Breast adenosis is a form of fibrocystic mastopathy, accompanied by an overgrowth of the glandular tissue of the breast. It is manifested by pain and swelling of the breast, the formation of dense areas in it, the appearance of discharge from the nipple. Diagnosis of adenosis is based on the collection of complaints and anamnesis, breast examination and palpation data, additional research methods (ultrasound and radiography of the mammary glands, determination of hormone levels, cytological examination of the nipple discharge and biopsy). Treatment of the disease depends on its form and includes conservative therapy (hormone administration) or surgery.
ICD 10
N60.2 Breast Fibroadenosis
General information
Adenosis refers to benign mammary gland formations of a hormone-dependent nature, which is confirmed by the appearance of symptoms in the second phase of the cycle. Synonyms of adenosis are “fibrosing adenosis”, “myoepithelial hyperplasia” or “lobular sclerosis”.
Adenosis affects women of reproductive age – the prevalence of the disease in the age group of 30-40 years is 30-70%. In women with gynecological diseases, the frequency of adenosis increases to 100%. This condition can develop in girls during the establishment of menstruation and in women in the first trimester of pregnancy, which is considered physiological, since all manifestations of adenosis disappear on their own after some time, after the stabilization of the hormonal background.
Causes of breast adenosis
The main and only cause of pathology is a hormonal imbalance – a lack of progesterone and an excess of estrogens. The etiological factors that cause hormonal failure include:
- Obesity. Adipose tissue synthesizes estrogens. If you are overweight, the production of estrogens increases, which leads to relative hyperestrogenism (progesterone levels remain normal).
- Spontaneous and artificial abortions. Termination of pregnancy, especially at long periods (15-22 weeks), provokes a sharp hormonal restructuring and disruption of compensatory mechanisms. The level of sex hormones does not immediately return to normal, which gives impetus to the development of endocrine problems, in particular, adenosis.
- Late pregnancy. In women over 35 years of age, ovarian functions fade. The onset of pregnancy activates the work of the ovaries, which causes a postpartum failure in the synthesis of estrogens and progesterone and hormonal breakdown.
- Postpartum agalactia. Agalactia indicates a lack of progesterone, which is responsible for the development and differentiation of mammary parenchyma cells, and an excess of estrogens. With hyperestrogenism, the stroma of the glands grows, the lack of progesterone leads to uncontrolled growth of the glandular epithelium.
- Refusal to breastfeed. An increase in the concentration of prolactin against the background of the absence of breastfeeding causes stagnation of milk in the ducts. Their blockage and expansion occurs, which leads to structural changes – the formation of cysts.
- Uncontrolled intake of COCs. Taking hormonal pills without taking into account individual characteristics and compliance with the scheme causes hormonal imbalance and the development of dysplastic processes in the breast.
Breast adenosis occurs more often in patients with gynecological pathology (endometrial hyperplasia, ovarian tumors, uterine fibroids, endometriosis), which also develop against the background of hyperestrogenism. Triggers triggering hormonal disorders can be somatic diseases (hypertension, pancreatic and liver diseases), chronic stress, sexual disorders, disturbed ecology, smoking.
Pathogenesis
Cyclic changes occur in the mammary glands, which are regulated by hormones: hypothalamus-releasing factors, FSH and LH, estrogens, prolactin, chorionic gonadotropin, androgens, glucocorticoids, progesterone, thyroid and pancreatic hormones. Adenosis is accompanied by absolute and relative hyperestrogenism, which is combined with progesterone deficiency. Estrogens ensure the proliferation of the milky passages due to excessive cell proliferation and stroma hyperplasia by activating fibroblasts. Progesterone functions include reducing the number of estrogen receptors on cell membranes and reducing the effect of estrogens on target organs (breast, uterus).
With a lack of progesterone, differentiation of the glandular epithelium and collagen formed in a significant number of cells decreases, blocking of proliferative processes is inhibited. As a result, cell division becomes uncontrolled, the process of inhibition of proliferation in the tissues of the glands is disrupted. This leads to structural and morphological rearrangements: proliferation and edema of intra-lobular connective tissue, activation of the proliferation of glandular epithelium in the milk ducts, which causes their blockage, expansion and formation of cysts.
Classification
In mammology, a unified classification of breast adenosis is used. The systematization of formations is carried out according to the area of lesion of the gland tissues and the histological structure of adenosis. According to the prevalence of pathological education , there are 2 forms:
- Focal (local). A mobile large formation of a spherical or disc-shaped shape is formed in the gland. The node has a fibrous capsule and consists of lobules.
- Diffuse. There are several areas of seals in the mammary gland, the shape and boundaries of which are blurred. Education grows indefinitely and is located unevenly.
According to the type of overgrown epithelial cells of the parenchyma gland, there are:
- Sclerosing adenosis. It is accompanied by the proliferation of acinuses (areas of lobules of glands) with the preservation of the integrity of their epithelial and myoepithelial layers. Despite the compression of the acinuses by fibrous tissue, their configuration is preserved.
- Apocrine adenosis. It is characterized by apocrine epithelial metaplasia (transition of cuboidal epithelial cells into cylindrical ones with the appearance of apocrine secretion). According to the histological structure, apocrine adenosis is similar to infiltrating cancer, but its nature is benign.
- Ductal adenosis. It is distinguished by expanded milk ducts, which are limited to epithelial cells with cylindrical metaplasia. Similar to sclerosing adenosis.
- Microglandular adenosis. It is accompanied by diffuse and disorderly proliferation of small ducts. Sclerosis and compression of the gland tissues are absent.
- Adenomyoepithelial adenosis. This form is very rare and is combined with the formation of breast adenoepithelioma. It is a focal adenosis.
Symptoms of breast adenosis
The symptoms of adenosis are similar to the clinical picture of mastopathy. Depending on the form of the disease, the severity of certain signs differs. Common symptoms of adenosis include mastodynia (soreness, swelling of the glands, their hypersensitivity), pain that increases on the eve of menstruation, the appearance of discharge from the nipples, breast soreness during palpation.
Local form
With a local form of pathology, a dense, mobile seal with a lobular structure is felt in the gland, not soldered to the surrounding tissues and having clear boundaries. Pain during palpation, discharge of mucus/milk from the nipple, skin deformation and enlargement of axillary lymph nodes are not observed.
Diffuse form
The diffuse form of the disease is characterized by diffuse tenderness of the gland (pain covers the entire gland), the breast swells before menstruation, a yellowish or colorless discharge appears from the nipple. Diffuse adenosis is characterized by the formation of several nodules of different sizes in the gland, which do not have clear boundaries and a certain shape. Nearby nodular formations merge, which creates the illusion of a tumor of considerable size. Breast palpation is painful, regional lymph nodes are not enlarged.
Complications
Late diagnosis and therapy of adenosis increase the risk of complications (inflammatory diseases of the breast, deformity of the gland, formation of cysts in breast tissues and papillomas in the milk ducts). According to the latest scientific data, the connection of the disease with breast cancer has been proven, the probability of which increases with adenosis by 5 times. The frequency of malignancy of the neoplasm depends on the degree of proliferation of epithelial cells. Non-proliferative forms are malignized in 0.86%, in the case of moderate proliferation, breast cancer develops in 2.5%, adenosis with a severe degree of cell proliferation is transformed into a malignant tumor in 32% of cases.
Diagnostics of breast adenosis
For the diagnosis of adenosis, a consultation with a mammologist is necessary. The doctor collects anamnesis and complaints, clarifies the presence of concomitant somatic and gynecological diseases, performs physical examination and palpation of the breast. If necessary, a gynecologist, oncologist and endocrinologist are involved in the examination of a woman. If adenosis is suspected, instrumental and laboratory diagnostic methods are prescribed:
- Mammography. Allows you to determine the localization of the process, its prevalence and boundaries. The X-ray shows multiple shadows with blurred borders and irregular shapes, corresponding to areas of overgrown lobules.
- Ultrasound. It helps to establish the location of the affected area of the gland, its boundaries, consistency and size. Ultrasound reveals an increased density of glands in young women, cysts of small size (up to 3 mm) formed when the ducts are blocked, the condition of regional lymph nodes is assessed.
- Hormonal studies. The content of sex hormones, prolactin, FSH, LH is determined. According to the indications, the concentration of thyroid and adrenal hormones is examined.
- Histological, cytological examination. A cytogram of the discharge from the gland, a puncture biopsy of a suspicious breast area is performed. The presence/absence of atypical cells is determined in the smear, the degree of proliferation of the formation cells is assessed in the biopsy material.
Clinical blood and urine tests, blood biochemistry (sugar, liver enzymes, etc.) are also prescribed in order to detect somatic pathology. Differential diagnosis of adenosis is carried out with other dysplastic processes of the breast (adenoma, fibroadenoma, cyst) and breast cancer.
Treatment of breast adenosis
The tactics of treatment of adenosis (conservative therapy or surgery) is determined by its form and the nature of the course of the disease.
With a diffuse form of pathology, conservative treatment is prescribed, which includes taking sedatives, vitamins (A, E, ascorbic acid, P, group B), minerals and hormonal drugs. With a mild form of the disease, monophasic combined oral contraceptives are used for a course of 6 months. With severe symptoms of adenosis, the use of progestogens for at least 3 months is indicated.
Patients are recommended to revise their diet: limit animal fats, carbohydrates, increase consumption of fresh vegetables and fruits. With a sedentary lifestyle, it is necessary to increase physical activity and normalize weight, avoid stressful situations if possible.
In the case of a focal form of adenosis, a sectoral resection of the gland is performed – excision of the formation within healthy tissues with an urgent histological examination of the node. For cosmetic purposes, the breast incision is performed around the areola of the nipple, after the wound heals, an inconspicuous scar remains.
Prognosis and prevention
With early diagnosis and timely initiation of treatment, the prognosis for life and disease is favorable. Prevention of adenosis includes prevention of abortions, competent selection of hormonal contraceptives, treatment of gynecological and endocrine diseases, preservation of the first pregnancy and lactation for at least 6 months, rejection of bad habits and maintaining a healthy lifestyle. You should also regularly conduct breast self-examination, visit a gynecologist every six months, adhere to proper nutrition, plan your first pregnancy before the age of 30.
