Saturday, 19 July 2014

Fibrocystic breast changes

Fibrocystic breast changes (FBC) are not at all uncommon. Many women find that their breast tissue is "lumpy" or "ropey" all or just some of the time. When performing a breast exam it can be alarming to discover lumps and bumps. But we need not worry. Fibrocystic changes of the breast are actually a pretty normal occurrence and in the medical community this is no longer referred to as a pathology ("fibrocystic breast disease") because it is truly a variation of normal (Mayo). Over 50% of women will experience fibrocystic breast changes at some point in their life (Canadian Cancer Society). 

That said it's important to know how to tell the difference between fibrocystic breast changes and other causes of breast lumps. The vast majority of lumps found in breasts are benign - not cancerous. But of course breast cancer is what we all want to exclude when we discover something new in the breast zone.

So first of all - what are fibrocystic breast changes? Fibrocystic breasts are ones where the tissue is more fibrous (thus the ropey feeling) or cystic (the lumps). This is either because more of that tissue is present in the breast or because there is less body fat so existing fibrocystic tissue is more revealed and easier to feel when doing an examination.

The number one most important step to breast health is to assess your own body so you can know when something new has popped up. I know I know…in the past some organizations have suggested that research does not support women doing breast self-examination because it doesn't change breast cancer outcomes and can expose them to unnecessary tests (CMAJ, SOGC, BC Health Link, CBC). You know what I have to say to that? Nothing polite.

There are evidence-based guidelines and then there are the practical realities of our lives. I'm a big fan of research and ensuring that medical practice is supported by evidence. That said, I think it's equally important for patients to know their bodies and to be experts in their own health and wellness and I'm in good company with reputable organizations continuing to recommend self-examination (Johns Hopkins Breast Centre). In fact I think it is our right to perform self-examination. It's my body….I will examine it if I  want to thank you very much. Enough said.

So when you are performing the rebellious act of breast self-examination what are you looking for? FBC produces breast lumps and thick ropey areas that are not well defined. The lumps and bumps seem to blend into surrounding tissue and are "mobile", meaning they can be moved and are not anchored into deeper tissue. These lumps can fluctuate in size and can be quite tender. The changes can be in one or both breasts and can be a single lump or multiple changes. Changes are most commonly found in the upper outer quadrants of the breast. Sometimes women will also have nipple discharge (non-bloody) although this is less common. It is very common for the breast lumps to be more noticeable and tender from mid-cycle (ovulation), peaking just before menstrual period, and then reducing after the menstrual cycle has finished (Mayo, Canadian Cancer Society).

FBC typically shows up in women of childbearing age - 20 to 50 years old and is less common in women after menopause unless they are taking hormone replacement therapy (Mayo). Sex hormones (natural or HRT) enhance the fluctuation of fibrocystic size and tenderness. 

People with FBC do not have an increased risk of breast cancer (Canadian Cancer Society, American Cancer Society). Fibrocystic lumps and bumps do not evolve into cancerous tumours and there isn't anything about the condition that correlates with a higher breast cancer rate (Mayo). The only challenge for women with FBC is to recognize the difference between long-standing fibrocystic changes versus a new lump that could be breast cancer. 

At our clinic I tell our patients that if they ever have any concerns about breast lumps they can come in and be assessed. It is always better to have these things checked and nobody minds performing an exam in the clinic and ordering tests if they are needed. 

No treatment is required for FBC. If there are very large cysts and these are causing long-term discomfort they can be drained. But cysts can return after drainage and sometimes the aspiration procedure can be uncomfortable. It is vastly preferable to manage any symptoms with lifestyle changes.

Some things that may be helpful if you have uncomfortable FBC:
  • Reduce or avoid caffeine: this isn't always popular but it is often effective. I frequently see women with a flare-up of FBC symptoms during times in their lives where caffeine consumption has gone up and water consumption has bottomed out (university exams, busy work schedules, travelling). Reduce caffeine gradually to avoid rebound headaches. (Canadian Cancer Society, Mayo).
  • Wear a supportive bra: some women find fitted bras or sports bras provide more support and comfort and may use a sports bra for sleep wear. Your old favourite worn out bra that you can now see through when held up to the light? Chuck it. (Canadian Cancer Society, Mayo).
  • Change your hormone therapy: if you are on oral contraceptive pills your provider can change the brand and/or dosage and this will often help. Some women benefit from going on the pill to level out hormone fluctuations. Others benefit from switching to a non-hormonal method of birth control. If you are on hormone replacement therapy after menopause? Give your head a shake - there is ongoing research demonstrating the increased risk of both heart disease and breast cancer in women who take HRT for more than 5 years after menopause. Talk to your provider about other options. (Mayo)
  • Heating pads: some people find comfort in applying gentle heat when FBC is tender. (Amer Ca Soc) 
  • NSAIDs: ibuprofen (Advil, Motrin and similar) can provide a lot of relief and if breasts are tender only a couple of days each month this may be a great option. (Canadian Cancer Society, Amer Ca Soc).
  • Evening primrose oil: some women find that this reduces FBC tenderness. You may need to try it for 2 or 3 months before you can tell if it is going to work for you. It is believed that evening primrose oil binds to the same receptors as linoleic acid. Linoleic acid makes breast tissue less sensitive to hormonal fluctuations. But if that's true…why not just ensure you are getting enough linoleic acid in your diet????? See below.  (Amer Ca Soc, Mayo) 
  • Linoleic acid: Otherwise known as Omega 6. We tend to get a lot of this in our North American diet and are more concerned about close relative Omega 3. But Omega 6 is in fact an essential fatty acid and if you aren't consuming foods that have it you might be deficient. Don't go hog wild - Omega 6 and Omega 3 should be consumed in balance. You can get linoleic acid in foods that you should be eating anyway including walnut oil, hemp, poppy seeds, pistachios, almonds, chicken (in the fat) and egg yolks (Wikipedia). 
  • Flax Seed: Rich in Omega 3, limited study has shown that consuming 25 g per day (just under 2 tablespoons) may reduce breast pain from FBC (Canadian Cancer Society). As above, we should be eating flax and other omega 3 rich foods anyway so it's worth adding to your nutrition plan. Use ground flax seed for best absorption.
There are some sources that suggest reducing saturated fat will improve FBC symptoms (Mayo, Canadian Cancer Society) but I'm hesitant to recommend this simply because the research coming out now about saturated fat is truly changing everything. We need it for our brains and bodies. Excluding it from our intake has been part of a truly damaging North American diet in the past 60 years. It's probably a better idea to discuss saturated fat intake with your chosen health care provider (NP, MD, Registered Dietitian, Naturopath, RN etc) and decide what makes the best sense for you.  

I don't see a lot of recommendations for vitamin supplements for FBC. In the past B6 and vitamin E supplementation have been helpful for patients.  Ideally we get the best B6 from food sources and again, we should be eating those anyway. So that would include tuna, salmon, red meat, soya, pistachios, potatoes (with skin), bananas and chick peas (Registered Dietitians of Canada). Vitamin E can be obtained from almonds, sunflower seeds, peanut butter (yay!), hazelnuts, fish, and most of the leafy greens (Registered Dietitians of Canada 2).  Vitamin A may also be helpful (Livestrong). Like many of the strategies listed above consuming a diet rich in vitamins, minerals and micronutrients can do no harm and is a great idea for a lot of reasons. Remember that nutrients obtained from food are generally more bioavailable (better uptake) than tablet supplements.

Thanks for reading Getting Healthy With NP Sam. Comments and questions welcome - please click the pencil icon below. 

Fibrocystic breasts (Mayo Clinic)
Fibrocystic breast changes (Canadian Cancer Society)
Fibrosis and simple cysts (American Cancer Society)
Fibrocystic breast tissue (Johns Hopkins Breast Centre)
Linoleic Acid - info & sources (Wikipedia)
Food sources of vitamin B6 (Dietitians of Canada)
Food sources of vitamin E (Registered Dietitians of Canada 2)
Food sources of vitamin A (Registered Dietitians of Canada 3)
The Best Vitamins to take for Fibrocystic Breast (Livestrong)
Breast Self Examination (BC Health Link)
Breast cancer screening guidelines say skip exams (CBC)
New breast cancer screening guidelines (CMAJ)
Breast self-examination guideline (SOGC)

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