm or hard, with irregular borders or edges
2. A lump in the armpit (lymph node)
3. Arm swelling
4. Bone pain
5. Difference in breast size, compared with what it previously looked like
6. Nipple changes, including pulling inward, swelling, or itching, nipple rash that does not go away
7. Nipple discharge -- usually bloody or straw-colored fluid
8. Skin changes such as dimpling or "orange peel" appearance,
9. Breast redness, easy to see veins on breast surface, and eventually skin ulceration
10. Weight loss
If you feel that you may have any of the above mentioned breast problems, please contact your doctor to be checked. In addition to the clinical breast examination and mammogram, tests that may be used to determine if a lump is cancer may include:
1. Breast ultrasound
2. Breast MRI
3. Breast biopsy / fine needle aspiration (FNA)
The treatment and the long term outlook of the breast lump will depend on the underlying cause of the breast lump.
Breast cysts are common, particularly in women before menopause. They are fluid-filled sacs within the breasts often described as round or oval lumps with distinct edges. Although larger cysts can sometimes be felt as "lumps," many cysts cannot be felt by physical examination. Cysts that cannot be felt may be found during a mammogram or ultrasound. A woman can have one or more breast cysts; they can look different or disappear entirely on mammograms from one year to the next.
Breast cysts are commonly associated with hormonal changes and imbalance; are tender, and usually hurt worse in the second half of the menstrual cycle or during pregnancy. Breast cysts may be worrisome, yet they are generally benign and usually disappear after menopause, but may persist or reappear when using hormone therapy. Breast cysts can be part of fibrocystic disease. To avoid fibrocystic changes in your breast tissue, avoid excessive chocolate, fat and caffeine in your diet. Treatment is usually targeted at reducing pain and discomfort. In most cases, the discomfort they cause may be alleviated by draining the fluid from the cyst.
FIBROADENOMA OF THE BREAST
Fibroadenomas are benign (not cancerous) breast tumors that are made of fibrous connective breast tissue that supports the mammary gland (stroma) and breast tissue – and lobes that have become more developed (hyperplasia). They are likely to develop in women in their 20s or 30s, and may grow larger during pregnancy or lactation.
Most fibroadenomas are the simple type – where there's usually just one of them in your breast, with a definite border and very uniform cells. A simple fibroadenoma does not raise your risk for breast cancer. Complex fibroadenomas are less common. They may contain a collection of small cysts, calcifications, enlarged breast lobules, papillomas and different kinds of hyperplasia. Even though complex fibroadenomas don't become cancer, they may increase your risk of developing breast cancer and require close follow up with your doctor.
BREAST PAIN AND TENDERNESS
The most common type of breast pain is caused by the hormones that control the menstrual period. These hormonal changes can cause pain in both breasts several days before the menstrual period begins. Because the pain can come and go with the menstrual cycle, it is called "cyclical" breast pain. Cyclical breast pain is not usually caused by breast cancer or other serious breast problems.
Less commonly, a woman can have breast pain that does not come and go with the menstrual cycle (also called noncyclical breast pain). This type of pain is not related to the menstrual cycle and might occur in only one breast or one area of the breast. Noncyclical breast pain is usually caused by a problem outside the breast, such as muscle or connective tissue strain, skin injury, spinal conditions, or problems in another organ system (eg, heart burn, chest pain). Let us not forget the importance of a properly fitted bra and the damage that can be done with the tight underwire. Noncyclical breast pain is caused by breast cancer in only a very small percentage of women.
If you are worried about breast pain, speak to your healthcare provider to determine if you need further testing. If testing shows no signs of a serious problem, you can try one or more of the following treatments:
1. Wear a well-fitted support or sports bra
2. Pain relief medicines, such as acetaminophen, (Tylenol® and others) or ibuprofen (Advil®, Motrin®, and others).
3. A diet low in fat, caffeine, alcohol, and chocolate with high complex carbohydrates rich in fiber may be helpful for some women
4. Dietary supplements such as vitamin E and evening primrose oil
5. A hormonal evaluation and possibly birth control pills where there is a balance between estrogen and progesterone
As with other ducts in the body, breast ducts make and carry secretions. During the first year after giving birth it is common to have milky colored discharge (also called galactorrhea) from both nipples. This is due to a hormones called ‘prolactin’. Prolactin is produced in the pituitary, a part of the brain that commands hormones and glands. Many women can express (squeeze out) a small amount of yellowish, greenish, or brownish discharge particularly at the end of the menstrual cycle. This is often called "physiologic" discharge and is not a cause for concern. Physiologic discharge is not bloody.
If a woman has breast discharge yet she has not had pregnancy or recently delivered a baby, she should talk to her doctor about this. Nipple discharge from both breasts can occur in women with an underactive thyroid (hypothyroid), as a side effect of certain medications (the most common are the antidepressant group), or because of a growth in the pituitary, causing an increase in a hormone called prolactin. Prolactinomas are treated medically and have a good prognosis when caught early.
Spontaneous nipple discharge (discharge that occurs without squeezing) or nipple discharge that is clear or bloody may be caused by an abnormal growth within the breast or, less commonly, by breast cancer.
Any woman with nipple discharge should be evaluated by a healthcare provider. A mammogram, breast ultrasound, and/or exam of the breast ducts (ductogram) may be recommended in some cases.
Many women are born with nipples that naturally invert (pull in) at times and evert (poke out) at other times. Other women find that this happens after breast feeding. Nipple inversion of this type is not cause for concern.
If your nipples have always been everted, however, and begin to invert for no obvious reason, this should be evaluated by your healthcare provider. Most causes of nipple inversion are not a cause for concern, but occasionally this is the first sign of a breast cancer. New nipple inversion is usually evaluated with a breast examination and mammogram as a first step.
BREAST SKIN CHANGES
Skin problems can develop on or near the breast, some of which cause itching, scaling or crusting, dimpling, swelling, redness, or changes in skin color. While most of these changes are not caused by a serious breast problem, it is important to be evaluated if a skin problem on your breast does not resolve within a few days.
More serious causes of skin changes on the breast can include less common forms of breast cancer, such as Paget disease or inflammatory breast cancer. Other, more common skin problems, such as rashes, moles, cysts, or skin infections can occur on the skin of the breast, as well.
The evaluation of breast skin changes usually includes a breast examination and may include a mammogram. A skin biopsy may be needed to confirm the diagnosis.
Breast problems are more common than we think. It is important to know about breast health, and the proper care and maintenance of your breasts. Keeping close communication with your doctor, and performing self breast examinations routinely will keep you ahead of the game! Treatment of a breast problem depends on the cause of the problem.
If you notice any of the following, contact your doctor immediately:
1. A lump or thickening in the breast or armpit that is new or unusual.
2. A change in the size or shape of the breast.
3. Skin changes, such as a dimple or pucker in the skin of the breast.
4. Discharge or bleeding from the nipple that comes out without squeezing the nipple (spontaneous discharge).
5. A change in the nipple: Scaling or crusting of the nipple.
6. A change in the color or feel of the skin of the breast or the darker area around the nipple (areola).
7. A breast lump in a man.
These are signs that may relate to breast cancer…
I hope you have found this information useful.
Margarita Ochoa-Maya, MD