Fibrocystic breast disease is a disease manifested by proliferative and regressive changes in breast tissues. Develops due to hormonal imbalance. Risk factors include gynecological diseases, pathologies of the central endocrine organs, metabolic disorders. Disease is manifested by soreness, compaction and swelling of the mammary glands. Ultrasound and mammography, gynecological examination, and an expanded hormonal profile are performed for diagnosis. Treatment is carried out conservatively (hormone therapy, painkillers and sedatives) or surgically (sectoral resection of the gland).
N60 Benign breast dysplasia
Fibrocystic breast disease (fibrocystic mastopathy, FBD) is the most common disease of the mammary glands, which occurs in 30-60% of women of reproductive age. Among patients with gynecological diseases, the prevalence of pathology increases to 80%. Disease is of great importance in practical mammology, because it not only causes a number of unpleasant subjective symptoms, but also acts as a prerequisite for the development of breast cancer – the most common type of oncopathology in women.
Fibrocystic breast disease has a dishormonal origin. The basis for its development is an imbalance of sex hormones: an excess of estrogens, which stimulate the proliferation of gland tissues, and a deficiency of progesterone, which counteracts these processes. An important role is played by an increase in the level of prolactin, which causes breast swelling and soreness. The following factors contribute to the development of fibrocystic disease:
- Gynecological diseases. Diffuse proliferative processes in the mammary glands are detected in 90% of patients with uterine fibroids. When a benign tumor of the myometrium is combined with adenomyosis, the risk of nodular forms of mastopathy increases. The probability of FBD also increases with chronic adnexitis, since it is accompanied by a violation of the synthesis of estrogens and progesterone.
- Pathology of the hypothalamic-pituitary system. These organs are responsible for the central neurohumoral regulation of the reproductive system, therefore, with their dysfunction, the ratio of estrogens, progestogens and androgens changes. The defeat of the pituitary gland and hypothalamus is caused by tumors, traumatic brain injury, hemorrhages.
- Menstrual cycle disorders. Fibrocystic breast disease is observed in at least 35% of women with irregular menstruation and anovulatory cycles. The pathology of the mammary glands is caused by a constantly high level of estrogens, which contributes to tissue hyperplasia.
- Other diseases. Mastopathy occurs much more often in women with hypothyroidism, diabetes mellitus and obesity, compared with the general indicator in the population. The probability of LV hyperplasia increases with liver diseases, since the destruction of estrogens occurs in this organ.
- Psychoemotional factors. Stress disrupts the work of the central department of neuroendocrine regulation, as a result of which the balance of sex hormones in the female body changes. Chronic traumatic situations are more dangerous, since the development of glandular hyperplasia occurs gradually and requires a long period of time.
Another important risk factor for fibrocystic breast disease is a burdened obstetric and gynecological history. The disease is much more common in women with early onset of menarche and late menopause, as this prolongs the period of cyclic hormonal changes, against which hyperplasia occurs. A significant negative contribution is made by medical abortions, the absence of pregnancies and breastfeeding. The formation of FBD is possible with uncontrolled use of hormonal contraceptives without consulting a gynecologist.
The pathophysiological features of the disease have not been definitively studied. The leading role in proliferative processes is assigned to estradiol, which contributes to the differentiation of the epithelium of the ducts, increases the number of fibroblasts and collagen fibers, increases the vascularization of the connective tissue of the MJ. The hormone is also responsible for the degree of hydration, so its relative or absolute excess provokes severe swelling of the mammary glands.
Morphologically, mastopathy is characterized by dense strands, areas of granularity and multiple foci of compaction. Microscopically, they consist of connective tissue fibers that alternate with epithelial cysts with cloudy contents. In patients aged 20-35 years, the size of fibrocystic foci ranges from 3-4 mm to 2-3 cm, at the age after 35 years, large single cysts are typical.
Fibrocystic breast disease occupies a separate group in the histological classification of benign breast formations according to WHO. However, the issues of systematization of individual clinical and morphological forms of FBD still present difficulties in practical mammology. Today, several types of classifications are used:
- According to morphological changes, 3 forms of the disease are distinguished: fibrous, cystic and fibrocystic.
- According to the prevalence of the pathological process, there is focal (nodular), diffuse and mixed FBD.
- According to the histological type, there is non-proliferative mastopathy (lobular, ductal, cystic), epithelial proliferative, fibroepithelial and myoepithelial.
The clinical picture depends on the form of fibrocystic breast disease, the degree of activity of proliferative processes, the individual characteristics of a woman’s body. It is not uncommon for the disease to have no significant signs, or they are perceived by the patient as a component of premenstrual syndrome. In such cases, the diagnosis of mastopathy occurs during a scheduled visit to a gynecologist and a mammologist.
Symptomatic forms of the disease include 3 main signs: pain syndrome, discharge from the nipples, seals in the mammary glands. Pain is more often diffuse in nature and occurs in both MJ, can be given to the shoulder or armpit area. They increase in the second half of the cycle, disappear or decrease significantly after the end of menstrual bleeding. In menopausal women, the pain is permanent.
The second symptom is discharge from the mammary glands, occurs only when pressing on the nipples. The discharge has a white, yellowish or grayish color, is not accompanied by a specific odor. Occasionally, with fibrocystic breast disease, a thick yellowish liquid similar to pus flows out of the nipples, but a targeted examination does not confirm its inflammatory nature.
The third symptom is a seal in the glandular tissue, which depends on the shape of the FBD. For the diffuse variant of the lesion, large flat-shaped areas are typical, which correspond to hyperplastic lobules of the gland. They are moderately painful when pressed, have an elastic consistency and are easily displaced. Nodular mastopathy is characterized by local rounded formations that are not soldered to the skin or muscles of the chest wall.
The main problem of dishormonal diseases in women is a high risk of malignancy. The probability of developing breast cancer correlates with the degree of proliferation: with non-proliferative forms of mastopathy, it is 0.84%, with moderate activity it increases to 2.34%, with pronounced proliferative processes it increases to 31.4%. Nodular formations in women of the late reproductive and premenopausal period are recognized as the most dangerous.
Women with complaints of pain and swelling of the mammary glands need to consult a mammologist. The examination begins with collecting anamnesis of the disease and life, finding out the provoking factors of mastopathy, external examination and palpation of the mammary glands. If a dyshormonal breast disease is suspected, a comprehensive diagnostic program is prescribed, which consists of the following methods:
- Breast ultrasound. Echosonography is the most informative way to visualize fibrocystic changes in dense glandular breast tissue characteristic of young women. With the help of ultrasound, it is possible to determine even small cysts with a diameter of 2-3 mm, to assess the prevalence of proliferative processes, to study the condition of regional lymph nodes.
- Mammography. X–ray imaging is another classic method of diagnosing fibrocystic breast disease, which shows the best effectiveness in patients after 35-40 years. The study determines focal and diffuse changes in glandular tissue, informative for non-palpable neoplasms with a diameter of less than 1 cm.
- Breast MRI. Magnetic resonance imaging is prescribed in addition to ultrasound and mammography in order to study in more detail the condition of glandular tissue and neighboring anatomical structures. The technique is recommended in complex diagnostic cases when there is a suspicion of precancerous or malignant neoplasms.
- Breast biopsy. Invasive examination is indicated for nodular fibrocystic breast disease to exclude malignant processes. To obtain a tissue sample, technologies of fine-needle or thick-needle biopsy under ultrasound control are used. Further biopsies are subject to cytological and histological diagnostics.
- Gynecological examination. Taking into account the connection of dishormonal diseases of the genitals and mammary glands, patients need to consult a gynecologist. The reception includes an examination on a chair with a bimanual examination, an extended colposcopy, taking material for liquid oncocytology (PAP test). Additionally, ultrasound of the pelvic organs is performed.
- Laboratory tests. It is mandatory to perform a blood test for the concentration of ovarian hormones (estrogens, progesterone) and pituitary gland (follicle-stimulating, luteinizing, prolactin). Additionally, tests are carried out for testosterone, thyroid and adrenal hormones. According to the indications, a study of the main cancer markers is being done.
When making a diagnosis, it is necessary to exclude other variants of benign breast neoplasms. Differential diagnosis of nodular mastopathy is performed with intra-flow papilloma, fibroadenoma, leaf-shaped tumor. Diffuse mastopathy should be distinguished from mastodynia, which is not accompanied by structural changes in the gland. With severe pain and the presence of a bulky formation with uneven contours, it is necessary to differentiate FBD with breast cancer.
The selection of treatment for FBD is one of the most difficult tasks in modern mammology, since there is no single point of view and a universal clinical protocol. When prescribing therapy, the nature of structural changes in the mammary glands, the age and reproductive plans of the woman, the presence of concomitant gynecological and endocrine diseases are taken into account. The only case when it is possible to do without treatment is asymptomatic FBD without proliferative activity.
With diffuse mastopathy and pronounced clinical signs of the disease, symptomatic conservative therapy is recommended. Treatment begins with the appointment of a diet for the correction of metabolic and nutritional disorders, the correct selection of underwear, the elimination of modifiable risk factors. Pharmacotherapy of fibrocystic breast disease includes the following groups of drugs:
- Hormones. Antiestrogens, progestogens, gonadotropin-releasing hormone analogues are used to normalize the hormonal background and eliminate the pathophysiological mechanisms of FBD. To normalize menstrual cycles, combined oral contraceptives are prescribed.
- NSAIDs. Nonsteroidal anti-inflammatory drugs effectively relieve pain in the mammary glands, so they are recommended to be taken with severe mastalgia, especially a few days before the expected onset of menstruation.
- Sedatives. With stress-induced hormonal imbalance, it is necessary to normalize the psychoemotional state of the patient with the help of sedatives, anxiolytics. Sedative phytopreparations are used for mild forms of disorders.
- Vitamin and mineral complexes. Replenishing the deficiency of vitamin C and B vitamins has a positive effect on the metabolism and antioxidant protection of the body, which is important in the treatment of FBD. To reduce the manifestations of mastopathy and maintain the functions of the thyroid gland, iodine preparations are used.
Surgical interventions are advisable in the nodular form of the disease and the presence of large cysts, which are associated with a high risk of oncopathology. The optimal amount of treatment is sectoral breast resection. With its help, the foci of proliferation are removed, and at the same time a significant amount of healthy breast tissue remains in order to avoid a cosmetic defect. The material obtained during the operation is necessarily subject to histological examination.
Prognosis and prevention
Fibrocystic breast disease mainly has a favorable course: with the help of complex therapy, it is possible to control the symptoms and avoid the progression of the disease. A less optimistic prognosis is for women with focal forms of the disease, burdened with a family history and other risk factors. Primary preventive measures include maintaining a healthy lifestyle, preventing unwanted pregnancies and abortions, and regular checkups with a gynecologist.
The most important direction of prevention is breast self–examination, which should be carried out 1 time a month (it is advisable to choose a specific day in the first half of the cycle). The procedure includes a visual examination of the breast with lowered and raised arms, careful feeling of the glands with circular movements, examination of the nipple-areolar complex. Simple manipulations allow you to notice the seals in time and consult a doctor for an extended diagnosis.