Breast Diseases and Conditions
When many women think of breast disease, they think of breast cancer, but there are many other diseases and conditions which women need to be aware. Each breast has 15 to 20 sections, called lobes, each with many smaller lobules. The lobules end in dozens of tiny bulbs that can produce milk. Lobes, lobules and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple which is centered in a dark area of breast skin called the areola. The areola also has oil-producing glands that secrete a lubricant to make breastfeeding easier. The spaces between the lobules and ducts are filled with fat. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.
These normal features can sometimes make the breasts feel lumpy. The National Cancer Institute (NCI) says this is especially true in women who are thin or who have small breasts. A womans’ breasts also change each month with her menstrual cycle. The breasts also change as a woman gets older. Common breast changes fall into several broad categories. These include generalized breast changes, solitary lumps, nipple discharge and infection and/or inflammation.
Breast lumpiness, which is sometimes described as “ropy” or “granular”, can often be felt in the area around the nipple and areola and in the upper-outer part of the breast. Such lumpiness may become more obvious as a woman approaches middle age and the milk-producing glandular tissue of her breasts increasingly gives way to soft, fatty tissue. Unless she is taking replacement hormones, this type of lumpiness generally disappears for good after menopause.
There are times when this condition becomes more noticeable. For example, during the menstrual cycle, many women experience swelling, tenderness and pain before and sometimes during their periods. At the same time, one or more lumps or a feeling of increased lumpiness may develop because of extra fluid collecting in the breast tissue. Pregnancy also can bring changes. During pregnancy, the milk-producing glands become swollen and the breasts may feel lumpier than usual. If you have any questions about how your breasts feel or look, talk to your healthcare provider (HCP).
NCI says that the majority of breast lumps are benign, that means they are not cancerous. Even so, it is important that any woman, who notices a lump or change in her breast, see her HCP. Although benign lumps rarely, if ever, turn into cancer, according to NCI, cancerous lumps can develop near benign lumps and can be hidden on a mammogram. Even if you have had a benign lump removed in the past, you cannot be sure any new lump is also benign.
Breast cancer is a malignant or potentially life-threatening tumor.
Cysts are fluid-filled sacs. The National Institute of Health (NIH) say they occur most often in women ages 35 to 50, and they often enlarge and become tender and painful just before the menstrual period. They are usually found in both breasts. Some cysts are so small they cannot be felt; rarely, cysts may be several inches across. Cysts often show up clearly on an ultrasound.
Although a cyst is not cancer, it’s important for a woman who notices any lump or change to see her HCP. According to NIH, when a cyst is suspected, some doctors proceed directly with aspiration, a procedure that uses a very thin needle and a syringe. Sometimes the cyst will disappear after that. If the lump turns out to be solid, it may be possible to use the needle to biopsy or withdraw a clump of cells which can then be sent to a laboratory for further testing.
Fat necrosis is the name given to painless, round and firm lumps formed by damaged and disintegrating fatty tissues. According to the NIH, this condition typically occurs in obese women with very large breasts. It often develops in response to trauma, such as a bruise or blow to the breast, even though the woman may not remember the specific injury. Sometimes the skin around the lumps looks red or bruised. Again, it is important that any women who notices a lump or change in her breast, sees her HCP.
Fibroadenomas are solid and round benign tumors that are made up of both structural (fibro-) and glandular (-adenoma) tissues. Usually, these lumps are painless and found by the woman herself. They feel rubbery and can easily be moved around. Fibroadenomas are the most common type of tumors in women in their late teens and early twenties, and NIH says they occur twice as often in African American women as in other American women.
Fibroadenomas have a typically benign appearance on mammography (smooth, round masses with a clearly defined edge), and they can sometimes be diagnosed with fine needle aspiration. Although fibroadenomas do not become malignant, they can enlarge with pregnancy and breastfeeding. Again, it is essential that a woman who notices a lump or other change, sees her HCP.
Galactorrhea occurs when a woman’s breast makes milk even though she is not breastfeeding a baby. The American Academy of Family Physicians (AAFP) says this may occur when the breasts are touched, or it may start spontaneously. Men can have galactorrhea too, but it is much less common. Causes can include hormonal imbalance, medications such as hormones, antidepressants or blood pressure medicines, use of herbs, pregnancy, pituitary tumor and a number of other causes. The condition can go away on its own. Again, it is essential that a woman who notices changes or discharge, sees her HCP.
Recent studies show that certain very specific types of microscopic changes put a woman at higher risk of developing breast cancer according to the NCI. These changes feature excessive cell growth or hyperplasia. NCI says hyperplasia can increase the risk of developing breast cancer. Approximately 5 percent of benign breast biopsies reveal both excessive cell growth, i.e. hyperplasia, plus cells that are abnormal (atypical). The location of these abnormal cells can be in the lobules (atypical lobular hyperplasia) or the milk ducts (atypical ductal hyperplasia). A diagnosis of atypical hyperplasia moderately increases breast cancer risk. If a biopsy finds hyperplasia, surgery can remove the abnormal cells and also determine if in situ or invasive cancer is also present. Since atypical hyperplasia increases your risk of developing breast cancer, it is essential that you continue to monitor your breasts with regular mammograms and clinical breast exams. Depending on your other risk factors and family history, your doctor may also want to use magnetic resonance imaging for screening. Your doctor may also suggest preventive medications to inhibit the effect of estrogen on your breast tissue.
One of the most common sources of a bloody or sticky discharge is an intraductal papilloma, a small, wart-like growth that projects into breast ducts near the nipple. Any slight bump or bruise in the area of the nipple can cause the papilloma to bleed. Single (solitary) intraductal papillomas usually affect women nearing menopause.
If the discharge becomes bothersome, according to NIH, the diseased duct can be removed surgically without damaging the appearance of the breast. Multiple intraductal papillomas, in contrast, are more common in younger women. They often occur in both breasts and are more likely to be associated with a lump than with nipple discharge. Multiple intraductal papillomas, or any papillomas associated with a lump, need to be removed. Again, it is important that any woman who notices a lump or change in her breast, sees her HCP.
Mammary duct ectasia
Mammary duct ectasia is a disease of women nearing menopause. Ducts beneath the nipple become inflamed and can become blocked. Mammary duct ectasia can become painful, and it can produce a thick and sticky discharge that is gray to green in color. A woman who notices pain or discharge should see her doctor. Treatment consists of warm compresses, antibiotics and, if necessary, surgery to remove the duct.
Mastitis (sometimes called “postpartum mastitis”) is an infection most often seen in women who are breast-feeding. A duct may become blocked allowing milk to pool which causes inflammation and may set the stage for infection by bacteria. Bacteria can also enter via cracked nipples. The breast appears red and feels warm, tender and lumpy.
In its earlier stages, mastitis can be cured by antibiotics. If a pus-containing abscess forms, it will need to be drained or surgically removed. It is important that a woman who notices pain or changes sees her doctor immediately.
Nipple discharge accompanies some breast conditions. Since the breast is a gland, secretions from the nipple of a mature woman are not necessarily a sign of disease. For example, NIH says that small amounts of discharge of a milky fluid called galactorrhea (see above) commonly occur in women taking hormonal or other medications, including sedatives and tranquilizers. Nipple discharge can also be a warning sign of benign disease or of breast cancer. The American Cancer Society (ACS) says most nipple discharges or secretions are not cancer. Even so, it’s important that a woman who notices discharge or unusual changes consult her doctor.
Nipple discharges come in a variety of colors and textures. A milky discharge can be traced to many causes, including thyroid malfunction or certain medications. A bloody discharge needs to be evaluated immediately. Women with generalized breast lumpiness may also experience nipple discharge.
NIH says doctors can take a sample of the discharge and send it to a laboratory to be analyzed. Benign discharges are treated chiefly by keeping the nipple clean. A discharge caused by infection may require antibiotics.
Sclerosing adenosis is a benign condition involving the excessive growth of tissues in the breast’s lobules. It frequently causes breast pain. Usually the changes are microscopic, but adenosis can produce lumps, and it can show up on a mammogram, often as calcifications. Short of biopsy, adenosis can be difficult to distinguish from cancer. NIH says surgical biopsy, which furnishes both diagnosis and treatment, is a common option. Again, it is important that any woman, who feels pain or notices a lump or change in her breast, sees her HCP.
J. Courtney Clyde, MD, FACS
Paul H. Lin, MD, FACS
Michael R. Moore, MD, FACS