Dr B. S. Suvarna
B.A, D.I.Hom[Lond.], M.I.H, PhD,PGDPC(Psychotherapy & Counselling, USA)
MAMTHA HOMOEO CLINIC
Jeevan Shanthi, Near AIT Girls Hostel, Bypass Road, Kalyan Nagar, CHIKMAGALUR 577102
Karnataka State, INDIA
Breasts are part of the endocrine system responding to hormonal changes occurring at puberty, menstrual periods and menopause and producing milk following the giving of birth. Having healthy, well-shaped breasts is important for most women and psychological distress is not an uncommon consequence of misshaped, too small or too large breasts, almost every women’s magazine will give tips for developing well-shaped breasts and millions of rupees are spent each year on breasts enlargements or breast reduction.
The breasts are made of glandular tissue supported by fibrous bands and interspersed with fatty cells which swell and are some times visible during pregnancy and periods. The nipple is made of erectile tissues similar to that found on the lips or vagina which responds to sexual stimulation.
A woman’s breasts also change each month, with her menstrual cycle. The breasts also change as a woman gets older. Different sizes of breast are not uncommon and do not necessarily indicate diseases. Common breast changes fall into several broad categories. These include generalized breast changes, solitary lumps, nipple discharge, and infection and/or inflammation.
Thirty-three percent of all women between the ages of 30 and 50, and 50 percent of women of all ages, may at some point, are told by their physician that they have fibrocystic breast disease or other benign breast conditions. Other terms women may hear include benign breast disease, chronic mastitis (inflammation), and mammary dysplasia. There are a number of disorders that can affect the breasts and the most common of them are described below:
Mastalgia or painful breasts is a fairly common occurrence of many women and is the result of the raised oestrogen levels found at times during the menstrual cycle and pregnancy. A high circulating level of oestrogen and sodium will trap more water in the breasts so that they swell and become tender and painful. If this occurs regularly during each monthly cycle the condition is called fibrocystic disease and can lead to “lumpy” breasts, these lumps are benign and do not lead to cancer Benign breast lumps are not uncommon in women and may be single cyst or multiple cysts often associated with fibrocystic diseases .
Mastitis can also result from an infection usually occurring during breast feeding because of a cracked nipple.
Bacterial mastitis: It is most commonly associated with lactational mastitis; most cases are caused by Staphylococcus aureus.
Treatment: Support of the breast, application of local heat. Incision and drainage are performed when abscess is formed.
Fibrocystic breast diseases: Fibrocystic breast disease is the most common benign lesion, generally observed between 20-50 years of age. The exact aetiology is unknown, but hormonal imbalance of estrogen, progesterone or hypersensitiveness of breast tissues to prolactin can be the cause. Stress factor may at times be related.
Histologically, a fibrocystic mass is characterized by adenosis, fibrosis, ductal epithelial proliferation and papillomatosis. Two types are observed: localised and diffuse. The patients are usually premenopausal.
Risk factors are nulliparity and delayed menopause. The patient presents with breast pain throughout the cycle but aggravated premenstrually (cyclic). The pain is either dull continous or intermittent and severe.
About 4% patients with cellular atypia have the risk of having breast cancer.
Examination reveals affection of both the breasts; coarsely nodular areas resembling ill defined lumps either localised or diffused, are felt. These are prominent in premenstrual phase.
Careful palpation, mammography and aspiration biopsy is helpful to exclude malignancy.
Treatment: Assurance and re-examination at intervals.
To wear a well fitting brassier day and night.
Vitamin E 400mg daily may be helpful.
Periductal mastitis (Duct ectasia): In this condition, pain occurs at all times of menstrual cycle and in cold weather. Its site is located in an area below the areola or to the inner quadrant of the breast. Mammography reveals characteristic flame shaped shadow.
Treatment by medicines is effective.
Surgical excision of the affected wedge shaped area and the subareolar duct system can provide relief.
Discharge from the Nipple : A nipple discharge when spontaneous, persistent and unrelated to lactation is considered abnormal. Any significant nipple discharge must be thoroughly evaluated with the following information: Nature of discharge, Unilateral or bilateral, From a single duct or multiple ducts, Association of any mass in the breast, History of any drugs (Oral contraceptives or phenothiazines)
Common causes of nipple discharge:
Except milky discharge, one should exclude malignancy by all means before concluding a benign lesion
|Milky||Physiological (lactation); Oral contraceptives; Galactorrhoea|
|Bloody||Intraductal papiloma; Intraductal cancer; Malignancy; Duct ectasia; Fibrocystic disease.|
|Serous or sticky||Fibrocystic disease|
Discharge from the surface of breast is seen in Paget’s disease; Skin diseases such as eczema and psoriasis; Rare causes such as chancre may also cause discharge.
Galactorrhoea: Secretion of milk-like discharge from one or both breasts unrelated to childbirth is called galactorrhoea. The secretion contains fat globules when examined under microscope and is confirmatory for milk. A high prolactin level is encountered in one-third of cases with idiopathic amenorrhea.
Causes-Hypothyroidism; Pituitary tumor
A change in skin texture (for instance a rough and “dimpled” feel like the surface of an orange) along with discharge may indicate a malignant growth.
Breast Lumps and Mastitis : A tender lumpiness may arise in one or both breasts during early pregnancy or occasionally at the time of a period . This is normally hormone induced and is not serious. If the breast becomes tender and redness develops over the pain full area , either a breast abscess is about to form or acute mastitis is present , simple non-malignant lumps do frequently develop in the breast as do simple cysts , but medical diagnosis is essential when any lump or cyst is discovered in the breast .
Differential diagnosis of Breast lumps
|Clinical||Age 15-30yrs <2cm Well defined Mobile||30-50yrs Any size Well defined||30-90yrs Any size Ill defined Hard Fixity|
|Imaging||Discrete Solid Clear margins No acoustic shadows||Discrete Cystic Acoustic Enhancement||Ill defined Solid Acoustic shadow Microcalcifications|
Fibroadenoma: This is the most common benign tumour of the breast occuring among the younger (20-35 years) women. It is asymptomatic being accidently discovered by self palpation.
On examination, an uniform, firm mobile painless and well defined mass is felt. Commonly they are bilateral and 2-3cm in diameter.
Histologically they have an epithelial and a stromal component. A young patient may be reviewed 6 monthly as the risk of malignancy is less than 0.2%.
Surgical excision is indicated only when the mass enlarges and or report of FNAB is inconclusive.
Cracked nipple: This may occur during lactation and be the forerunner of acute infective mastitis. If the nipple becomes cracked during lactation, it should be rested for 24-48 hrs and the breast emptied with the breast pump. Feeding should be resumed as soon as possible.
Papilloma of the nipple, retention cyst of a gland of Montgomery and Chancre of nipple are surgical diseases and should be excised.
Eczema of the nipple is a rare condition, is bilateral and generally associated with eczema elsewhere on the body.
Paget’s disease of nipple is a superficial manifestation of an underlying breast carcinoma. It presents as a eczema like condition of the nipple and areola. The nipple is eroded slowly and eventually disappears.
Injuries of breast:
Haematoma of the breast gives rise to a lump.
Traumatic fat necrosis may be acute or chronic, and usually occurs in stout, middle-aged women. Following a blow, or indirect violence, a painless lump may occur. This can mimic a carcinoma, even displaying retraction of nipple and tethering of skin. Biopsy is required for diagnosis.
Breast Cancer: Breast cancer affects around one in 12 women in the western world and is associated with certain well known risk factors
- Race : more common in white races .
- Menstrual History : Early on set of periods and late menopause .
- Age : Over 50 years
- Family history : Increased risk if your mother or sister has had cancer
- Marital history : Never having married or been pregnant increases the risk
- Hormonal Drugs : HRT for women over 50 is thought by some authorities to increase breast cancer , the contraceptive pill is thought to protect against breast cancer
- Diet: A high saturated fat diet (high in diary products, red meat and fatty foods) increases the risk.
- Emotions: This is still controversial but there is some evidence that the way women respond to stress may affect their chances of getting breast cancer. Those who do not express their emotions and have a sense of hopelessness and helplessness seem at greater risk
- Previous Breast cancer: Women who develop breast cancer in one breast are six times more likely to develop breast cancer in the other.
Pain and swollen enlarged breasts is a common feature of hormonal changes and affect both breasts.
Pain in one breast may be the result of mastitis.
A pain less lump is the most common presentation for breast cancer.
Painful lumps are not usually malignant, discharge from the nipple may be clear.
The commonest diseases of the breast as seen in practice are:
1. Mastitis: It is characterized by sore pain in the breast with fever and tired, achy, rundown condition.
O/E : Tender, painful lump and swelling associated with redness , in 99 % the involvement is unilateral.
1. Improper positioning of the baby at breast
2. Long delays between breast feedings
3. Dried secretions covering nipple openings
1. Complete bed rest
2. Lots of free fluids should be consumed
3. Apply hot pack to breast before nursing and cold pack after.
4. It is important to continue nursing as the milk is not affected and it contains antibodies beneficial to the baby, it is also very important to position the baby. It is also very important to position the baby in all three positions alternately in order to empty all ducts , the positions are as follows:-
Lying down with baby along side mother
Foot ball position , i.e. baby lying on side with head over mother’s arm , back against the wall (or similar support )
Cradling in arms.
2. Abscess: Preceeded by a hard or soft lump which does not change with nursing
3. Cracked Nipples: Tender or cracked near the base of the nipple where it connects to areola, caused by bad positioning of baby can occur , if the baby does not open mouth wide enough or if the gums slide off during sucking , cracking can also occur if thrush is present in the baby . It is good to manually express the milk to soften the areola, resulting in the nipple being easier for the baby to subsequently feed. The foot ball position is the best to be encouraged.
Prevention and Self help
1. Breast self examination is easy to learn and you should get into the habit of examining your breasts once during your monthly cycle. The American College of Obstetricians and Gynaecologists (ACOG) says you should know what is normal for your breasts. ACOG recommends lying down with a pillow under your right shoulder and placing your right arm behind your head. Using the finger pads of the three middle fingers on your left hand, feel around for any lumps in the right breast. Press firmly but gently. If you’re not sure how hard to press, talk with a health care professional to learn the correct technique.
The American College of Obstetricians and Gynecologists (ACOG) says you should know what is normal for your breasts. ACOG recommends lying down with a pillow under your right shoulder and placing your right arm behind your head. Using the finger pads of the three middle fingers on your left hand, feel around for any lumps in the right breast. Press firmly but gently. If you’re not sure how hard to press, talk with a health care professional to learn the correct technique.
ACOG says you can either move up and down or in a circular motion going outward from the nipple. Just make sure you cover the entire breast, chest and armpit area. You’re checking for:
- changes in appearance including puckering and dimples
- changes in size or shape
- pushed-in or misshapen nipples
Reverse arm positions and repeat this procedure on your left breast.
You can also examine your breasts while standing, with your one arm behind your head. Again, make sure you cover the entire breast, as well as the chest and armpit area. You can do this standing examination in the shower. You might also want to check your breasts this way by standing in front of a mirror so you can look for any changes in the appearance of your breasts such as swelling or dimpling.
If you find any lumps or changes in the breast’s feel or appearance, see a doctor right away. NCI says that, although many lumps turn out to be non-cancerous, it’s essential to avoid delays in getting professional advice and treatment.
2. Regular medical examinations, if you are on oral contraceptive pills or hormone replacement therapy is an important part of a preventative program.
3. Diet is an important factor in preventing breast disease. You should aim to reduce the fatty content of your diet together with your salt intake. Eat plenty of fresh fruit and salads. The fatty acid gamma linolenic acid (GLA) is known to reduce the pain of mastalgia and is found in evening primrose oil, supplements of vitamin B(pyridoxine) – one tablet twice a day for 2 weeks before the period , will help with the symptoms associated with premenstrual tension and has been used as a treatment for this condition .
4. Exercises: Many exercises are to be found in “stay fit and healthy” that are claimed to improve –size, but as the breast itself contains no muscle tissue, the effect of exercise is only on the pectoral muscles beneath the breast, strengthening these muscles may improve breast “lift” but a good supporting bra and ensuring you are not over weight are equally helpful measures. Breast sagging is more often the result of poor posture and the Alexander technique may help with the condition.
5. Naturopaths will suggest a diet including plenty of green vegetables, including cress and cabbage (vegetable) juice may be a more convenient way of obtaining the ingredients known to improve healthy tissues. Additional vitamins are some times prescribed in fibrocystic disease or in breast cancer. Splashing or spraying the breasts with cold water on a regular basis will help to keep them healthy and firm. For mastalgia, pressure between the third and fourth rib above the nipple will help to relieve breast tenderness and improve lactation.
Hormonal and cyclical changes affecting the breast are often treated with a variety of hormonal combinations which alter the balance of progesterone and oestrogen, painful cysts will be “aspirated” (having the fluid drawn off using a fine needle and most lumps in the breast will be subjected to careful examination including mammography, special x- ray of the breast ) .
In almost all cases a biopsy will be taken to reveal whether the lump is malignant, surgery is now confined to removing the lump (lumpectomy) or removing same or the entire breast (mastectomy). Radiotherapy and chemotherapy will be utilized if thought to establish visualization. Meditation, relaxation exercises will help to improve the sense of general well being and have been shown to alleviate the level of depression found the women who have developed breast cancer.
Breast Lumps and Mastitis :
Mastitis occurs after a chill – Aconitum
Red streaks radiate from a central point in the breast – Belladonna
Pulsating pain with hardness of the breast, a sudden headache often accompanies the mastitis – Belladonna
Pain occurs because of bruising –Bellis perennis
The breast is hard to touch, heavy and painful—Bryonia alba
Mastitis occurs after with stiching pains and tense swelling are experienced — Bryonia alba
Tender and swollen breasts occur before a period — Calcarea carb
Piercing pain which is worse at night – Conium maculatum
Tenderness of the rest of the breast , which feels hard , the breast is painful even
From the touch of clothes or when out walking –Conium maculatum
Pain full cracked nipples – Graphites
Chronic mastitis (medical diagnosis essential) – Silica
Worst right breast, discoloration of breast with red streaks, breast very sensitive to touch, high fever with throbbing carotids — Belladonna
Breast hard as stone worse right or left breast, lips dry and parched, tongue coated thick white. Psychologically patient is irritable and wants to be alone, does not want to be touched or moved, headache, feels as if head would burst –Bryonia.
Cracked nipples, swelling of the mammae esp right, internal itching in breast, drives patient to despair, better by rubbing and scratching, mammae heavy, hard to walk down steps .—Castor equi
Cracked fissured nipples, blisters with honey type discharge; mentally the patient is extremely dull, sluggish, and lethargic. On the other hand there is extreme anxiety over trifles — Graphites
Extremely useful in abscess where the only comfort is from heat. The patient is extremely sensitive to pain, patient will be adequately covered with blankets, breast tender to touch, it limits the extent of suppuration if used in high potency —- Hepar sulph
Salivation during sleep – pain breast at night – worse heat or cold – swelling without heat – cracked ulcerated nipples – discharge offensive. Psychologically patient has a strong impulse to kill the child or husband (post-–partum depression) —Mercurius
Tendency to recurrent abscess, spasm of pain when child nurses, pain in the breast radiates all over the body, breast hard or soft. Milk too lumpy and thick, tongue has red tip. Psychologically patient is depressed, wants to be left alone and weep grief over loss of pregnancy — Phytolacca
Breast usually tender and sore – pain in uterus when child nurses, -abscess – heal very slowly –inverted nipples, plugged duct- tender breast — Silica
Therapeutic medicines nodosities in the breasts. It can also be applied locally on:
Cancerous glands. —- Scrophullaria nodosa
Indicated in breast nodules of stony hardness.—- Calcarea flour
Glands have a certain elasticity and pliability about them rather than the stony
Hardness of Calc-f. and Cistus.—- —- Lapis alba.