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Why are my breasts so tender?
Will I need a biopsy?
What can I do to decrease my breast tenderness?
Fibrocystic Disease
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BREAST TENDERNESS
Why are my breasts so tender?
Breast tenderness is a very common symptom. It
is rarely associated with breast cancer, but a
thorough exam by an experienced physician is
important to be sure.
Most women experience at least some increase in
sensitivity or tenderness in their breasts as
their menstrual cycle In some women this can
become quite severe. The tenderness may be
diffuse, involving all of the breast tissue, or
it may be localized to one breast, or one area
of one breast. Though it usually lessens after
the menstrual period it may be constant. It is
clear that changing hormone levels in the blood
stream are the primary explanation, but there
may be other contributing factors. Certain
medications may increase tenderness, including
birth control pills, estrogen or progesterone (Premarin,
Provera, Ogen, Climara, Estratest, and others),
and medications which contain xanthines (Theodur,
caffeine containing stimulants). Caffeine seems
to cause increased breast tenderness for many
women, though it seems to have no effect in
others. Marked breast tenderness frequently
occurs in the very early stage of pregnancy
also. Sometimes a cyst can develop and enlarge
rapidly, causing localized tenderness. Less
commonly, an area of infection may occur which
can be extremely tender.
If you have recently noticed that your breasts
are more tender, you should be sure to do a good
self-exam of your breasts. See if can identify
a specific area that hurts, and feel for any
lumps. Look for any visible changes such as a
visible lump, or a dimpling of the skin, or
redness. Schedule an appointment with your
physician, and take a list of your current
medications. Be aware of how much caffeine you
are using, including coffee, tea, sodas,
chocolate, and any caffeine-containing
medications, such as diet pills or
stimulants. Be able to pinpoint when your last
menstrual period was, and whether is was normal
or not. Ask your physician's office if you
should have a mammogram or other studies before
your appointment, and if you should bring your
mammograms with you.
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Will I need a biopsy?
For
most women with breast tenderness, the
physician's exam will not identify any problem
which needs a biopsy. However, occasionally
there is an associated lump, which could be a
fluid-filled cyst, an abscess, or a solid growth
of tissue. Such findings will likely require a
procedure, such as use of a needle, or other
sort of biopsy or removal. This may frequently
be done at the time of the initial visit.
(Please note that some insurance companies do
not cover procedures to be done on the same day
as your exam. If not, you will be scheduled to
return for the procedure after your insurance
company has given authorization.)
Cysts can be treated simply with drainage of
the fluid through a needle. The pain from the
fluid drainage is similar to what you would feel
if you have a blood test done. The cyst fluid
usually has a greenish, yellowish, or brownish
tint. There is usually no need to "test" the
fluid if it has this typical appearance.
Abscesses usually require a small incision to
drain the infection. For small abscesses,
treatment can be done immediately. The
infection causes more surrounding tenderness
than a cyst, so the drainage procedure is likely
to be more painful, but brief. The advantage of
immediate treatment may outweigh the extra
tenderness. Larger abscesses may require
drainage in a hospital setting in order to
provide adequate sedation and /or anesthesia.
Solid growths of tissue may be biopsied with a
needle at the initial visit. Some anesthetic is
injected around the area to be biopsied. The
needle is then inserted into the lump to obtain
a sample of tissue for analysis. An ultrasound
machine is frequently used to place the needle
precisely. Most women experience little or no
discomfort with the procedure.
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What
can I do to decrease my breast tenderness?
(There are a number of options discussed below
that may help. We have summarized these in a
brief one page summary information sheet, which
you can
review and download or print here.)
Once
your physician has examined for any possible
problems such as a cyst, abscess or possible
cancer, there are several things you can do. If
you are taking in any caffeine on a daily basis,
try cutting out all caffeine products for a
period of six weeks. This simple step may be
all that is necessary. If your tenderness goes
away, you may want to experiment by starting
back on caffeine to see if your tenderness comes
back. You may find that there is a certain
amount of caffeine which you can tolerate
without the symptoms.
Both vitamin E and evening primrose oil have
been found to be helpful for many women. Though
the exact mechanism of action is not known, both
supplements have been found to be beneficial in
decreasing tenderness. Recommended dosages for
vitamin E range from 400 U to 1000 U per day. It
is available at all drug stores and many
supermarkets without a prescription. As an
added benefit, there appears to be a decrease in
risk of heart disease in patients taking vitamin
E on a regular basis.
Evening primrose oil is carried by many drug
stores, though it may be difficult to find than
vitamin E. It is more commonly recommended in
England than here in the United States.
Recommended dosage is up to four tablets per
day. It can cause some gastrointestinal side
effects, such as bloating or gas, and changes in
your bowel movements. These side effects are
less likely at lower dosages.
There are many simple measures to try that may
help. If your tenderness is predictable with
each menstrual cycle, you may want to begin
taking on over-the-counter pain medicine, such
as Tylenol, Advil, Alleve, or other, for the
week before your period. A good hot bath once
or twice a day can help. Changing to a
different bra is also occasionally beneficial.
Depending on the severity of your tenderness,
you may want to use some or all of these
measures. Most women will obtain sufficient
relief with the steps described above. For the
small group of women with persistent disabling
tenderness despite all these measures, there is
a hormonal treatment which is very effective,
but which has a high likelihood of side
effects. It involves use of Danazol, a hormone
used in treatment of endometriosis. Side effects
include changes in menstrual cycle, voice
changes, and body hair growth.
(We
have summarized these options in a brief one
page summary information sheet, which you can
review and download or print here.)
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Breast Pain./
Fibrocystic Disease
Painful breast tissue is an exceedingly common
symptom but is usually of "functional" origin
and very rarely a symptom of breast cancer. Many
years ago, a surgeon named Haagensen carefully
recorded the symptoms of women presenting with
breast cancer and found that only 5% of patients
had pain at time of diagnosis. And this was a
long time ago, when screening mammography was
not used routinely; breast cancers were often
much larger at diagnosis than they usually are
today
Although not typically a symptom of cancer,
breast pain is a common reason for patients to
seek medical attention. Breast pain appears to
be aggravated by abnormal menstrual cycles and
may be seen in young women with menstrual
irregularity, as a premenstrual symptom, or when
hormones, such as estrogen, are taken during and
after the menopause. In addition, fibrocystic
change, in its severest forms, may cause
disabling breast pain. Although many observers
find breast pain and tenderness is aggravated by
excessive intake of caffeine, nicotine, or
commonly used antihistamines, other
investigators disagree.
Fibrocystic Disease, Fibrocystic
Change (Cystic Mastopathy, Cystic Mastitis).
(Note: This portion is a bit more technical, so
be prepared!!)
Fibrocystic change, popularly referred to as
fibrocystic disease, represents a spectrum of
clinical and histologic findings including
cysts, nodular breast tissue, and some other
changes that have technical terms like "stromal
proliferation, and epithelial hyperplasia".
Fibrocystic change appears to represent an
exaggerated response of breast stroma
(background and supporting tissue) and
epithelium (the lining of the breast ducts and
lobules) to a variety of circulating and locally
(in the breasts) produced hormones and growth
factors. Clinically, patients with fibrocystic
change have dense, firm breast tissue with lumps
and frequently gross cysts, or pockets of fluid.
This condition is commonly painful and tender to
touch. Under the microscope, the lesion
recognized as fibrocystic complex contains
various sized cysts, stromal fibrosis (fibrous
background tissue), adenosis (overgrowth of
glands), and a variable amount of "epithelial
metaplasia and hyperplasia". All these changes
can occur alone or in combination and to a
variable degree in the normal female breast.
Autopsy studies have questioned whether any of
these changes, except perhaps macrocysts, are
abnormal. In fact, all of these lesions occur
commonly in the breasts of elderly patients and
appear to have no particular tendency toward
evolving into breast cancer. Since these sorts
of changes are so common, it really is not
appropriate to term it a "disease".
Nevertheless, the term "fibrocystic disease" is
so commonly used, it would be hard to get
everyone to stop using it. But ideally, the
term fibrocystic disease should be abandoned in
the absence of any well-defined clinical and
pathologic syndrome.
There is no consistent
association between fibrocystic changes and
breast cancer. It is well established that women
who have undergone breast biopsy for any reason,
regardless of the underlying pathology, have a
slightly higher risk of developing subsequent
breast cancer. Moreover, the incidence of
finding fibrocystic disease in autopsied breasts
from women dying of causes other than breast
cancer exceeds the incidence of these same
changes in cancer-containing breasts. For those
patients with fibrocystic changes, higher risk
appears to concentrate in those whose biopsy
specimens show abnormal ductal and lobular
hyperplasia and, to a lesser extent, cyst
formation. Therefore, the fibrocystic complex
appears to be an exaggerated or abnormal
response to otherwise physiologic stimuli in
most patients and represents a health risk only
in certain subsets.
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