Breast lumps and breast pain

Summary

• The female breast changes with puberty, the monthly menstrual cycle, pregnancy and hormonal replacement therapy.
• These changes may be associated with nodularity and pain.
• Most of these changes are normal and no cause for concern.
• Some breast conditions require medical attention.
• The most common breast problems involve lumps or pain.

Description

Between 80 to 85 percent of all breast nodules are benign, and it is particularly likely that breast lumps in women younger than 30 years old will be benign.

A nodule that is movable and feels unattached to the chest wall usually indicates a cyst (a fluid-filled sac) or a fibroadenoma (a benign tumour containing glandular tissue). A lump that is hard, immovable, or feels attached to the chest wall, with or without pain, possibly with dimpling or puckering of the breast, must be regarded as breast cancer until proven otherwise.

Some women experience nodularity of the breasts immediately preceding or during a menstrual period. A certain amount of nodularity in breast tissue is normal, but new nodules require prompt evaluation by a doctor. Nine out of ten breast lumps are benign and not cancer.

The most common breast condition many women experience once they have begun to menstruate is monthly swelling and sometimes painful tenderness preceding a period. This is not dangerous, and no treatment is necessary if the discomfort can be tolerated.

Each monthly cycle is associated with hormonal changes, including increases in oestrogen and progesterone, that bring more fluid into the breasts, expanding tissue, stretching nerve fibres, and sometimes producing pain. Symptoms usually subside near the end of the period. Some women experience a similar condition as a side-effect of birth-control pills or hormonal replacement therapy.

Cause

There are many causes for breast nodules and breast pain, including normal, physiological findings.

Benign causes of nodules include fibroadenoma, fat necrosis and breast abscess. Most nodules are fibroadenomas. Fibrosis refers to connective tissue or scar tissue formation. The breasts may feel nodular or lumpy.

Fibrocystic changes and fibroadenomas can be associated with breast swelling and pain. Cysts sometimes occur cyclically, and may be painful. With the cessation of menstruation at menopause, many cystic lumps diminish or disappear; therefore, any lump that forms after menopause should be checked immediately. Benign breast tumours such as fibroadenomas or papillomas are abnormal growths which do not spread outside the breast to other organs and are not life-threatening.

Some nodules are age-dependent. Both male and female newborn infants have lumps of enlarged breast tissue beneath the nipples. These lumps are the result of the feto-maternal hormones and disappear within a few months after birth. Beginning as early as eight years old, girls may develop tender nodules beneath one or both nipples (frequently only one). These nodules are breast buds and are an early sign of puberty.

Boys at mid-puberty (around the age of 14 to 15) may develop tender lumps beneath one or both nipples in response to hormonal changes. Breast buds tend to disappear over six months to a year.

Researchers are studying the incidence of breast nodules in women taking birth-control pills or using hormone replacement therapy. With hormone replacement therapy, women take varying amounts of the female hormones oestrogen and progestogen to alleviate symptoms of menopause and to reduce the risk of osteoporosis and possibly cardiovascular disease. While evidence is inconclusive, some doctors may have concerns about hormone replacement therapy and breast nodules. An additional concern is that using hormone replacement therapy changes breast structure, increasing breast density and making mammograms more difficult to read and evaluate, thus making cancer detection more difficult.

Symptoms

Cysts and fibroadenomas may be painful, but breast cancer rarely is - although pain does not rule out the possibility of cancer.

Pain accompanied by redness and warmth or discharge from the nipple may indicate an infection. (Discharge can also signal a benign growth or breast cancer.)

Other causes of breast pain may include injury or growths. One must keep in mind that breast pain not originating in the breast includes such diverse causes as Tietze's syndrome (pain and tenderness over the ribs beneath the breasts, which may be related to excessive muscle strain), cervical radiculopathy, fractured rib, Mondor's disease (pain in the lower breast from an inflammation of a vein crossing within the breast tissue), angina, gall bladder inflammation, hiatus hernia and peptic ulcer disease.

When to see a doctor

• Any kind of new or unusual nodule in the breasts, especially one that remains throughout your menstrual cycle, should be examined. Although most nodules are harmless, in rare instances they may signal infection or cancer.
• Any unusual changes in the breasts or discharge from the nipples should be checked by a doctor, also if one suspects that there is an infection. The doctor will examine the breasts and do appropriate tests if necessary.

Diagnosis and treatment

For breast nodules, diagnosis and treatment are frequently related. The best test for distinguishing a cyst from a solid tumour is ultrasound. A fine needle aspiration may also be done. The doctor may insert a thin needle into a cyst and aspirate any fluid, both to examine the fluid and to eliminate the cyst. If the fluid is clear and the cyst disappears, it will probably be diagnosed as a benign cyst and will require no further treatment. The fluid will be checked by cytology - microscopic examination of cells within the fluid.

If a lump does not disappear and is still present after the next menstrual period, it will become necessary to have a follow-up visit so that the doctor repeats the examination. If the fluid extracted from a suspected cyst is blood-stained or if little or no fluid can be extracted, this is a cause for concern, and a biopsy may be indicated to check for cancer.

A mammogram - detailed x-ray pictures of the breasts - may be performed to examine a suspicious area of the breast and reveal tumours too tiny to be felt by hand.

Home treatment

For pain relief, heat can be applied with a heating pad or hot-water bottle for 20 to 30 minutes. If one uses a heating pad, it is important to follow the manufacturer's instructions and do not fall asleep while using it.

Some doctors recommend eliminating caffeine to shrink breast cysts, but this has not been proven. Several studies have suggested (although none has proved) a link between dietary fat - especially saturated fat - and benign nodules, as well as breast cancer. Limiting fat may help shrink or eliminate nodules.

To prevent and treat monthly breast swelling, a change in diet may help. The doctor may recommend to maintain a healthy weight and to eat a balanced diet as good preventive measures. Because salt can contribute to fluid retention and thus worsen symptoms, salt intake should be restricted close to the menstrual period.

Other foods to consider avoiding in excess are sugar and alcohol. Furthermore, doctors may suggest wearing a bra, even 24 hours round the clock, to reduce breast movement and lessen the discomfort until the tenderness has passed.

Medication

The reassurance that no cancer is present and pain relief with an analgesic such as aspirin or ibuprofen for periods of intense pain is usually all the treatment necessary. If this is not sufficient, cyclical breast pain (cyclical mastalgia) can be treated with vitamin B6 (pyridoxine) and gamma linolenic acid (evening primrose oil). Gamma linolenic acid tends to stabilise breast epithelial activity via the so-called prostaglandin metabolism. A woman in whom this treatment is not effective should be seen by a specialist at a breast service clinic, as further interventions may be indicated such as tamoxifen (an anti-oestrogen) and danazol (an anti-gonadotropic hormone). However, these drugs have potentially serious side-effects in healthy women.

Reviewed by Dr Jenny Edge, General Surgeon, BSc, MB BS, FRCS (Edin), M Med (Stell), September, 2004

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