Primer on the Management of Benign Breast Diseases
Table 3: Recommended Management of Selected High-risk Breast Lesions Lesion
Surveillance Recommendations Atypical ductal or lobular hyperplasia Lobular carcinoma in situ
Mammography—annually starting at time of diagnosis Clinical breast exam every 6–12 months
Self breast awareness, consider teaching self breast exam Mammography—annually starting at time of diagnosis Clinical breast exam every 6–12 months
Self breast awareness, consider teaching self breast exam Consider annual breast magnetic resonance imaging (MRI)
literature. A low-fat diet (<15 % of calories from fat) has been demonstrated to decrease breast pain, but compliance with this over the long run is problematic. Restriction of methylxanthines/caffeine in the diet is frequently advocated, but has not been conclusively demonstrated to impact mastalgia or the histologic changes of fibrocystic breast disease in studies. Decreased salt intake and/or diuretic use have not shown benefit.
OCP users generally report less breast pain than non-users and therefore stopping the OCP is not advocated as treatment for mastalgia. If the onset of mastalgia correlates with initiation of OCPs or a change in formulation, then altering or stopping the medication may be useful. Persistent or new-onset mastalgia may be a side effect of hormone therapy in postmenopausal women, and this may be a reason to discontinue the medication if alternatives exist.
Prescription medications are reserved for the most severe or refractory cases of mastalgia. In general, if a prescription medication is chosen then it should be used for three–six months, then tapered and discontinued. Reliable, non-hormonal contraception is advised for women using these prescription medications. Danazol (100 mg twice daily) has been demonstrated to reduce breast pain in 60–90 % of subjects, but its use is limited by the side effect profile, which includes androgenic symptoms of acne, hair thinning, weight gain, voice changes, nausea, anxiety, depression, and menstrual irregularity. Tamoxifen, a selective estrogen receptor modulator, has demonstrated reduction in breast pain in 80–90 % of subjects at a dose of 10 mg/day, though up to 30 % of women may relapse after discontinuation.33 Bromocriptine (2.5 mg twice daily) has demonstrated efficacy in 50–65 % of women with mastalgia, but use is also limited by the side effect profile including dizziness, rhinitis, and headaches.34
Extra-mammary pain due to costochondritis (Tietze’s syndrome) is characterized by tenderness to palpation of the chest wall at the costochondral junction. Superficial thrombophlebitis of the lateral thoracic vein (Mondor’s disease), an unusual disease, presents as pain with a palpable cord or linear skin dimpling that may extend onto the
1. Cancer Research UK. Breast Cancer – UK incidence statistics. 2011. Available at:
http://info.cancerresearchuk.org/ cancerstats/types/breast/incidence/ (accessed 18 August 2011).
2. Tyczynski J, Bray F, Parkin DM, Breast Cancer in Europe. European Network of Cancer Registries Cancer Fact Sheets, 2002;2:1–4.
3. National Comprehensive Cancer Network, NCCN Clinical Practice Guidelines in Oncology for Breast Cancer Screening. 2011. Available at:
www.nccn.org (accessed 18 August 2011).
4. American College of Obstetricians and Gynecologists, ACOG Committee on Practice Bulletins – Gynecology, ACOG Committee of Genetics, Oncologists SoG. ACOG Practice Bulletin
Risk Reduction Recommendation Discuss risks/benefits of tamoxifen or raloxifene x 5 years
Discuss risks/benefits of tamoxifen or raloxifene x 5 years
Mastectomy generally not recommended
abdomen. Because breast cancer was identified in 13 % of cases of Mondor’s disease in a small case series, breast imaging is appropriate.35 Both costochondritis and Mondor’s disease can be successfully treated with usual NSAID dosing and reduction in activity that aggravates the pain until it is resolved. Extra-mammary pain can also be due to cardiac or lung disease or other musculoskeletal origin, such as degenerative disc disease. Care should be taken to exclude these entities in appropriate patients. When pain is accompanied by inflammatory changes in the breast and systemic symptoms, mastitis is the most likely cause. Mastitis is treated as routine for soft tissue infections; specific considerations are outside of the scope of this article. Inflammatory changes in the breast that do not respond to appropriate antibiotic therapy should raise concerns for abscess, other unusual causes of mastitis, granulomatous disease or, very importantly, inflammatory breast cancer. If a short course of antibiotic therapy does not lead to complete resolution, referral to a breast specialist for evaluation of this presentation is appropriate.
Follow-up of Atypical Hyperplasias and Lobular Carcinoma In Situ
Because these histologic finding are associated with an increased future risk of breast cancer, both increased surveillance and risk reduction conversations are appropriate. Current management recommendations are listed in Table 3 (see also sections on ADH, ALH and LCIS).
Conclusion
Most obstetricians/gynecologists will manage patients with breast problems regularly in their practice. Ordering and interpreting screening mammography, identifying high-risk women who would benefit from intensive surveillance, breast cancer risk reduction methods, and referral for genetic testing are increasingly being managed by obstetricians/gynecologists. A working knowledge of all of these management scenarios as well as identification and long-term management of high-risk lesions by obstetricians/gynecologists will serve all women well. n
No. 103: Hereditary breast and ovarian cancer syndrome, Obstetrics and Gynecology, 2009;113(4):957–66.
5. Kelsey JL, Gammon MD, John EM, Reproductive factors and breast cancer, Epidemiologic Reviews, 1993;15(1):36–47.
6. Anderson G, Limacher M, Assaf A, et al., Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial, JAMA, 2004;291(14):1701–12.
7. Rossouw J, Anderson G, Prentice R, et al., Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial, JAMA, 2002;288(3):321–33.
8. Colditz GA, Willett WC, Hunter DJ, et al., Family history, age, and risk of breast cancer. Prospective data from the Nurses’ Health Study, JAMA, 1993;270(3):338–43.
9. Gail M, Brinton L, Byar D, et al., Projecting individualized probabilities of developing breast cancer for white females, J Natl Cancer Inst, 1989;81(24):1879–86.
10. National Comprehensive Cancer Network, Genetic/Familial High- Risk Assessment: Breast and Ovarian, NCCN Practical Guidelines in Oncology, 2011.
11. Dupont WD, Page DL, Risk factors for breast cancer in women with proliferative breast disease, N Engl J Med, 1985;312(3):146–51.
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