by Tori Hudson, N.D.
Tender or lumpy breasts are one of the most common reasons why women consult their women's health practitioner for assessment and treatment.
Since painful breasts are not always lumpy, and lumpy breasts are not always painful (and neither is usually abnormal), it is useful to create descriptive categories of symptoms and conditions to replace the generic term "fibrocystic."Physiological, Cyclical Pain and SwellingMany women notice painful or sensitive breasts just prior to menstruation.
This has been attributed to a more prominent estrogen than progesterone effect on breast tissue at this time. Occasionally, less progesterone is made late in the cycle, as in irregular ovulation.
Other women may have average amounts of progesterone but increased tissue sensitivity to estrogen with related fluid retention. Most women tolerate this well enough once reassured it is normal, and the symptoms always resolve with menses.
Women who take exogenous estrogen, such as oral contraceptives or estrogen replacement therapy during menopause, may be similarly affected.
Mastalgia Mastalgia refers to any breast pain, unilateral or bilateral, severe enough to interfere with the quality of a woman's life, causing her to seek treatment. Physiologic cyclical mastalgia is this severe about 15 percent of the time, and comprises the bulk of this group.
Women who suffer from noncyclical pain are more rare, and the pain is less likely to be hormonal in cause. Pain may be due to old trauma, acute infection, or sometimes inflammation of the intercostal cartilage, i.e. costochondritis.
In contrast,
breast cancer presents as a unilateral painful firm lump about 5 percent of the time. The majority of the time, breast cancer does not present as breast pain, and especially tends not to present as cyclic present pain. Painful swellings that flux with the cycle unchanging over time are not worrisome as cancer signals.
Breast Nodularity or Diffuse LumpinessBreast lumpiness may be either cyclic or non-cyclic, and may be painful. The distinction between these and normal breasts is often simply a matter of degree. Normal breasts are always irregularly textured because the breast tissue is not homogeneous. It is a mix of glands, fat, and connective tissue.
Glands can vary in prominence, and are more or less obscured by fat or fluid, so all breasts feel different on physical exam. Symmetry is important; finding a mirror-image thickening in the opposite breast indicates a normal condition.
Non-Dominant Masses
Densities that are not symmetrical are largely due to benign non-progressive causes, but do require careful distinction from dominant masses.
When palpation of the lump reveals that the density merges in one or more places with the surrounding breast tissue, it is considered "non-dominant" and may be comfortably observed for change over time. When these lesions are biopsied or, preferably, a sample of cells is taken in the office through a needle to be looked at microscopically (fine-needle aspirate), approximately 70 percent will show "non-proliferative changes" (adenosis, fibrosis, microcysts, mild hyperplasia, and more); 20 percent will show "proliferative changes without atypia" -- mostly epithelial hyperplasia. None of these conditions places one at increased risk for cancer, and all are self-limiting.
Only a fraction, roughly the 5 percent that show atypical hyperplasia, carry a significantly increased risk of breast cancer, especially when coupled with a positive family history.
Dominant Masses
Non-cyclical unilateral lesions are clearly distinct on all sides from the surrounding breast tissue.
They persist over time, and except in the very young, demand some kind of assessment. Although rare, breast cancer can occur in women in their twenties. Assessments in younger women are more difficult due to the dense breast tissue therefore rendering mammograms less accurate. And, since most of these unilateral lesions are benign, mammograms and biopsies deserve a more restrained approach, although continued monitoring and revisiting clinical decisions are very important.
Most commonly dominant masses are either fibroadenomas or gross cysts. A fibroadenoma is a rubbery, smooth, benign, fibrous tumor common in younger women. In women under age 25, it can be observed over time. They generally do not grow bigger. Large cysts are more common in women aged 25 to 50 -- an age group when cancer just begins to appear.
They are softer, squishier, and can be made to disappear by draining them through a needle in the office. Unless they recur frequently, no further treatment is necessary. Recurrent large cysts have been shown to slightly increase cancer risk in some studies but not in others; fibroadenomas do not. Unfortunately, non-cyclical unilateral dominant masses can sometimes be cancerous.
Overview of Alternative Treatments for Cyclic Breast Pain and Swelling
Alternative medicine principles for fibrocystic breast tissue or cyclical pain and swelling include the recognition that the liver is the primary site for estrogen clearance or estrogen metabolism. A compromised liver function can lead to a state of estrogen dominance, contributing to texture and density changes in the breast.
To assure that estrogens are being metabolized properly, it may be necessary to provide nutritional and herbal support for the liver.Digestion and elimination are also fundamental factors involved in a more holistic approach to hormone-related health problems.
Women having fewer than three bowel movements per week have a risk of fibrocystic breasts four to five times greater than women having at least one bowel movement per day. The longer it takes food to move through the colon, the more waste products can be reabsorbed into the bloodstream, creating a potentially toxic physiological environment.
Bacterial flora in the large intestine, such as Lactobacillus
acidophilus, improves the transit time of bowel toxins, as well as improving the excretion and detoxification of estrogens.
NutritionRemoval of caffeine from the diet is probably the most well-known alternative lifestyle approach for fibrocystic breasts. The first randomized study of a large number of women was conducted by Dr. Virginia Ernster.
One hundred fifty-eight women eliminated all caffeine (coffee, tea, cola, chocolate, and caffeinated medications) from their diets for four months.1 There was a significant reduction in clinically palpable breast findings in the abstaining group compared with the control group, although the absolute change in the breast lumps was quite minor and considered to be of little clinical significance. Several other studies provided mixed reports: three studies show no association between methylxanthines and benign breast disease,2,3,4 and two studies show a correlation with caffeine consumption.5,6
Caffeine content of common items
Beverage
Serving Size
Caffeine (mg)
Coffee, drip
5 oz
110-150
Coffee, perk
5 oz
60-125
Coffee, instant
5 oz
40-105
Doffee, decaffeinated
5 oz
2-5
Tea, 5 minutes steep
5 oz
40-100
Tea, 3 minutes steep
5 oz
20-50
Hot cocoa
5 oz
2-10
Coca-Cola
12 oz
45
Food
Serving Size
Caffeine (mg)
Milk chocolate
1 oz
1-15
Bittersweet chocolate
1 oz
5-35
Chocolate cake
1 slice
20-30
OTC Drugs
Dose
Caffeine (mg)
Anacin, Emprin
2
64
Excedrin
2
130
NoDoz
2
200
Aqua-Ban
2
200
Dexatrim
1
200
How dietary fat affects the human breast is confusing and controversial. Reducing the fat content of the diet to 15 percent of total calories, while increasing complex carbohydrate consumption, has been shown to reduce the severity as well as the actual breast swelling and nodularity in some women.
Reducing the dietary fat intake to 20 percent of total calories also results in significant decreases in circulating estradiol. Since fibrocystic breasts are a result of estrogen dominance, it is logical that decreasing estrogens in the body would improve the symptoms of breast pain and swelling.
However, only a slight reduction in fat intake has repeatedly shown very little, if any, effect on breast problems, including breast cancer. A more rigorous approach to lowering the amount of fat in the diet is clearly needed. Of note, women on a vegetarian diet excrete two to three times more detoxified estrogens than women on an omnivorous diet.Nutritional SupplementsVitamin EFor more than 35 years, clinicians have used vitamin E in the medical management of benign breast disease.
This practice was initially based on positive reports from small numbers of patients as far back as 1965, and in subsequent studies in 1971, 1978, and 1982. When larger numbers of women were studied, vitamin E did not show significant effects. However, two studies demonstrated that vitamin E is clinically useful in relieving pain and tenderness, whether cyclical or non-cyclical.7,8 The studies have been done with varying dosages: 150, 300, or 600 IU daily.
In clinical practice, practitioners generally recommend from 400-800 IU of D-alpha-tocopherol with a minimum trial period of two months.Evening Primrose OilThe pain and tenderness of benign breast disease associated with "cyclic mastalgia" have been alleviated with evening primrose oil, the only one of the fatty acids to be scientifically studied in relation to fibrocystic breasts. In a study of 291 women who took three grams per day of evening primrose oil for three to six months, almost half of the 92 women with cyclic breast pain experienced improvement, compared with one-fifth of the patients who received the placebo.
For those women who experienced breast pain throughout the month, 27 percent responded positively to the evening primrose oil, compared to 9 percent on the placebo.9 Another study of 73 women received three grams per day of evening primrose oil or placebo.
After three months, pain and tenderness were significantly reduced in both cyclical and non-cyclical groups, while the women who took placebo did not significantly improve. IodineThyroid hormone with low or even normal thyroid function may result in improvement of fibrocystic breasts.
These results suggest that iodine deficiency may be a factor in fibrocystic breasts. Breast tissue has an affinity for both thyroid hormone and iodine. Without iodine, it becomes more sensitive to estrogenic stimulation, which in turn produces microcysts high in potassium content. The potassium is believed to be an irritant that produces fibrosis and eventually cyst isolation.
Four types of iodine have been studied in the treatment of fibrocystic breasts, only one of which has been truly effective for both pain reduction and cyst reduction, and free of side-effects on the thyroid gland. All forms of iodine relieve subjective clinical symptoms: sodium iodide (Lugol's solution); potassium iodide; caseinated iodine (protein-bound); and aqueous (diatomic) iodine.
Symptom relief varied a great deal with the different iodines, but only the aqueous or diatomic iodine achieved both symptom relief in 74 percent of the women, as well as objective reduction in nodules and resolution of fibrosis in 65 percent of the patients, without adverse effects on the thyroid gland.10 The recommended dose of aqueous iodine is a prescription of 3-6 mg per day.
Other
Supplements that may improve liver function and thereby perhaps promote a more balanced estrogen metabolism include methionine and choline. B vitamins, particularly vitamin B-6, can help the liver to properly metabolize and conjugate estrogens. Probiotics such as Lactobacillus acidophilus may be able to improve the absorption and transport of estrogen by supporting a normalized intestinal microflora environment.
Botanicals
Herbal therapies for addressing the symptoms of breast pain, swelling, and cystic nodules in breast tissue are largely arrived at from traditional uses of herbal medicines and from observational empirical evidence in clinical practice.
Herbal diuretics can be useful in decreasing breast swelling and the discomfort associated with it.
The most effective of these is dandelion leaf, but other diuretics to consider are cleavers, yarrow, and uva ursi. Poke root has been used in traditional naturopathic medical practices for decades. It can be applied topically as an oil to the breasts, reducing painful lumpiness and nodularity.
Herbal support for the liver improves how the liver metabolizes steroid hormones. Traditional herbs that support the liver and the normalization of biochemical steroid pathways may include burdock root, dandelion root, and milk thistle.
Natural Progesterone
Assuming fibrocystic breasts are at least in part due to a high-estrogen, low-progesterone ratio, then it is logical to use progesterone therapy as a treatment. Many practitioners and women have experienced that the application of natural progesterone in a cream or gel routinely solves the problem. It may be that progesterone is desensitizing the breast to estrogen. General use guidelines are tsp twice per day, on days 15 to 27 of the monthly cycle.
Summary
These simple therapies, along with lifestyle modification, generally yield very satisfying results within 1 to 3 months, even in women with significantly painful breasts. Although uncommon, if there is no change after three menstrual cycles, a more aggressive alternative treatment plan must be initiated.
If this does not bring relief, then the conventional medical approaches, to be contemplated in very difficult, unbearable cases with no response from natural therapies, include decreasing hyperinsulinemia, synthetic progestin, Danazol, Tamoxifen and bromocriptene. Many women's medicine healthcare providers agree that the term fibrocystic breast "disease" or "condition" should be abandoned in favor of a more accurate physiologically based description. Benign breast conditions are present in almost all women to some degree.
Moreover, the widespread misconception that women with painful or lumpy breasts are at increased risk of breast cancer is inaccurate. This reinforces misinformation and fear, and obscures the safe and simple means that exist for obtaining relief and reassurance.
References1 Ernster V, Mason L, Goodson W, et al. Effects of caffeine-free diet on benign breast disease: a randomized trial. Surg 1982;912:263-267.2 Lubin F, et al. A case-control study of caffeine and methylxanthine in benign breast disease. JAMA 1985; 253(16)2388-92.3 Shawer C, Brinton L, Hoover R. Methylxanthine and benign breast disease. Am J Epid 1986;124(4): 603-11.4 Marshall J, Graham S, Swanson M. Caffeine consumption and benign breast disease: a case-control comparison. Amer J Pub Health 1982;72(6):610-12.5 La Vecchia C, et al. Benign breast disease and consumption of beverages containing methylxanthines. JNCI 1985;74(5):995-1000.6 Boyle C, et al. Caffeine consumption and fibrocystic breast disease: a case-control epidemiologic study. JNCI 1984;72(5):1015-19.7 London R, et al. Mammary dysplasia: Endocrine parameters and tocopherol therapy. Nutr Res 1982;7:243.8 London R, et al. Endocrine parameters and alpha-tocopherol therapy of patients with mammary dysplasia. Canc Res 1981;41:3811-13.9 Pye J et al. Clinical experience of drug treatment for mastalgia. Lancet 1985;2:373-77.10 Ghent W, et al. Iodine replacement in fibrocystic disease of the breast. Can J Surg 1993. Oct; 35(5):453-60.
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