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.
A nodule that is movable and feels unattached to the chest wall usually indicates a cyst or a fibroadenoma.
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.
Finding a lump in your breast can be very upsetting and should be investigated. However, don’t panic. Most breast lumps - up to 90% - are non-cancerous. It is particularly likely that breast lumps in women younger than 30 will be benign.
Breast tissue has a naturally glandular texture which is subject to hormonal changes, such as the menstrual cycle and pregnancy. Breasts tend to become lumpier and tender just before the menstrual period, but this may vary from woman to woman.
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.
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.
Breast mass, breast nodule
There are many causes for breast nodules:
Fibrocystic lumps are the most likely phenomenon in women in their thirties and early forties. The lumps are fluid-filled groups of cysts which are often tender and may move slightly when pressed. The lumpiness might feel like clusters of peas or grapes, and is most notable in the upper outer quadrant of both breasts. There might be a sense of fullness and dull pain – especially before menstruation. The lumps often shrink or disappear after menopause and menstruation, which generally is reassuring as a sign of non-malignancy.
Fibrocystic breasts do not increase the risk of developing breast cancer, but can make it more difficult to notice new lumps. It’s especially important that women with fibrocystic breasts do monthly breast self-examinations to “memorise” their breasts.
If there is minimal discomfort and there is no doubt about the diagnosis, no specific treatment may be required. Over-the-counter analgesics, a well-fitting support bra and limiting caffeine and chocolates may be helpful. Oral contraceptives are sometimes prescribed.
Cysts are fluid-filled sacs caused by dilated ducts and can usually be easily felt. The cysts are firm, rubbery, mobile and can become painful when large. Women in their forties are more prone to cysts due to hormonal fluctuations. It is not possible to make the diagnosis by a physical examination alone, and the doctor will drain the cyst and send the fluid to a laboratory for investigation.
A fibroadenoma is a solid benign tumour of the glandular tissue and typically occur in teenagers and in young women under the age of 30. Unlike the lumps or nodules of fibrocystic breasts, a fibroadenoma is quite distinct and round with smooth edges, and feels like a small, slippery marble. It feels hard and rubbery and is easy to move. The lump is usually painless and can often be found near the nipple.
Fibroadenomas may disappear spontaneously over time. Surgical removal may be recommended if it persists, grows or if it causes anxiety.
A cancerous lump usually occurs in only one breast and feels distinctly different from the surrounding tissue. It feels firm and hard and does not have smooth edges. It is usually painless. About 50 percent of cancerous lumps occur in the upper outer quadrant of the breast nearest to the armpit. In the early stages, the lump may move freely beneath the skin under the fingers. In more advanced cases, the lump usually adheres to the overlying skin or chest wall.
There may be puckering or dimpling (like an orange peel) of the skin and changes in the shape of the breast. Painless nipple retraction or a new scaly, crusting skin rash around the nipple or a bloody discharge from the nipple could be early symptoms of breast cancer.
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. 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. 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.
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 that a healthy weight and a balanced diet are 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 limiting are sugar and alcohol. Furthermore, doctors may suggest wearing a bra around the clock, to reduce breast movement and lessen discomfort until the tenderness has passed.
When to see a doctor
It may be difficult for you to know what type of lump you have. See your doctor if you feel a large or unusual lump or think that an area of your breast feels different. Be prepared to describe whether the lump is hard or soft and whether it moves easily under the skin.
Women older than 40:
Any lump should be investigated by your doctor as soon as possible.
Women younger than 40:
In all women:
- if you develop a discharge of the nipple, especially if the discharge is spontaneous and only from one nipple
- if you notice a change in how your breast feels (without being able to feel a lump) that does not disappear after one or two menstrual periods
- if you notice a change in shape or size of one breast
all lumps should be evaluated. One percent of breast cancer occurs in men.
What to expect at the doctor
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.