Fibrocystic Breast Condition
Fibrocystic Breast Condition
| DRG Category: | 601 |
| Mean LOS: | 3.6 days |
| Description: | MEDICAL: Nonmalignant Breast Disorders Without CC or Major CC |
Fibrocystic breast condition (sometimes called fibrocystic complex) is the most common type of benign breast disorder. It was previously referred to as fibrocystic breast disease. Fibrocystic breast condition is a catch-all diagnosis used to describe the presence of multiple, often painful, benign breast nodules. These breast nodules vary in size and blend into surrounding breast tissue. However, the histological changes responsible for the breast nodules could belong to one of several different categories.
The College of American Pathologists has categorized the types of fibrocystic breast condition according to the associated increased risk for subsequent invasive breast cancer and the particular histologic (microscopic) change that is present: no increased risk (nonproliferative changes, including microcysts, adenosis, mild hyperplasia, fibroadenoma, fibrosis, duct, apocrine metaplasia, and gross cysts); slightly increased risk (relative risk, 1.5 to 2; proliferative changes without atypia, including moderate hyperplasia and papilloma); moderately increased risk (relative risk, 4 to 5; proliferative changes with atypia or atypical hyperplasia); and significantly increased risk (relative risk, 8 to 10; ductal and lobular carcinoma in situ).
Causes
The monthly variations in the circulating levels of estrogen and progesterone are thought to account for most fibrocystic breast changes. Although the exact contribution of each hormone is not well understood, it is believed that an excess amount of estrogen over progesterone results in edema of the breast tissue. At the onset of menses, hormone levels decrease and the fluid responsible for the breast edema is removed by the lymphatic system. All the fluid in the breast may not be removed; eventually, the fluid accumulates in the small glands and ducts of the breast, allowing cyst formation.
Genetic considerations
Having a family history of cyst formation is common among women with fibrocystic breast disease.
Gender, ethnic/racial, and life span considerations
Fibrocystic changes that cause premenstrual pain, tenderness, and increased tissue density usually begin when a woman reaches her mid 20s to early 30s. Cysts occur most frequently in women in their 30s, 40s, and early 50s. Advanced stages can occur during the mid to late 40s. Symptoms should resolve and cysts should disappear once menopause is complete. However, symptoms may persist in women who are taking hormone replacement therapy for menopausal discomfort. Breast cysts are uncommon in women who are 5 years postmenopause and are not undergoing hormone replacement therapy. Therefore, the possibility of a more serious breast problem in any woman who is more than 5 years postmenopause and who presents with a breast mass should be carefully investigated. Ethnicity and race have no known effects on the risk for fibrocystic breast.
Global health considerations
Limited data are available internationally. Some evidence exists that rates among Japanese women are lower than other groups of women because they consume a diet high in iodine from seafood intake.
Assessment
History
Elicit a reproductive history. Women with a fibrocystic breast condition often have a history of spontaneous abortion, shortened menstrual cycles, early menarche, and late menopause. Patients are frequently nulliparous and have not taken oral contraceptives. Cyclic, premenstrual breast pain and tenderness that last about a week are the most common symptoms. With time, the severity of the breast pain increases, and onset occurs 2 to 3 weeks before menstruation. In advanced cases, the breast pain can be constant rather than cyclic.
Fibrocystic breast changes usually occur bilaterally and in the upper outer quadrant of the breast. A woman may appear with gross nodularity or with one or more defined lumps in the breast. The abnormality may be described as a hardness or a thickening in the breast. The areas are usually tender and change in size relative to the menstrual cycle (becoming more pronounced before menstruation and decreasing or disappearing by day 4 or 5 of the cycle). Approximately 50% of patients have repeated episodes of breast cysts.
Physical examination
The most common symptoms include premenstrual breast pain and tenderness. The breasts should be inspected in three positions: with the patient’s arms at her side, raised over her head, and on her hips. Instruct the patient to “press in” with her hands on the hips to contract the chest muscles. Compare her breasts for symmetry of color, shape, size, surface characteristics, and direction of nipple. Women with deep or superficial cysts or masses may have some distention of breast tissue in the affected area, but often, no changes are noted on examination. Dimpling, retraction, scaling, and erosion of breast tissue indicate more serious breast conditions, and none of these disfigurations are usually found in fibrocystic breast condition.
Palpate the breasts in both the sitting and the supine positions. Use the pads of the three middle fingers to palpate all breast tissue, including the tail of Spence, in a systematic fashion. Breast cysts are filled with fluid and feel smooth, mobile, firm, and regular in shape. Superficial cysts are often resilient, whereas deep cysts often feel like a hard lump. Cystic lesions vary from 1 to 4 cm in size, can appear quickly, are often bilateral, and occur in mirror-image locations.
To conclude palpation of the breasts, gently squeeze the nipple. About one-third of women with advanced fibrocystic change experience nipple discharge. Nipple discharge in benign conditions is characteristically straw-yellowish, greenish, or bluish in color. A bloody nipple discharge often signals the presence of ductal ectasia or intraductal papillomatosis and should be further evaluated.
Psychosocial
Finding a lump or irregularity in the breast is distressing. The almost “overnight” appearance of cysts can make a woman doubt the validity of a recent negative physical examination or mammogram. In addition, the pain associated with advanced fibrocystic changes can be debilitating. Assess the patient’s prior experience with breast problems and her use of coping strategies.
Diagnostic highlights
General Comments: Diagnostic testing is needed to rule out malignancy as well as to confirm the diagnosis. Some 80% of breast lumps are found to be benign.
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Fine-needle aspiration (FNA) | Not applicable | Green, brown, or yellow fluid obtained | Confirms diagnosis; bloody fluid is suspicious and should be sent to pathology |
| Mammogram | No tumor noted | Well-rounded mass with a discrete border noted (cyst); vague asymmetrical radiodensity (white) | Confirms diagnosis |
| Ultrasound | No abnormalities seen | Will show a fluid-filled mass, which is consistent with a cyst (not a solid mass, which is consistent with a malignant lump) | Confirms diagnosis |
| Biopsy | Benign | Benign | Performed if a lump remains after an FNA, to diagnose cancer |
Primary nursing diagnosis
Diagnosis
Pain (acute, chronic) that is related to edema, nerve irritation, and a pinching sensation in the breastOutcomes
Comfort level; Pain control; Pain: Disruptive effectsInterventions
Analgesic administration; Pain managementPlanning and implementation
Collaborative
The physician will attempt an FNA of a breast mass that appears to be cystic. Once the fluid is removed, the cyst collapses and the pain is relieved. Medical therapies may be used in an effort to decrease breast nodularity and relieve breast pain and tenderness.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Low-estrogen, high-progesterone oral contraceptives | Estrogen and progesterone dosages vary; 1 tab q day | Estrogen-progesterone combination | Successful in 60%–70% of young women; relieves pain during the first cycle and improves the condition in 6 mo |
| Danazol (Danocrine) | 50–200 mg PO bid or tid, until desired response, then wean | Synthetic androgen (gonadotropin inhibitor) | Effective with 70%–90% of women with repeat episodes |
| Tamoxifen (Nolvadex) | 10 mg PO q day | Antiestrogen | Prescribed for perimenopausal women |
Controversial Therapy: The efficacy of vitamins E and A in reducing the symptoms of fibrocystic changes has been reported with conflicting results. Likewise, the benefit achieved by decreasing or eliminating the intake of methylxanthine (caffeine) has met with controversy. Injection of omega-3 fatty acids are now being investigated as an anti-inflammatory and antiproliferative compound to reduce nonproliferative breast disease. Iodine intake has also been implicated as a protective mechanism to promote breast health.
Independent
Women who are undergoing evaluation for a breast lump need support and understanding, especially if it is the patient’s first experience with the condition. Encourage the patient to express her feelings. Explain the purpose and procedure of diagnostic studies and surgical techniques (FNA, excisional biopsy). Encourage patients to request information as to the exact nature of a benign breast lump (such as whether it was nonproliferative or proliferative), and explain the actual risk for malignant breast disease that is associated with the various histological changes.
Advise the patient to wear a brassiere that offers good support. Assess the amount of caffeine and salt present in the diet. Help the patient identify foods that are high in these substances and adopt measures to reduce their dietary intake. Other suggested dietary patterns that may decrease fibrocystic breast are supplementing diet with vitamin B6 and primrose, eating organic foods, and avoiding unnecessary chemicals. Some organic topical substances such as soothing oils and poultices may lead to pain relief.
Evidence-Based Practice and Health Policy
Gumus, I.I., Koktener, A., Dogan, D., & Turhan, N.O. (2009). Polycystic ovary syndrome and fibrocystic breast disease: Is there any association? Archives of Gynecology and Obstetrics, 280(2), 249–253.
- Women with hormonal dysfunction, such as those with polycystic ovarian syndrome (PCOS), may be at greater risk for developing other hormone-related conditions, including fibrocystic breast condition.
- A case-control study that compared 53 women diagnosed with PCOS to 40 women without PCOS revealed significant differences in the proportion of women with fibrocystic changes in one or more breasts. Eight percent of the women without PCOS had fibrocystic breast disease compared to 39.6% of women diagnosed with PCOS.
- Women with PCOS were 3.17 times more likely to be diagnosed with fibrocystic breast disease than women without PCOS (95% CI, 1.31 to 7.68; p = 0.004).
Documentation guidelines
- Description of breast lump or any breast abnormality: Location, size, texture; color and amount of any nipple discharge
- Characteristics, location, intensity, duration of breast pain