Fibrocystic Breast Change

Fibrocystic breast change is a benign, common spectrum of cyclical breast changes (lumpiness, nodularity, tenderness, cysts, fibrosis, adenosis, epithelial hyperplasia) in premenopausal women, most often aged 30 to 50. About 50 percent of women have clinical symptoms, and over 60 percent have histological changes in autopsy series. It is not a disease and carries no increased cancer risk in most cases.

• Mechanism: exaggerated stromal and epithelial response of breast tissue to cyclical oestrogen and progesterone, prolactin and thyroid hormone, with cysts arising from dilated lobules.
• Histology: non-proliferative changes (cysts, fibrosis, mild hyperplasia; no increased risk), proliferative disease without atypia (florid hyperplasia, sclerosing adenosis, papilloma; relative risk of breast cancer about 1.5 to 2), and atypical hyperplasia (relative risk about 4 to 5, needs surveillance and risk reduction).
• Resolves after menopause unless on hormone therapy.
• Factors worsening symptoms: caffeine (evidence limited), nulliparity, hormone therapy, stress, high fat diet (evidence limited), and certain drugs (oestrogens, spironolactone, digoxin, methyldopa, antipsychotics, antidepressants).
• Diagnosis relies on excluding malignancy by triple assessment when a dominant lump is present.

• Cyclical bilateral breast pain and heaviness in the late luteal phase, relieved by menses; diffuse nodularity most prominent in the upper outer quadrants; tender, mobile, smooth or rubbery cysts that appear suddenly and fluctuate with the cycle.
• Pain may radiate to the axilla and arm.
• Examination: bilateral granular or lumpy breast tissue, discrete mobile cysts; no skin change, nipple retraction, fixed mass or axillary nodes.
• Red flags: a dominant, hard, irregular or fixed lump, a mass persisting through the cycle (re-examine after menses), unilateral bloody or spontaneous nipple discharge, skin dimpling, peau d'orange, nipple retraction or eczema, axillary lymphadenopathy, a new lump in a woman over 40, family history of breast or ovarian cancer (BRCA), persistent focal pain, a previous diagnosis of atypical hyperplasia.

• Clinical breast examination (ideally in the first half of the cycle, days 5 to 10).
• Triple assessment for any discrete or dominant lump: clinical examination, imaging and biopsy.
  • Imaging: ultrasound for women under 40 (cysts are anechoic with well defined walls); mammography with ultrasound for women aged 40 and over.
  • Biopsy: fine needle aspiration of a cyst (clear, yellow or green fluid is benign; discard if clear and the lump resolves; send bloody fluid for cytology); core needle biopsy for solid lesions.
• For diffuse bilateral cyclical pain with normal examination in women under 30: imaging is not usually required; use a pain diary (Cardiff chart) for 2 months.
• Pregnancy test, thyroid function and prolactin when atypical symptoms or galactorrhoea.
• Women over 40: screening mammography at the intervals applicable to age and risk.

• Reassurance after triple assessment confirms benign disease (the main treatment in 80 to 90 percent).
• Supportive well fitting bra (including a sports bra at night in severe pain).
• Analgesia: paracetamol 1 g orally every 6 hours; ibuprofen 400 mg orally three times daily with food during the painful phase; topical diclofenac 1 percent gel applied to the painful area 2 to 4 times daily (lower systemic exposure).
• Review drugs that contribute (hormone therapy, antipsychotics, spironolactone).
• Symptomatic cysts: ultrasound guided aspiration with a fine needle (recurrence 20 to 30 percent; repeat once; excise if recurrent or complex).
• Evening primrose oil 3 g daily (or gamolenic acid) has limited benefit and is not recommended routinely. Vitamin E, vitamin B6, caffeine reduction and low fat diet have limited evidence; reasonable to use for 2 to 3 months if the woman wishes.
• Severe cyclical mastalgia (affecting daily life after 3 months of simple measures; specialist initiated):
  • Tamoxifen 10 mg orally daily (5 mg is also used) for 3 to 6 months on days 15 to 25 or continuously; effective in about 70 percent; contraception required; counsel on hot flushes, vaginal dryness, venous thromboembolism, endometrial changes.
  • Danazol 100 to 200 mg orally daily (or luteal phase only); side effects (weight gain, acne, hirsutism, voice deepening, menstrual disturbance); contraception required.
  • Bromocriptine 1.25 mg at night increased to 2.5 mg twice daily; nausea, dizziness.
  • Oral contraceptives or progestogens may help or worsen symptoms; review individually.
• Atypical hyperplasia on biopsy: excision, surgical follow up, risk assessment, consider chemoprevention (tamoxifen 20 mg daily for 5 years, or anastrozole 1 mg daily for postmenopausal women) and annual mammography.
• Refer to a breast clinic: any dominant mass, suspicious imaging, bloody discharge, skin changes, persistent focal pain, family history, or failure of treatment.
• Review at 3 months with a pain chart.