Women's Health Update: Fibrocystic Breast Disease... Or Is It?

Women's Health Update: Fibrocystic Breast Disease...Or Is It?

The term "fibrocystic breast disease" (FBD) is still widely used even though it does not represent either a distinct clinical or pathological entity. This term, along with synonyms such as "chronic cystic mastiffs" and "mammary dysplasia" is used to describe a benign condition characterized by cyclically fluctuating palpable irregularity of the breast tissue accompanied by swelling, pain, tenderness that fluctuates with the menstrual cycle. The controversy exists as to whether or not the condition constitutes a disease process because the defining characteristics are present in 50% of all women clinically and 90% histologically.( 1) Many think that these palpable lumps probably represent physiologic changes rather than a pathologic process.( 2) Pathologically, the changes included under the heading of fibrocystic disease include macroscopic and microscopic cysts, stromal fibrosis, apocrine metaplasia, and a variety of proliferative lesions. Since these changes are ubiquitous in f emale breasts, it may be misleading to diagnose this condition as a disease.

The significance of "fibrocystic disease" has been attributed to its possible relation to an increased incidence of developing breast cancer. However, several studies have clearly demonstrated that the relative risk is only related to which of the histologic subgroups are present.

The classification system for benign breast lesions of Dupont and Page separates the various components of fibrocystic disease into three groups, with different relative risks for the subsequent development of breast cancer: nonproliferative lesions, proliferative lesions without atypia, and atypical hyperplasias.( 3) In their study, the only patients in the nonproliferative category with an increased risk of developing breast cancer were those with gross cysts plus a family history of beast cancer. In the patients with proliferative lesions without atypia the risk was only slightly higher when they had a positive family history.( 4) Atypical hyperplasias are proliferative lesions that possess some of the features of carcinoma in situ. Atypical hyperplasias are categorized as either ductal or lobular. In the study of Dupont and Page, patients with atypical hyperplasia had a significantly increased risk of developing breast cancer. Among the patients with atypical hyperplasia who a lso had a family history of breast cancer, the risk was even greater, approaching that of patients with carcinoma in situ.( 5)

The cause of FBD remains unknown although most researchers agree that ovarian hormones are implicated. They do not agree, however, as to whether or not FBD is an indication of abnormal hormone production or an exaggerated response to normal hormone levels by hypersensitive tissues.

Many investigators and clinicians and patients, also attribute a causative role to methylxanthines (a closely related group of alkaloids that includes caffeine). The methylxanthines act as competitive inhibitors of the enzyme that breaks down cyclic adenosine monophosphate (cAMP), therefore an increase in methylxanthines causes an increase in cAMP.( 6) Women with FBD have been found to have statistically significant higher levels of cAMP in their breast tissue.

FBD is most common in women of about 40 years of age and more common in nulliparous women. FBD occurs more frequently in women with early menarche, late menopause, and irregular or anovulatory cycles. Women with FBD also are more likely to suffer from PMS.( 7) FBD tends to be a progressive condition if not attended to. Symptoms tend to increase and continue for longer time periods as women age, up until the menopause.

When giving a breast exam, check each breast for a rise or irregularity without a symmetric counterpart. Palpation reveals an area that is firmer than surrounding tissue, slightly irregular, tender, and generally mobile. A similar area palpated in the same quadrant in the other breast is generally a comforting finding. Any single, unilateral dominant nodule is considered a critical finding and must be appropriately worked up. Any dominant solid mass that persists through a menstrual cycle mandates further evaluation regardless of mammographic findings.

Conventional management is most often achieved by hormone manipulation via pharmacological intervention. Oral contraceptives have been found to relieve FBD symptoms in 90% of women within three to six months of treatment, with 80% experiencing less tenderness after only one month of therapy.( 8) Progestins have been used to correct the estrogen/progestin ratio of luteal insufficiency that is thought to be implicated in FBD. Administering 10 mg of medroxyprogesterone acetate on days 15 through 25 relieves symptoms in 80-85% of the patients with FBD. Continued use for three to four months generally brings marked improvement, although symptoms are not relieved permanently and weight gain and depression are fairly common.( 9) Danazol and Bromocriptine therapy have also yielded 80-90% improvement but the side effects of these drugs make them generally unacceptable solutions.

The natural medicine approach to fibrocystic breast disease might first be to rename it "fibrocystic changes" as well as to offer both preventive measures and drugless therapeutics. Most practitioners of alternative medicine as well as our patients, have observed a relationship between caffeine and FBD. Researchers in some studies have found symptomatic improvement in subjects who reduced cafffeine, while other studies have found no changes and one study showed that symptoms worsened. The use of vitamin E has probably been the most studied supplement for FBD. Vitamin E appears to regulate the synthesis of specific proteins and enzymes required in tissue differentiation. Doses of 600 IU daily were found subjectively and objectively beneficial in some studies.( 7) Improving dietary habits to decrease estrogen sources in the diet, increasing fiber and following a low fat diet regime would be the hallmarks of a therapeutic diet for FBD. Additional therapeutic plans often include eve ning primrose oil, beta carotene, iodine, methionine, B-complex, choline, and/or flaxseed oil depending on the individual case and the response to simple dietary changes, the avoidance of caffeine and supplementing vitamin E.

Botanical diuretics are successfully used to decrease premenstrual fluid engorgement of the breasts. My favorite choice here is Taraxacum leaf. Botanical formulations are also successfully used to restore proper hormonal balance. Botanicals such as Foeniculum, Angelica, Macrotys, and Arctium are observed to have estrogenic effects while Glycyrrhiza, Dioscorea, and Smilax are observed to have progesterone effects. In my personal experience, I have not had a patient who was unresponsive to natural therapeutics for FBD. In the most difficult patients, I have added iodine supplementation to the basic plan of low fat diet plus avoidance of caffeine and vitamin E supplementation.

References
(1.) Love, SM, RS Grelman, and W Silen. 1982. Fibrocystic disease of the breast: A nondisease? N Engl J Med. 307 (16): 1010-14.

(2.) Paulshock BZ: Tutankhamun and his brothers. Familial gynecomastia in the 18th Dynasty. JAMA 244:160-164,1980.

(3.) Harris J, Hellman S, Henderson C, Kinne D. 1991. Benign Breast Disorders. Breast Diseases. (2): 15-20.

(4.) Williams MJ: Gynecomastia: Its incidence, recognition and host characterization in 447 autopsy cases. Am J Med 334:103, 1963.

(5.) August GP, Chandra R, Hung W: Prepubertal male gynecomastia. J. Pediatr. 80: 259, 1972.

(6.) Hindi-Alexander, M, M Zielezny, N Montes, et al. 1985, Theophyline and fibrocystic breast disease. J Allergy Clin Immunol. 75(6):709-15.

(7.) Wang, D, and I Fentiman. 1985. Epidemiology and endocrinology of benign breast disease. Breast Cancer Research and Treatment. 6:5-36.

(8.) Vorherr, H. 1986. Fibrocystic breast disease: Pathophysiology, pathomorphology, clinical picture, and management. Am J Obstet Gynecol. 154(1): 161-79.

(9.) Drukker, B, and W de Mendonca. 1987. Fibrocystic change and fibrocystic disease of the breast. Obstet Gynecol Clin North Am. 14 (3): 685-702.

Article copyright Townsend Letter for Doctors & Patients.

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By Tori Hudson

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