Breast awareness

Benign breast conditions

Most breast changes aren't cancerous. Even so, it's important to show your doctor any unusual changes.

Changes can occur naturally in the breast during menstrual cycles, pregnancy,breastfeeding and aging.

Many people who see their GP about a breast change will have one of these benign (not cancerous) conditions. It's important that you show any changes to your doctor, so that breast cancer can be ruled out.

Breast pain (Mastalgia)

Cyclical Pain

Most women will have experienced breast pain at some point in their lives. Usually the pain is related to hormonal fluctuations in the menstrual cycle, developing in the second half of the monthly cycle and becoming worse in the days before the period starts. This is known as cyclical breast pain and it usually settles down again in the days following the period.

Cyclical breast pain usually occurs in both breasts, particularly in the upper outer region which is where the greatest concentration of glandular breast tissue is situated. The pain is often dull, heavy or aching and sometimes the breasts may appear swollen and feel “lumpy”.

Often the pain is mild and as long as there are no other concerning symptoms, no treatment is needed. Many women are concerned that the pain may be a symptom of an underlying cancer, so reassurance after a clinical breast examination may be all that is required. Pain alone is generally not a sign of breast cancer.

Wearing a supportive, well-fitted, non-underwired bra during the day, and at night if needed, usually provides some relief. A proper sports bra should be used while exercising. For moderate pain, over the counter medications such as paracetamol or ibuprofen may help. Anti-inflammatory gels rubbed into the skin might provide some relief. If the pain is more severe a pain diary should be kept for 1-2 months to help doctors see if there are patterns to the pain, or triggers which could be avoided before considering the use of prescription drugs.

The oral contraceptive pill, HRT and some antidepressants can make some breast pain worse, so discuss this with your doctor.
Some women have success using Evening Primrose Oil or Starflower Oil over a few months. This may change the balance of fatty acids in the body, although clinical trials haven’t clearly proven this to be beneficial.

Non-cyclical breast pain

The pattern of this pain shows no relation to the menstrual cycle. It may be present constantly or come and go. It can be confined to a localised area, or felt over one or both breasts and is more likely to affect women over the age of 40.

Causes:

  • Pain in the breast tissue can sometimes occur without any obvious cause or underlying abnormality.
  • Referred pain. Sometimes the pain, while felt in the breast, originates elsewhere. Referred pain from the chest wall is quite common and can be due to trauma, muscle strain after repeated upper body activity, chest infection or costochondritis (Tietze’s Syndrome.) Costochondritis is inflammation of the cartilage in the rib cage, usually in the area where the upper ribs attach to the sternum (breastbone). Pain in the breast may also be referred from the neck.
  • Pregnancy. In early pregnancy the breasts often swell and become tender. Breast feeding may also cause pain in some women.
  • Mastitis. This is inflammation of breast tissue, usually due to infection and most commonly associated with lactation.
  • Large, pendulous breasts can cause supportive ligaments to stretch, causing pain.
  • Large breast cysts can cause pain and might need to be drained to provide relief.

Fibrocystic change

This is a very common breast disorder in pre-menopausal women, characterised by firm fibrous tissue and a lumpy texture to the breasts. The lumps are smooth and mobile. Breast tenderness or aching is common and the changes are usually related to the hormonal changes of the menstrual cycle. In some cases there may be a green or brown nipple discharge.

Breast cysts

Breast cysts are the result of fluid accumulation inside the glandular tissues of the breast. Cysts are influenced by hormonal fluctuations and may be singular or multiple, in one or both breasts. They may be too small to feel and only detected on imaging or they may be large enough to be felt as a lump. Large cysts may put pressure on other tissue in the breast and cause discomfort.

Cysts can’t be reliably diagnosed on clinical examination alone. Ultrasound will confirm whether the lump is solid or cystic (fluid-filled) and this should be performed before any cyst is drained.

Small, simple cysts which are not producing any symptoms don’t need any treatment but large or complex cysts are usually drained with a syringe and fine needle. If the cyst totally collapses nothing further needs to be done, but if a portion remains after aspiration, or the fluid is blood-stained, the fluid will be examined under a microscope and further biopsy may be necessary to exclude cancer.

Duct ectasia

As the breasts age, the ducts near the nipple become shorter and wider. This is known as duct ectasia and mostly affects women of peri-menopausal or post-menopausal age. Sometimes secretions can accumulate in these widened ducts and cause irritation. Nipple discharge may be produced and this might be thick or watery, green, black or occasionally bloodstained. A lump may be felt behind the nipple due to thickened, scarred tissue. Occasionally the nipple may start to indraw as the ducts shorten. These symptoms need to be thoroughly investigated to exclude cancer.

Periductal mastitis

This is an inflammatory condition, typically affecting women in their 30s. Its symptoms include redness and pain around the areola with or without an associated lump, and nipple retraction may be present with pain and nipple discharge. Smoking is the most important risk factor.

Treatment usually involves antibiotics, although the condition often recurs because the damaged ducts remain. If abscesses develop they are managed with aspiration or incision and drainage, but in severe cases removal of the ducts is required.

Radial scar (complex sclerosing lesion)

Radial scars are not actually scars – they are areas of hardened breast tissue with surrounding abnormal ducts and tissue structures. Despite being benign these lesions look suspicious on imaging and are often difficult to distinguish from cancer. The majority of radial scars don’t produce a palpable lump so they are usually incidentally picked up on screening mammograms. A referral to a breast surgeon is required for further investigation. A core biopsy will identify a radial scar but full excision of the lesion is often recommended to make sure there are no other atypical features or associated malignancy.

Sclerosing adenosis

This is an overgrowth of tissue in the breast lobules. It might be asymptomatic or may be detected on a mammogram, where it can sometimes be difficult to distinguish from cancer, as it can produce distortion of breast tissue and sometimes calcifications. A biopsy is needed to confirm the diagnosis and exclude cancer. No treatment is needed but it is associated with a slightly increased risk for developing breast cancer.

Hyperplasia

Hyperplasia (abnormal multiplication of cells) is an increase in the epithelial cells which line the breast ducts and lobules. Depending on the cells of origin it will be labelled either ductal or lobular hyperplasia. Sometimes changes are seen on a mammogram but diagnosis can only be made on a biopsy.

Usual-type hyperplasia might be described as mild, moderate or florid, but it doesn’t raise breast cancer risk. No further treatment or follow up is needed after diagnosis.

Atypical hyperplasia has cells with a more abnormal appearance under the microscope. It can occur in the ducts (atypical ductal hyperplasia or ADH) or the lobules (atypical lobular hyperplasia or ALH). Atypical hyperplasia slightly raises the risk of developing breast cancer so a wider excision of the area may be recommended followed by regular mammograms and breast checks.

Fibroadenoma

This is a benign breast lump, made up of mixed glandular and fibrous tissue and is commonly found in young, premenopausal women. Fibroadenomas usually occur singly but some women may have many. They are generally painless, firm and rubbery and move freely when touched.

A core biopsy is needed to confirm the diagnosis. Regular observation with ultrasound and clinical examination is used to check for growth but most don’t require surgical removal. A small percentage will continue to grow but most stay the same size or become smaller over time. Large or growing fibroademas require removal.

Intraductal Papilloma (Papillary Neoplasm)


This is a wart-like growth which develops in a breast duct close to the nipple. There may be a palpable lump or it might only be detected on a mammogram, and in some cases, it produces a clear or blood-stained nipple discharge. Papillomas are most common in women aged 35 -55.

Referral to a breast clinic is needed for a triple test. Single papillomas with no atypical cells don’t increase breast cancer risk but women who have multiple papillomas (papillomatosis) have a slightly higher breast cancer risk and regular surveillance is advised.

Mastitis

Mastitis is an inflammation of the breast, occurring most commonly in women who are breastfeeding.

It can be caused by infection (usually with a bacteria called staphylococcus aureus) via a break in the skin or cracked nipples. Non infective mastitis can be caused by milk stasis – this can occur when a duct becomes blocked due to inadequate emptying, because of infrequent feeding or problems with the baby latching on to the nipple. Milk stasis provides an ideal environment for bacterial growth.

Symptoms of mastitis include a red, hot, swollen and tender area on the breast, flu like symptoms, raised temperature and fatigue.
Treatment with antibiotics is required for an infection. Milk stasis can be relieved with frequent feeding, the use of a breast pump, and feeding from the affected breast first to ensure adequate emptying.

If the breast remains hard, red and painful after treatment mastitis may have developed into an abscess.

Breast Abscess

This is when a painful collection of pus forms in the breast, usually following mastitis. Abscesses need to be drained, which is done with a syringe and needle if the abscess is small, but larger abscesses may require a small incision and drainage. Drainage and irrigation needs to be repeated until the abscess has resolved, but in most cases hospital admission and more extensive surgery can be avoided.

Mastitis or breast abscess in a non-lactating woman requires investigation for an underlying clinical condition or malignancy.

Sebaceous cyst

Sebaceous cysts develop in sebaceous glands which secrete sebum, an oil which coats hair and skin. They are often seen on the face, back and neck but also occur quite commonly in breast skin. The cysts are often surgically removed for cosmetic reasons and because they tend to reoccur and become infected.

Intertrigo

Many women, particularly those who are older with large, pendulous breasts, are troubled by this fungal infection of the skin under the breasts. It is caused by moisture and friction so it’s important to keep the skin clean and dry. Careful use of a hairdryer on low heat to dry the skin after a shower may help, as well as wearing cotton bras which absorb moisture.

Nipple discharge

Up to 20% of women are able to express fluid from their nipples. Benign discharge is usually not spontaneous, but only occurs when the nipples are squeezed. It tends to be from both breasts and come from multiple ducts, and is often creamy, brown or green.

Benign conditions such as intraduct papilloma, duct ectasia and fibrocystic change can also produce a discharge. Any discharge which occurs without squeezing, comes from a single duct in the nipple and is clear or blood stained needs further assessment to exclude breast cancer.

Galactorrhoea is a milky discharge which is not associated with breastfeeding. It is usually caused by an overproduction of Prolactin, the hormone which is responsible for milk production. This can be the result of certain medications (some sedatives, antipsychotics or antidepressants), excessive breast stimulation, or disorders of the pituitary gland.

Nipple/areola eczema

Eczema on the nipple-areola complex usually starts on the areola, and sometimes spreads to involve the nipple. Treatment with topical corticosteroid creams is usually successful but if treatment is not working and the “eczema” on the nipple persists or worsens, a referral to a breast clinic for a biopsy is required, to exclude Paget’s Disease, a rare type of breast cancer.

Nipple inversion

An inverted or retracted nipple may be present from birth (congenital) or acquired over time. The nipple is pulled in because the ducts are shortened and tethered, and it can occur in one or both breasts. The process tends to happen slowly, over a number of years and generally has benign causes.

If necessary, mild cases can be treated with regular use of external suction devices or surgical stretching of the tight bands of tissue. Repair of severe inversion may require surgical division of the ducts but this results in a loss of the ability to breastfeed.

If the inversion occurs rapidly, it requires investigation to exclude an underlying cancer.

Gynaecomastia

This is a benign condition characterised by an overgrowth of glandular tissues in the male breast, sometimes causing discomfort. It is usually the result of a hormone imbalance and is mostly seen in males at infancy, puberty and in mid-to-later life. The condition often goes away without any intervention.

Older men produce less testosterone, and those with excess body fat produce more oestrogen, which causes growth of breast glandular tissue. Teenage boys may have a degree of gynaecomastia during puberty which usually resolves as hormone levels stabilise.

The use of marijuana, heroin, alcohol, anabolic steroids, hormonal drugs and many prescribed medications can also cause gynaecomastia. The condition usually resolves when the use if these agents is stopped.

Medical assessment of gynaecomastia is important in order to establish the cause as it may be due to an underlying medical condition.

Gynaecomastia should not be confused with pseudo-gynaecomastia which is seen in overweight men who have increased fat deposits in their breasts.

Accessory nipples or breast tissue

These are congenital conditions arising from residual breast tissue which persists from embryonic development and can occur in both women and men.

In about 5% of the population an extra nipple develops, usually it is seen on the lower part of the breast but may occur anywhere along the embryonic milk lines. Often they are small and may be mistaken for moles. They are usually surgically removed for cosmetic reasons or because of ulceration or another clinical concern.

Accessory breast tissue is a prominent swelling that contains breast tissue, often in the underarm area, but more than one site may be affected. As the tissue contains all the elements of normal breast tissue it is subject to hormonal influences and may come to attention during puberty, pregnancy or lactation. All diseases of the breast, both benign and cancerous can occur in accessory breast tissue. Surgical excision +/- liposuction of the tissue is warranted for large problematic cases but most cases are so small patients are unaware of their presence.

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Lipoma

These benign fatty tumours can occur anywhere in the body where fat cells are found and are sometimes seen in the breast. They are painless, mobile lumps and usually don’t require treatment unless they are producing symptoms or show signs of growing.

Hamartoma

This is a painless soft lump which results from an overgrowth of fibrous, glandular and fatty tissue within a thin capsule of connective tissue. In some cases it can lead to breast enlargement without a localised lump being felt. It is usually detected on breast imaging but requires a biopsy to confirm the diagnosis. Not to be confused with a haematoma which is a collection of clotted blood within the tissues.

Fat necrosis

This is a benign condition resulting from damage to fat cells, usually from trauma or surgery. The blood supply to the fat cells is disrupted causing cell damage or death. It may be felt as a lump or be seen on a mammogram. No treatment is required.