Basics
Description
- Generalized term for benign breast changes that are poorly defined
- No longer considered a pathologic disease process as they are found in the majority of healthy women
- Most common of all benign breast conditions
- Changes include:
- Benign cysts
- Breast pain (mastalgia or mastodynia), which may or may not be cyclic
- Diffuse and focal nodularity
- Palpable fibroadenomas
- Nipple discharge-may be green or brownish, though usually nonbloody
- Spontaneous, persistent discharge warrants further evaluation
- Occurs in ~60% of women
- Symptoms of pain and tenderness become progressively worse until menopause
- Pain is often most prominent during the premenstrual phase and improves with the onset of menses
- Breast pain alone is a rare symptom of cancer and accounts for only 0.2-2% of cases
- Synonyms: Adenosis, benign breast disease, cystic mastitis, cystic disease of the breast, fibroadenosis, fibrocystic disease, mammary dysplasia.
Etiology
- Mechanism of development not well understood
- Likely an enhanced or exaggerated reaction of breast tissue to cyclic levels of female reproductive hormones:
- May be caused by imbalance of the estrogen to progesterone ratio
- May occur secondary to increased daily prolactin production
- Most common in women 30-50 yr old
- Pain is most likely caused by rapid expansion of simple cysts
- Symptoms may continue into menopause secondary to hormone replacement therapy
- Incidence is decreased in women taking oral contraceptives
- Risk factors include:
- Family history of fibrocystic changes
- Oral contraceptives
- Hormone replacement therapy
- Increasing age
- Diet (high fat intake; caffeine/methylxanthines)
Diagnosis
Signs and Symptoms
History
- Mastalgia and tenderness:
- Persistent or intermittent
- Often occurs during premenstrual phase of normal menstrual cycle
- Usually bilateral
- Pain may radiate to shoulders and upper arms
- Lumpiness, nodularity:
- May be localized or generalized
- Increased engorgement and breast density:
- Breasts described as being dull and heavy
- Caused by fluctuations in the size of the cystic areas
- Spontaneous or expressible nipple discharge
- Abnormal nipple sensations, including pruritis
- Family history of cysts is common
Physical Exam
- Palpate the 4 breast quadrants while patient is sitting and then while lying down
- Note any changes from normal, including overlying erythema and warmth that may suggest an alternative diagnosis
- Examine for regional nodes (axillary, clavicular, etc.)
- Fibrocystic changes feel doughy with vague nodularity
- Nodules are typically discrete and mobile
- Usually more marked in the superior and lateral quadrants
- Small groups of cysts often described as palpating a "plate full of peas"�
- Large cysts have consistency of a balloon filled with water
- Breast exam is most sensitive 7-9 days after 1st day of menses when the breasts are least congested
Diagnosis Tests & Interpretation
Lab
- A detailed lab evaluation is usually not necessary in the emergency department
- Prolactin and thyroid-stimulating hormone may be helpful if galactorrhea is present
Imaging
- Ultrasound if <30 yr old
- Mammography if >30 yr old
- Ultrasound:
- Can differentiate cystic from solid masses
- Benign cysts:
- Typically demonstrate a uniform outer margin without asymmetry or irregular thickness of the cyst wall
- Have no central echoes
- Posterior wall enhancement is normal
- Can assist in aspiration of deep and nonpalpable cysts
- Also used to conservatively follow cyst size
- Performed at a specialized breast center with trained techs and interpreting radiologists
- Mammography:
- Benign changes may falsely appear malignant
- Difficult to interpret in women <30 yr old due to breast tissue density
- Should be performed either before aspiration or 7-10 days afterward to avoid artifact
Diagnostic Procedures/Surgery
- Fine needle aspiration:
- Usually performed by a specialist
- May be performed therapeutically for symptomatic or large masses
- Allows differentiation between cystic and solid masses
- Obtain cytology studies to evaluate for malignancy
- Excisional biopsy:
- Performed by surgeon
- Indicated for solid lumps that are not proven benign
Differential Diagnosis
- Benign breast masses:
- Breast abscess
- Duct ectasia
- Mastitis
- Simple fibroadenomas
- Solitary papillomas
- Malignant breast masses:
- Atypical hyperplasia
- Complex fibroadenomas
- Diffuse papillomatosis
- Ductal hyperplasia without atypia
- Sclerosing adenosis
Treatment
Ed Treatment/Procedures
- Majority of women will not require any medical treatment
- Conservative therapy:
- Support bra:
- Reduces tension on supporting ligaments of the breast
- May reduce inflammatory response and edema
- Low dose diuretic for 2-3 days before onset of menses
- NSAIDs
- Dietary changes are somewhat controversial:
- Restricting dietary fat (to 25% of total calories) and eliminating caffeine
- Increasing vitamin E and vitamin B6
- Herbal preparations such as primrose oil
- Hormonal therapy:
- Should be initiated by PCP to enable follow-up during course of treatment
- Oral contraceptives:
- May decrease symptoms, particularly after 1 yr of use
- Danazol (synthetic androgen) and Tamoxifen (partial estrogen antagonist):
- Shown to be equally effective for treatment of severe cyclical mastalgia
- Use may be limited by side effects (acne, hirsutism, weight gain, teratogenicity)
- Bromocriptine (inhibits prolactin production):
- Use also limited by side effects (headache, dizziness, nausea, constipation, weakness)
- Surgical intervention:
- If a persistent nodule exists, excision is recommended regardless of findings on diagnostic imaging
- If a large cyst recurs after aspiration on 2 occasions, it should be excised and sent for pathology
Medication
- Bromocriptine: 2.5-5 mg/d BID
- Danazol: 100-400 mg/d BID for 6 mo
- Tamoxifen: 10-20 mg/d
- Oral contraceptive pills (vary)
Follow-Up
Disposition
Discharge Criteria
- Patients with fibrocystic changes are appropriate for discharge with outpatient follow-up
- Encourage patient to keep a breast pain record to determine whether pain is cyclic
- The importance of follow-up should be stressed to ensure patient health, disease prevention, and patient satisfaction
- Encourage regular breast self-exam, annual physical exams, and annual mammograms when appropriate
Issues for Referral
- Practically speaking, all breast masses evaluated in the ED need referral to a primary provider or specialized breast clinic
- Further investigation with imaging and possible biopsy are required for masses that persist throughout menses and are not cyclical
- Referral to a general surgeon may be required in certain cases where tissue biopsy is necessary
Pearls and Pitfalls
- Breast cancer may coexist with benign breast disease and fibrocystic changes:
- Consider all cancer risk factors
- Confirm follow-up plan
- Mastitis in a nonlactating patient should be treated as inflammatory carcinoma until proven otherwise
- Fibrocystic changes are usually bilateral; unilateral changes are suspicious for cancer
- Fear of breast cancer is high in all patients:
- Give reassurance that fibrocystic breast changes are not cancerous
- Have a low threshold for referral to a specialist
Additional Reading
- Grube �BJ, Giuliano �AE. Benign breast disease. In: Berek �JS, ed. Berek & Novaks Gynecology. 14th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:652-654.
- Institute for Clinical Systems Improvement (ICSI). Diagnosis of Breast Disease. Bloomington, MN: Institute for Clinical Systems Improvement; 2005.
- Katz �VL, Dotter �D. Breast diseases: Diagnosis and treatment of benign and malignant disease. In: Lentz �GM, Lobo �RA, Gershenson �DM, et al., eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier; 2012:304-306.
- Marchant �DJ. Benign breastdisease. Obstet Gynecol Clin North Am. 2002;29:1-20.
- Parikh �JR. ACR appropriateness criteria on palpable breast masses. J Am Coll Radiol. 2007;4:285-288.
- Parikh �JR, Evans �WP, Bassett �L, et al. Expert Panel on Women's Imaging-Breast. Palpable Breast Masses. Reston, VA: American College of Radiology (ACR);2006.
- Rastelli �A. Breast pain, fibrocystic changes, and breast cysts. Probl Gen Surg. 2003;20:17-26.
- Santen �RJ, Mansel �R. Benign breast disorders. N Engl J Med. 2005;353:275-285.
Codes
ICD9
- 610.1 Diffuse cystic mastopathy
- 610.2 Fibroadenosis of breast
- 610.9 Benign mammary dysplasia, unspecified
ICD10
- N60.19 Diffuse cystic mastopathy of unspecified breast
- N60.29 Fibroadenosis of unspecified breast
- N60.99 Unspecified benign mammary dysplasia of unspecified breast
- N60.11 Diffuse cystic mastopathy of right breast
- N60.12 Diffuse cystic mastopathy of left breast
- N60.1 Diffuse cystic mastopathy
- N60.21 Fibroadenosis of right breast
- N60.22 Fibroadenosis of left breast
- N60.2 Fibroadenosis of breast
- N60.91 Unspecified benign mammary dysplasia of right breast
- N60.92 Unspecified benign mammary dysplasia of left breast
- N60.9 Unspecified benign mammary dysplasia
SNOMED
- 27431007 fibrocystic breast changes (finding)
- 23260002 Fibroadenosis of breast (disorder)
- 57993004 Benign mammary dysplasia (disorder)