FIBROCYSTIC CHANGE
I-MASTODYNIA
Fibrocystic change (previously called fibrocystic disease) is a nonspecific term that includes mastalgia (mastodynia), breast cysts, and nondescript lumpiness. These may occur in isolation or together. The breasts generally have a nodular and dense texture and are tender when palpated. Fibrocystic change is responsible for the most commonly reported breast symptoms.
Mastalgia is the nonspecific term
used for breast pain of any etiology. Mammary pain may occur in obese,
pendulous breasts at or after the menopause when the weight of the breast
stretches the suspensory ligaments and puts traction on the nerve fibers. These
cases are not true mastodynia and are relieved by a supportive brassiere and by
weight reduction. Another form of mammary pain, which does not arise in the
parenchyma, is due to intercostal neuralgia, which may complicate spondylitis,
fatigue, or respiratory infections.
Most women experience breast pain at
some point in their lives, but in most cases it is transient. The most common
cause of persistent breast pain is fibrocystic change. Breast pain can also
arise from rapid hormonal change (especially a change that involves a rise in
estro- gen levels, such as starting birth control pills, hormone replacement,
or pregnancy). In the absence of obvious pathologic changes, mastalgia has been
attributed to caffeine consumption and high-fat diets, but hard data are
lacking. Nongynecologic causes include dorsal radiculitis or inflammatory
changes in the costochondral junction (Tietze syndrome), sclerosing adenosis,
chest wall muscle spasms, costochondritis, fibromyalgia, and referred pain.
Older patients may also suffer postherpetic neuralgia or neuritis following
herpes zoster infections. This pain may mimic mastalgia.
The pain of fibrocystic change, at
first present only in the premenstruum, becomes progressively more prolonged and
more severe until it persists throughout the cycle. The breast affected is
usually well developed. A swollen granular zone of increased density is felt,
which is located far more frequently in the upper lateral quadrant than in
other parts of the hemisphere. On com- pressing this swollen area with the
examining fingers, pain is produced. The fibrocystic change is often bilateral. Definitive
masses are generally not felt. Unilateral or localized pain suggests a
pathologic process. Mammography may be indicated for other reasons but seldom
directly assists in the evaluation of mastalgia.
When biopsied, the painful breast
tissue is found to be more dense and fibrous than normal. The lobular tissue
stands out as small pink dots in the dense white stroma, which encloses
occasional small cyst formations. On microscopic examination, the lobules are
stunted or irregular, with minute cystic dilatations. Proliferating immature
connective tissue, which stains poorly, surrounds the epithelial structures.
Mastodynia usually responds to
medical therapy and to reassurance against the fear of cancer. General measures
include analgesics, mechanical support (a well-fitting brassiere worn day and
night), local heat, and reassurance. A reduction in methylxanthine intake is
often beneficial. Premenstrual restriction of salt or fluids is recommended for
selected patients. The role of vitamins A and E is unknown. Evening primrose
and chasteberry have shown efficacy in limited trials
but standardization of both therapy and active ingredients in varying
preparations limits the ability to fully evaluate these as therapeutic options.
Combination oral contraceptives improve
symptoms for between 70% and 90% of patients. In moreresistant cases, treatment with spironolactone, danazol
sodium (begun during menstruation or once pregnancy has been ruled out), or
bromocriptine may be required.
In very selective patients gonadotropin-releasing hormone agonists
may be required. Diuretics must be used with care to avoid fluid and electrolyte
disturbances. Bromocriptine may cause hypotension during the first several days
of therapy. Care should also be exercised with patients who have compromised
hepatic or renal function.
Whatever therapy is used, it remains
essential to consider the possibility of cancer in
all cases.
