Benign Diseases of the Breast
Nipple Discharge
The breast is designed to make milk. This it sometimes does this even when a woman is not breast feeding.
It may occur when on the pill or hormone replacement as this artificially raises the hormone levels. It often occurs for no apparent reason. Many women can express a small amount of milk by squeezing the nipple.
Nipple discharge is rarely the sign of anything serious provided there are no other symptoms such as a lump, permanent pulling in of the nipple or severe pain. There are several ducts coming to the surface on each nipple. Discharge frequently comes from several ducts at the same time - can be due to duct ectasia..
Intermittent discharge which is clear, yellow, creamy, bluish, greenish or brown is considered normal. Red blood can also mean papilloren in a duct - which is benign. It is only if the discharge is red blood coloured that it needs further investigation by your doctor. The best way of distinguishing red from brown discharge is to dab a little onto a white tissue and look at it under a good light.
Occasionally a woman may get such large amounts of discharge that it stains her clothes. There are ways of controlling this if it becomes a cosmetic problem and your doctor will be able to advise you.
If you get either persistent or blood stained discharge, should report to your doctor.
Nipple Retraction
Pulling in of the nipple often happens when it is cold or for other reasons and usually lasts for a few minutes only. There are many women whose nipples have always been pulled in and some cannot breast feed because of it. Can also be a sign of breast cancer
Pulling in of the nipple is only important if it is permanent and recent (progressing over a few weeks or months). Not always important if permanent - can happen innocently.
It can occur for many reasons other than cancer. Indeed the usual reason is because a little inflammation has scarred a duct behind and this has pulled it in.
However, if your nipple has changed shape, especially if it is associated with other symptoms such as a lump or blood stained nipple discharge, then it should be reported to your doctor without delay.
Patient Information Sheet about Fibrocystic Change:
Cysts (fluid filled lumps) of the breast are commonly found particularly between the ages of 40and 60. It also can occur in those on the pill or hormone replacement therapy (HRT). Although often it is called fibrocystic disease, it is not a disease, but simply a sign of the changing hormone levels which occur naturally throughout life.
The breasts first develop at the age of about 12 as the hormone levels rise and periods start. As the menopause approaches, the hormone levels fall again and most of the milk producing part of the breast is replaced by fatty tissue. During this phase there is a tendency for cysts to form, often in several parts of the breast at the same time. Many more women get cysts than is realised because cysts are usually soft, painless and cannot be felt. It is only if they become inflamed because of a minor infection or a bruise that they become tense, hard and sometimes tender.
Cysts are benign and have nothing to do with cancer. Cysts do not turn into cancer, although the two can be confused as they both cause lumps. This is why any lump should be reported to your doctor so that a full examination can be carried out. If the lump proves to be a cyst, then you need worry no longer. Sometimes removing the fluid with a needle is required if the cyst is painful or to prove beyond doubt that it is not a solid lump.
If you have once had a cyst then you will be more likely to get cysts in the future, sometimes at other sites in the breast. However, once you go through the menopause, the cyst problem will disappear of its own accord except if you choose to use hormone replacement therapy (HRT). Unfortunately, HRT often makes a cyst forming tendency worse. This is not a reason for not using HRT if your symptoms of the menopause are troubling you, but you will have to accept this as a possible side effect.
As with all women, we suggest you get used to examining yourself and report to your own doctor if you notice anything new or unusual. (The Breast Care Sister can provide a form for you if you wish, which can show you how to examine your breasts and give you breast awareness leaflets. If you do get another lump, it is most likely to be only another cyst. However, it is still important that you have it properly checked by your GP.
Information on Fibroadenomas
A lump is most likely to be fibroadenoma if you are under 30. Fibroadenoma's are caused by an over-development of fibrous tissue in the breast and can vary in size. Some women can have several lumps. They feel like little marbles in the breast tissue and often seem to move about which has led to the term ("breast mouse"). They are usually painless.
Fibroadenomas are harmless and do not develop but if shown signs of Atypical hyperplacion an cytology may need to br removed.. Provided the surgeon has proved that a lump is a fibroadenoma by feel, ultrasound examination and by fine needle aspiration cytology (needle test) it is safe to leave the lump alone unless you wish to have it removed. They generally stay the same size, but if they do get larger or become uncomfortable it is simple to have them removed by doing a small operation under general anaesthetic usually as a day case (you do not have to stay in hospital over night).
Patient Information Sheet about Cyclical Breast Pain and Hormonal Mastitis:
Breast pain is common - two out of three women suffer it at some time in their lives. Like any other breast problem, it can be worrying, but most breast pain can be treated and has nothing to do with cancer.
There are two types of breast pain: it may be related to the menstrual cycle (cyclical breast pain also known as hormonally mediated mastitis) or unrelated to your cycle (non-cyclical breast pain).
Why does cyclical breast pain occur?
Breast tissue is influenced by the hormones which control your periods. From the time of ovulation, (generally halfway between periods,) the hormones (particularly progesterone) build up and then fall rapidly once the period starts. During this build up some women find the breast tissue is more sensitive even though their hormone levels are normal. This is the reason why in the few days leading up to the period many women feel discomfort in their breasts. Sometimes this can be severe enough to interfere with personal relationships, such as hugging partners and children.
Until recently, the cause of breast pain was something of a mystery. Most women with breast pain have normal levels of circulating hormones. It is now accepted that the problem is abnormal sensitivity of breast tissue to normal hormone levels.
This increase in sensitivity is linked with the pattern of fatty acids in the blood stream. Fatty acids are substances present in all fats and oils which can affect the way the body responds to its own hormones. Women with breast pain have low levels of a fatty acid called gamolenic acid (GLA). Low levels of GLA are not caused by dietary deficiencies but by an inefficient conversion process in the body.
What can I do about cyclical breast pain?
Make sure that your bra fits correctly. Go along to a specialist fitter to make sure it fits and supports you properly. Many large department stores have a specialist bra fitter who can advise you.
There is evidence that increased breast sensitivity is related to the balance between saturated and unsaturated fats, so adjusting your diet by reducing animal fats (such as butter, cream and fatty meat) and increasing your intake of fresh fruit and vegetables can be helpful.
What can a doctor prescribe for breast pain?
There are medicines which your doctor may consider you need. These are Evening Primrose Oil, Danazol, and Bromocriptine.
Non-cyclical Breast Pain (constant or intermittent breast pain occurring at different times in the cycle each month):
How common is breast pain?
Breast pain is common - two out of three women suffer it at some time in their lives. Like any other breast problem, it can be worrying, but most breast pain can be treated and has nothing to do with cancer.
What causes non-cyclical breast pain?
Non-cyclical breast pain often comes from your ribs, or the muscle of your chest wall. Most muscle or joint pains settle more quickly if you rest the area. Unfortunately, the chest is constantly moving when you breath or cough and the muscles that move your shoulders attach to the ribs behind the breast. Resting this area is nearly impossible and this means that mild strains can become chronic and take a long time to settle. Simple painkillers can help if the pain is troublesome - such as panodol (paracetamol) or ibuprofen (neurofen). Sometimes there is a trigger spot for the pain, and injection of this with local anaesthetic and a steroid may help.
Sometimes the joint between the front end of a rib and the breastbone can become inflamed and painful (Tietze's syndrome) and similar treatment is recommended. Once you know the cause, you may begin to recognise the sorts of activities which make the pain worse. If you can avoid these, it will help the area heal more quickly.
Non-cyclical breast pain can come from inflammation in the breast ducts, usually directly behind the nipple. The pain may be mild aching, but often there is associated needle pain behind the nipple and spasms like the milk is being let down when breast feeding. This can be treated with a short course of antibiotics, usually metronidazole, but it will often settle by itself.
Is non-cyclical breast pain a sign of breast cancer?
Non-cyclical breast pain rarely indicates cancer unless there are other symptoms as well, such as the presence of a lump, nipple distortion, blood stained nipple discharge, general enlargement or dimpling of the skin of the breast. If you notice any of these in addition to the pain, then you should return to your doctor for further advice.
Patient advice sheet on Duct Ectasia, Nipple Discharge, Periductal Mastitis and Mammilary Fistula.
It may occur when on the pill or hormone replacement as this artificially raises the hormone levels. It often occurs for no apparent reason and even after the menopause, although smokers seem to be more likely to get the problem. Many women can collect milk in the ducts (tubes within the breast) behind the nipple which causes them to become a little engorged. This can be seen on an ultrasound examination. It is called duct ectasia.
Does duct ectasia cause symptoms?
No. Most women who have duct ectasia shown on an ultrasound examination of the breast have no symptoms, and will never get any symptoms. Sometimes they may be able to express a small amount of milk by squeezing the nipple or they may have a little spontaneous nipple discharge.
Does nipple discharge matter?
Nipple discharge is rarely the sign of anything serious provided there are no other symptoms such as a lump, permanent pulling in of the nipple or severe pain. There are several ducts coming to the surface on each nipple. Discharge frequently comes from several ducts at the same time.
Intermittent discharge which is clear, yellow, creamy, bluish, greenish or brown is considered normal. It is only if the discharge is red blood coloured that it needs further investigation by your doctor. The best way of distinguishing red from brown discharge is to dab a little onto a white tissue and look at it under a good light.
What is periductal mastitis?
Periductal mastitis is inflammation around a breast duct. In duct ectasia, the milky substance filling the duct occasionally attracts infection. The infection is usually very mild and caused by one of the bacteria which normally lives on the skin where it does no harm. Unfortunately within a breast duct filled with milk, the bacteria can multiply and cause some inflammation. This causes non-cyclical breast pain, usually directly behind the nipple. The pain may be a mild aching, but often there is associated needle pain behind the nipple and spasms like the milk is being let down when breast feeding. The nipple may feel itchy.
This can be treated with a short course of antibiotics, usually metronidazole, but it will often settle by itself.
What causes breast abscess?
Breast abscess is most common while breast feeding, but can occur at other times as well. It can occasionally occur as a progression of periductal mastitis as described above. If the infection set up in the milk duct breaks out into the tissue of the breast, then an abscess will develope.
Breast abscesses cause a lot of pain in the breast, usually just behind the nipple. This is usually associated with a lump and reddening of the skin. The glands under the arm may become tender.
A prompt course of antibiotics from your doctor may resolve the problem, but sometimes surgery is required to drain the abscess. If the antibiotics only partly treat the problem, then aspiration of the abscess with a needle may help.
What is mammilary fistula?
Sometimes the infection of a breast abscess works its own way to the surface causing a discharge from the edge of the areolar (the brown skin around the nipple). If this happens the discharge tends to contiue on and off, frequently asscoiated with bouts of redness and pain. This is called a mammilary fistula.
Mammilary fistula may settle with a long course of antibiotics, but often it requires surgery to remove the affected duct. Even surgery sometimes has to be carried out several times before the infection is completely cleared.
The Pill and Hormone Replacement Therapy (HRT) and Their Effects on the Breast
Both the Pill (oral contraceptive) and HRT contain either the hormone oestrogen or progesterone or both. These are the normal female hormones which control breast development at the menarche, the normal menstrual cycle and enlargement of the breast in pregnancy and contribute to milk production when breast feeding.
The side effects which these medications cause are all as a result of these normal effects. It is normal to get some or all of the following particularly in the first few weeks after starting either the Pill or HRT.
1. Enlargement of the breasts.
2. Increased tenderness of the breast especially running up to the period time.
3. Increased lumpiness especially in the upper outer parts of the breast in the few days before the period starts.
4. A little milky discharge especially if you squeeze the nipple.
If any of these symptoms become particularly troublesome, please report to your doctor who can arrange to reduce the dose or give you an alternative medication.
There is no evidence so far shown which proves that either the Pill or HRT cause breast cancer to develop, but you should not take either medication if have had or suspect that you may have breast cancer as it may cause this disease to grow and spread more quickly.
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Patient Advice Sheets on Treatments:
Evening Primrose Oil and Breast Pain:
Evening Primrose Oil is a natural product refined from a common flower. As such it is a food rather than a drug, and has few side effects.
It is used to reduce hormonally related (cyclical or premenstrual) breast pain and helps to prevent cyst formation. It does this by increasing the amount of anti-inflammatory hormone (called prostaglandin) which naturally controls breast tenderness. Chemically, Evening Primrose Oil is very similar to this important hormone.
The usual dose is 250mg three times a day. There are several different brands available over the counter without prescription, which can be bought in all good chemists. Some of these brands may be mixed with other natural oils or vitamins. If you require any help choosing a suitable type, your local chemist can offer you advice.
Evening Primrose Oil usually has to be taken for about six weeks before the full effect is felt. If it works to control your symptoms (as it does in more than 70% of women) then you are advised to continue with it for about six months. Normally the improvement in your symptoms will continue even after you have stopped taking it. However, if they do return, there is no reason why you cannot continue with it for much longer if you wish.
Side effects are very rare, but the occasional person may develop an allergy, sickness or headache. There are several beneficial side effects which include an improvement in hair and skin texture, reduced premenstrual tension and reduced lumpiness of the breasts.
If Evening Primrose Oil does not work in your case, then you should return to your GP or to the breast clinic, if you were given another appointment. There are several other stronger treatments for breast pain and cysts available. The disadvantage of stronger drugs is the increased risk of side effects. However, if your symptoms are severe enough to justify such medications, we will be pleased to give you more information about these drugs and give you a prescription if necessary.
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Patient Information Sheet About Danazol:
PATIENT INSTRUCTIONS
A. DANAZOL (ORAL)
1. DESCRIPTION: DANAZOL (oral) is used for the treatment of pain and infertility associated with endometriosis.
The drug is also used for breast pain and fibrocystic breast disease (cysts in the breasts).
2. BRAND NAMES: Danol(R)
3. SIDE EFFECTS:
a. If you have problems with these or other bothersome side effects, check with your doctor immediately. Other side effects not listed below may also occur in some patients.
(1) Irregular menstrual period; fluid retention; weight gain; acne; hair loss; voice change; sore throat; enlargement of clitoris; flushing; sweating; vaginal dryness; reduction in breast size; nervousness; yellowing of skin and eyes; itching; nasal congestion; dizziness; fainting; headache; tremor; appetite changes; chills; fever; bleeding gums; pelvic pain; joint swelling; vaginitis
4. CONTRAINDICATIONS: Do not take this medication if you have had an allergic reaction to DANAZOL in the past. DO NOT TAKE THIS MEDICATION IF YOU ARE PREGNANT, OR BREASTFEEDING. Do not use birth control pills while on this medication. A nonhormonal method of birth control (eg, condom) should be used instead. Women of childbearing age must not become pregnant during or shortly after taking DANAZOL.
5. PRECAUTIONS: Consult your doctor before taking if you have kidney or liver disease, epilepsy, migraine, headaches, or heart disease. This medication can cause your skin to be more sensitive to sunlight. Avoid being exposed to sunlight for long periods of time.
6. DRUGS/FOODS TO AVOID: Do not take any other medications, including over-the-counter products without consulting your doctor. Check with your doctor or pharmacist if you are taking a blood thinner (eg, WARFARIN), CARBAMAZEPINE, INSULIN, or CYCLOSPORINE.
7. STORAGE/ADMINISTRATION GUIDELINES:
a. ORAL CAPSULES: Take this medicine exactly as your doctor ordered. Do not use this medicine more frequently, or in greater amounts than prescribed by your doctor. Keep this medication in the original tightly-closed, light-resistant container. Store at room temperature, away from heat or moisture.
8. MISSED DOSE: Do not take the missed dose and continue with your regular dosing schedule. Do not take two doses at the same time.
PLACE IN THERAPY: DANAZOL is also useful for the palliative treatment of cyclical breast pain and fibrocystic breast disease in patients who are unresponsive to simple measures, such as analgesics or evening primrose oil.
Danazol counteracts your own hormones, and generally one 100 mg tablet should be taken each day for the first two weeks and then increased to 100 mg twice daily for 4 weeks. Then you will be reviewed by your doctor who will advise you on any adjustment of dose needed.
The course of treatment is likely to last six. After three cycles, you may be able to reduce the dose to one tablet on alternate days or only use the medication during the second half of your cycle.
Patient Information Sheet on Bromocriptine
PATIENT INSTRUCTIONS
A. DESCRIPTION: BROMOCRIPTINE is an ergot alkaloid medicine used to treat several different medical conditions. It is used to control severe cyclical breast pain where other simpler measures such as evening primrose oil, analgesics (painkillers) and danazol have failed.
B. BRAND NAME: Parlodel(R)
C. SIDE EFFECTS:
1. Dizziness or lightheadedness, headache, nausea, dry mouth, drowsiness.
2. If you have these or other bothersome side effects, check with your doctor. Other side effects not listed above may also occur in some patients.
3. Certain side effects may be associated with more serious complications or become life-threatening. CALL YOUR DOCTOR IMMEDIATELY IF ANY OF THE FOLLOWING EFFECTS OCCUR:
a. Blurred vision, headache (severe or unusual), nausea and vomiting (severe), chest pain, rapid heartbeat, shortness of breath.
D. CONTRAINDICATIONS:
1. Do not take BROMOCRIPTINE if you have had an allergic reaction to BROMOCRIPTINE or to another ergot alkaloid medicine, such as ERGOTAMINE. BROMOCRIPTINE should not be taken by children under the age of 15 or nursing mothers.
2. Tell your doctor if you have other medical conditions, especially high blood pressure, toxaemia of pregnancy, liver or kidney disease, peptic ulcer, heart or blood vessel disease, or mental illness.
3. It is important for your doctor to know if you are taking a high blood pressure medication, ergot alkaloid medicine, birth control pills, oestrogen, progesterone, or LEVODOPA.
E. PRECAUTIONS: If you are pregnant, you should obtain your doctor's approval before taking BROMOCRIPTINE. If you become pregnant while taking BROMOCRIPTINE, contact your doctor immediately. Taking the first dose causes some people to become dizzy. Therefore, it is suggested that you take your first dose at a time and place where you can lie down. Because BOMOCRIPTINE makes some people dizzy or lightheaded, exercise caution in driving a car or operating machinery.
F. DRUGS/FOODS TO AVOID: Do not take any other medications in addition to BROMOCRIPTINE unless you check with your doctor first. Avoid consuming alcoholic beverages while you are using bromocriptine.
G. STORAGE/ADMINISTRATION GUIDELINES:
1. ORAL CAPSULES AND TABLETS: May be taken with meals or milk to avoid stomach upset. It may take 2 to 3 weeks after you start taking BROMOCRIPTINE before its full effects are seen. Do not stop taking BROMOCRIPTINE without consulting your doctor first. Store at room temperature in a tightly-closed container away from heat, light, and moisture.
H. MISSED DOSE: Take the missed dose if you remember it within 4 hours of your scheduled dosing time. If more than 4 hours have passed, skip the missed dose and return to your regular dosing schedule. Do not take double doses.
Information kindly Provided by Prince Phillip Hospital, Llanelli
