Common Breast Problems
Breast Cysts
Breast cysts are probably the commonest cause for developing a discreet lump in the breast. Nearly every woman will have cysts in the breast at some time during her life. They are usually very small and most women are not aware of cysts until they have an ultrasound scan. Breast cysts primarily develop as the result of hormonal changes in the breast and are uncommon after the menopause except in women who take hormone replacement treatment (HRT). The most common age to develop breast cysts is between 30-50 years becoming more common the closer one gets to the menopause.
A breast cyst consists of a very thin lining of cells which originally derive from a small breast duct. The cyst is full of fluid which contains oestrogen. Cysts can develop very quickly over just a matter of days and this can sometimes lead to a lump that appears to have arisen almost overnight. Initially breast cysts are often quite sore or tender. Most breast cysts eventually disappear by themselves though this may take many months or even years. The size of the cyst can vary from just a small pinhead to something more like a golf ball.
Breast cysts are best diagnosed by an ultrasound scan. It is very unusual indeed to develop any serious consequences from breast cysts. They are nearly always entirely harmless and this is very effectively demonstrated by the scan. It is only in very rare cases that breast cysts develop pre-cancerous changes, and when one considers that nearly every woman will have breast cysts at some time in her life you should not consider breast cysts as having any significant malignant potential. Most surgeons will advise that breast cysts are left alone. If the cyst is large and uncomfortable a needle can be inserted in the cyst and the fluid contents withdrawn. The cyst will then disappear and it is uncommon for it to refill. If the cyst does refill we would advise that you come back to the clinic for a repeat ultrasound scan.
Breast pain (mastalgia)
Breast pain is sometimes an annoying and quite troublesome symptom, but is hardly ever a sign of underlying breast cancer. In fact most women naturally have some degree of breast pain particularly for a few days prior to each menstrual period. The breast tissue is very sensitive to your hormones and it is therefore normal to have changes including pain and tenderness on occasions. Most breast cancer specialists in fact consider breast pain as a good sign because it is a normal physiological phenomenon and is not a sign of breast cancer.
Hormonal breast pain is generally felt as a soreness or an aching particularly along the side of the breast and up into the armpit. The breast is often tender to touch and it can be painful to embrace a friend or child, or to run. Often it is more comfortable to wear a supportive bra but is particularly painful in the evening when you take your bra off.
Breast pain can sometimes become more of a problem, occurring for a much longer time prior to your menstrual cycle or even occurring continuously. Sometimes this is a transient phenomenon but in some women breast pain is more of a persisting problem. In these cases it can become quite disruptive and can impact on your lifestyle. Some women find that severe breast pain and tenderness wakes them at night when they turn over, or prevents them from exercising. Once the pain gets to this level it is usually worth taking measures to reduce the discomfort. There are some simple remedies for this type of breast pain that are very often effective. Occasionally these simple measures do not work and more direct measures such as medication are sometimes needed. Hormonal breast pain is rarely affected by normal types of pain killer, but with the correct advice and treatment nearly all women with breast pain can achieve significant improvements in their discomfort and often complete relief is possible.
In addition to hormonal causes for breast pain a small number of women have breast pain caused by inflammation in the milk ducts of the breast. This is termed periductal mastitis. It occurs much more commonly in women who smoke though it can occur in non-smokers as well. The pain of peri-ductal mastitis is often briefer and sharper, sometimes described as a stabbing pain, and is frequently described as being centred on, or radiating through, the nipple. The cause of this inflammation is not infective and antibiotics do not need to lead to any improvement in the symptoms. In general the treatment is more difficult and may even require surgery.
Fibroadenoma
A fibroadenoma is the most common cause for a lump in young women, often occurring between the ages of 15-30. In contrast to a cyst, a fibroadenoma is a solid lump comprising, as the name suggests, swirls of fibrous tissue with occasional compressed breast ducts. Fibroadenomas are usually painless, and once again they probably arise due to hormonal changes in the breast. As a consequence, the lump may arise in an area of the breast were there is already more generalised hormonal breast pain and tenderness giving the false impression that the lump is causing the pain. Fibroadenomas tend to grow to around 1-2cm in diameter and then stop growing. Most women will first become aware of a fibroadenoma when it is already around this size and it is therefore most common for fibroadenomas to seem to stay approximately the same size and not to noticeably get any larger. Since they are solid lumps fibroadenomas generally do not disappear, although during pregnancy they may undergo noticeable changes resulting in either their disappearance or their progressive enlargement.
Fibroadenomas are entirely harmless and never turn into breast cancer. All fibroadenomas should however be carefully checked to prove their identity conclusively. Some fibroadenomas can feel very similar to small breast cancerous lumps, and although this is uncommon it is the reason why careful investigations, usually including an ultrasound and needle biopsy are very important. Once a lump has been shown to be definitely a fibroadenoma it is safe to leave. Alternatively a fibroadenoma can be removed by a small operation. A new treatment for fibroadenomas involves removal of the lump through a suction needle leaving only a small scar. Fibroadenomas that increase in size or that appear in any way abnormal on the ultrasound scan or needle test should be removed for safety sake.
Nipple Discharge
Nipple discharge is a common breast symptom which is only infrequently a sign of breast cancer. A small amount of nipple discharge can be entirely normal particularly for up to a year (or even more) after stopping breast feeding. Many women can produce a small amount of nipple discharge if they squeeze their nipples firmly (not advised). This is due to a small amount of fluid that is produced naturally within the milk ducts.
More copious nipple discharge, or the sudden onset of nipple discharge where this had not occurred before, should be investigated. The commonest causes are inflammation of the milk ducts in the breast or a small harmless warty growth (often only just the size of a pinhead and termed a papilloma), within one of the milk ducts. If the discharge is due to inflammation of the milk ducts it often occurs on both sides and may vary in colour from clear through to white, brown or even green. In these cases the discharge will frequently be visible as 2 or 3 drops of fluid on the tip of the nipple when the breast is squeezed. This should be contrasted to discharge caused by a duct papilloma which usually causes clear discharge coming from only one breast and from only one small duct opening on the tip of the nipple. Both of these causes of nipple discharge can lead to blood staining though this symptom can also be associated with breast cancer and it is particularly important that this is checked out quickly if you are aware of any blood within the discharge. It has to be emphasised that in the majority of cases, even with blood staining, that breast cancer is not the cause of the discharge.
Nipple discharge is usually investigated with a mammogram, an ultrasound and by analysis of a small drop of fluid under a microscope. Sometimes it is necessary to carry out a small operation to remove one or more of the breast ducts for analysis in order to be absolutely certain of the cause of the discharge. A very new development in this field is breast duct micro-endoscopy. In this procedure a small camera is passed down through the natural opening in the nipple and the inside of the milk ducts are visualised. This can sometimes establish diagnosis without resort to surgery. The Harley Street Breast Clinic is one of the only centres in the UK that are experienced in breast duct micro-endoscopy.
Nipple Inversion
Nipple Inversion may be present from birth or more frequently from the time of breast development. In this case it is a developmental problem caused by insufficient growth in length of the major milk ducts underneath the nipple. The short ducts pull the nipple inwards causing inversion. Sometimes the muscle within the nipple can temporarily bring the nipple out again (this particularly occurs in cold weather). Often however nipple inversion develops in a previously normal nipple. This is most often the result of chronic inflammation underneath the nipple (periductal mastitis), which eventually causes scarring of the ducts. The scarred milk ducts shorten and gradually pull the nipple inwards. Breast cancer can also pull on the breast ducts and cause nipple inversion, it is therefore very important to have a breast check if you noticed that your nipple has recently come inverted.
Breast infections
Breast infections frequently occur during breast feeding and may lead to a breast abscess. The problem is caused by bacteria infecting the milk that is within the breast. Prompt treatment with antibiotics at the outset often resolves the problem before it becomes very painful or before an abscess develops. The first signs of infection are pain within the breast, thickening and hardening of the tissue, and redness of the skin. You may also develop a temperature. Sometimes the infection develops further and a pocket of pus results. This is a breast abscess and needs to be treated not only with antibiotics but also by drainage of the pus. This is sometimes possible through a needle under ultrasound control but on occasions a small operation is the most effective and quick way of settling things down.
In women who are not pregnant or breast feeding breast infections can occur around the nipple, and this is particularly the case in women who smoke. In these cases infections arise due to a more long term irritation and blockage of the large breast ducts underneath the nipple. This results in a painful lump appearing either under, or just next to, the nipple. There is often redness of the skin or sometimes a discharge of pus from the tip of the nipple. Again this type of infection can be treated effectively with antibiotics if it is caught early. If the infection develops further and a small abscess develops, antibiotics on their own are less likely to work and a small operation to drain the pus is necessary. This type of breast infection can reoccur over and over again and may become a long term problem with the development of a constantly discharging opening at the edge of the nipple. This is termed a mammary fistula and will never heal by itself without surgery.