Fibrocystic Breast Disease

Fibrocystic breast disease (benign breast changes) is a common group of non-malignant conditions causing cyclical breast pain, nodularity and cysts, resulting from exaggerated response of breast tissue to hormones.

• It affects up to half of women aged 30 to 50 years and regresses after menopause (unless on hormone therapy).
• Histology: fibrosis, cysts, adenosis, ductal hyperplasia (non-proliferative, proliferative without atypia, atypical hyperplasia).
• Cancer risk: non-proliferative changes carry no increased risk, proliferative disease without atypia 1.5 to 2 times, and atypical hyperplasia 4 to 5 times.

Bilateral breast tenderness, heaviness and lumpiness that worsen in the premenstrual phase and ease after menses; palpable ill-defined nodular, ropy or granular thickening, upper outer quadrants.

• Smooth, mobile, round, tender cysts that appear suddenly and may fluctuate; occasional serous or greenish nipple discharge.
• Differential diagnosis: fibroadenoma, breast cancer, duct ectasia, mastitis, lipoma, galactocele, fat necrosis, intraductal papilloma, Mondor disease, chest wall pain, costochondritis, referred pain (cervical spine, angina).
• Complications: anxiety, delayed detection of cancer behind benign lumpiness, cyst infection, atypical hyperplasia as risk marker.

Triple assessment for any discrete lump or persistent area: clinical breast examination at the correct cycle time (days 5 to 10), imaging, core biopsy if needed.

• Ultrasound distinguishes simple cysts (anechoic, thin wall, posterior enhancement) from complex or solid lesions; mammography from 40 years (or earlier with risk factors).
• Aspiration of a palpable cyst confirms the diagnosis (fluid colour yellow-green; send cytology if bloody); residual mass after aspiration needs biopsy.
• Breast pain chart over two cycles to classify cyclical or noncyclical pain.

Supportive: reassurance (the single most effective measure), well-fitting supportive bra including during sleep and exercise, weight loss, regular exercise, reduce caffeine and fat intake (benefit is unproven), warm or cold compresses.

Pharmacological

• Analgesia: paracetamol 1 g every 6 hours; topical diclofenac 1 percent gel to the breast three times daily; oral ibuprofen 400 mg three times daily or naproxen 250 to 500 mg twice daily during pain.
• Evening primrose oil 1 to 3 g daily for 3 to 6 months (limited benefit), vitamin E 400 IU daily has little effect.
• Severe cyclical pain refractory to simple measures and analgesia: tamoxifen 10 mg daily (off-label) for 3 to 6 months (effective in about 70 percent; avoid in pregnancy; side effects hot flushes, menstrual disturbance), danazol 100 to 200 mg daily in the luteal phase (androgenic effects, teratogenic), bromocriptine 1.25 mg at night increasing to 2.5 mg twice daily, or combined oral contraceptive (may help or worsen).
• Stop or review hormone replacement therapy if pain is hormone-related.

Procedures: aspiration of symptomatic or palpable cysts (dry needle, 21 gauge; send fluid if bloody); biopsy of persistent masses; excision for atypia or recurrent cysts; no surgery for diffuse changes.

Special groups: women with atypical hyperplasia (high risk screening, chemoprevention with tamoxifen 20 mg daily or raloxifene 60 mg daily for 5 years, counselling), pregnancy (symptoms may change), women on hormone therapy.

Red flags: new discrete lump, bloody discharge, skin or nipple changes, axillary nodes, persistent post-aspiration mass, strong family history.

Follow-up: review in 4 to 6 weeks; annual clinical review; mammographic screening by age (from 40 to 50 years depending on risk); repeat ultrasound for recurrent cysts.