Fibrocystic breast changes

The changes in fibrocystic breast disease are characterised by the appearance of fibrous tissue and a lumpy, cobblestone texture in the breasts. These lumps are smooth with defined edges, and are usually free-moving in regard to adjacent structures. The lumps can sometimes be obscured by irregularities in the breast that are associated with the condition. The lumps are most often found in the upper, outer sections of the breast (nearest to the armpit), but can be found throughout the breast. Women with fibrocystic changes may experience a persistent or intermittent breast aching or breast tenderness related to periodic swelling. Breasts and nipples may be tender or itchy.

Symptoms follow a periodic trend tied closely to the menstrual cycle. Symptoms tend to peak in the days and, in severe cases, weeks before each period and decrease afterwards. At peak, breasts may feel full, heavy, swollen, and tender to the touch. No complications related to breastfeeding have been found.

Micrograph showing apocrine metaplasia associated with FCC. FNA specimen. Pap stain.

The exact mechanism of the condition is not fully understood, though it is known to be tied to hormone levels, as the condition usually subsides after menopause and is also related to the menstrual cycle. Post-menopausal women placed on hormone replacement therapy have also reported symptoms of fibrocystic breast change indicating hormones may play a role.

Fibrocystic breast changes is a cumulative process, caused partly by the normal hormonal variation during a woman's monthly cycle. The most important of these hormones are estrogen, progesterone and prolactin.

These hormones directly affect the breast tissues by causing cells to grow and multiply.[4] Many other hormones such as TSH, insulin, growth hormone and growth factors such as TGF-beta exert direct and indirect effects amplifying or regulating cell growth. Years of such fluctuations eventually produce small cysts and/or areas of dense or fibrotic tissue. Multiple small cysts and an increasing level of breast pain commonly develop when a woman hits her 30s. Larger cysts usually do not occur until after the age of 35.[5] Over time, presumably driven by aberrant growth signals, such lesions may accumulate epigenetic, genetic and karyotypic changes such as modified expression of hormone receptors and loss of heterozygosity.

Several variants of fibrocystic breast changes may be distinguished and these may have different causes and genetic predispositions. Adenosis involves abnormal count and density of lobular units, while other lesions appear to stem mainly from ductal epithelial origins.

There is preliminary evidence that iodine deficiency contributes to fibrocystic breast changes by enhancing the sensitivity of breast tissue to estrogen.[6][7][8][9]

Diagnosis is mostly done based on symptoms after exclusion of breast cancer. Nipple fluid aspiration can be used to classify cyst type (and to some extent improve breast cancer risk prediction) but it is rarely used in practice. Biopsy or fine needle aspiration are rarely warranted.[10]

Fibrocystic breast disease is primarily diagnosed based on the symptoms, clinical breast exam and on a physical exam. During this examination, the doctor checks for unusual areas in the breasts, both visually and manually. Also, the lymph nodes in the axilla area and lower neck are examined. A complete and accurate medical history is also helpful in diagnosing this condition. If the patient's medical history and physical exam findings are consistent with normal breast changes, no additional tests are considered but otherwise the patient will be asked to return a few weeks later for reassessment.[11] Women may detect lumps in their breasts during self-examination as well.

Most women with fibrocystic changes and no symptoms do not need treatment, but closer follow-up may be advised.[12]

There is no widely accepted treatment or prevention strategy for fibrocystic condition. When treatment of symptoms is necessary it follows the same strategies as treatment for cyclical breast pain.

It is controversial whether benign breast conditions improve or worsen with oral contraceptives or hormone replacement therapy.[13]

A few small-scale studies have indicated that the fibrocystic condition may be improved by dietary changes (especially by a reduced intake of caffeine and related methylxanthines or by a reduced intake of salt) and by vitamin supplements.[14]

Tentative evidence shown beneficial effects of iodine supplementation in women with fibrocystic breast changes.[6][15][16]

There are usually no adverse side effects to this condition. In almost all cases it subsides after menopause. A possible complication arises through the fact that cancerous tumors may be more difficult to detect in women with fibrocystic changes.

The estimated figures for the prevalence of fibrocystic breast changes in women over lifetime vary widely in the literature, with estimates ranging from about 30 to 60 %[21] over about 50 to 60 %[22] to about 60 to 75% of all women.[23]

The condition is most common among women between 30 and 50 years of age.[23]

In ICD-10 the condition is called diffuse cystic mastopathy, or, if there is epithelial proliferation, fibrosclerosis of breast.[24] Other names for this condition include chronic cystic mastitis, fibrocystic mastopathy and mammary dysplasia.[25] The condition has also been named after several people (see eponyms below). Since it is a very common disorder, some authors have argued that it should not be termed a "disease",[26] whereas others feel that it meets the criteria for a disease. It is not a classic form of mastitis (breast inflammation).[27]