Fibrocystic Disease of the breast - Most common cause of painful breast mass

This condition is characterized by painful, frequently multiple and typically bilateral masses in the breast. Rapid variation in the size of the masses is characteristic. Usually pain starts and / or, get worse and the size increases preceding the menstruation. Commonly women of 30 to 50 years are affected. This condition is rare after menopause unless on hormone replacement therapy.

Fibrocystic disease of the breast is the commonest lesion of the breast. Estrogen is considered a contributory factor. There may be an enhanced risk in those who consume alcohol, especially young women between 18 and 22 years of age. Fibrocystic condition presents a wide range of histologic changes. These lesions are constantly show benign changes in the breast epithelium, those are so commonly found in normal breasts. Most likely they are only the variants of normal breast histology. Only some variety of histopathological changes showing proliferation and atypical cells are said to have increased incidence of breast carcinoma.

Symptoms and Signs of fibrocystic disease of the breast

Usually a mass in the breast remain asymptomatic and sudden pain and tenderness brings attention and the mass is recognized by the concerned woman. Discharge from the nipple may sometimes be present. Mostly uneasiness starts or worsens preceding the menstruation, at which time the cysts increase in their sizes too. Changes in size and rapid emergence or disappearance of mass from the breasts typical with this disease. Multiple or bilateral masses are usual findings, and many patients will give a history of cyclical breast pain and transient formation of mass in the breasts.

How fibrocystic disease of the breast is diagnosed?

Pains, multiplicity of the mass, rapidly changing size are the most helpful features in differentiating fibrocystic disease from breast carcinoma. If a persistent mass is there, the diagnosis of cancer should be suspected unless nullified by a biopsy. Ultimate diagnosis depends on histopathologic examination of the excisional biopsy specimen. Mammography may help, but the breast tissue is usually radiodense in these young women is usually much radiodense and proper study is difficult at times. Sonography can differentiate cystic mass from a solid mass. The solid mass points more towards carcinoma.

Treatment of fibrocystic disease of the breast

After diagnosis of fibrocystic disease has been established either by histopathologic study or by the classical history; aspiration of the discrete cyst can be done to ease pain. This procedure also helps to verify the cystic nature of the mass. The patient is reviewed at intervals subsequently. If no fluid is recovered by aspiration or, if fluid is blood stained or, if the mass remains after aspiration, or if in subsequent follow-up a constant or recurrent mass is noted, biopsy is done to exclude carcinoma.

Breast pain due to fibrocystic disease is best managed by wearing a good supportive brassiere for 24 hours and avoiding any kind of trauma. Hormone therapy is not indicated as it does not cure the disease and produce undesirable side effects. Danazol, a synthetic androgen in a dosage of 100–200 mg orally twice daily sometimes prescribed to alleviate severe pain in some patients. This acts by suppressing pituitary gonadotropins, but androgenic side effects like acne, edema, hair loss and hirsutism is not acceptable to many of the women.
Tamoxifen, an antiestrogen and anti cancer drug also reduces some symptoms of fibrocystic disease, but due to its side effects it is not prescribed for young women except it is prescribed to lessen the risk of carcinoma.

Postmenopausal women on hormone replacement therapy (HRT) usually get relief after stopping the hormones. Evening primrose oil, a natural form of gamolenic acid is found effective to reduce pain in around 50% of the users and can be tried for treatment. The dose of gamolenic acid is 3 g twice daily orally.

Reducing the fat in diet, lowering caffeine consumption in the form of tea coffee or chocolate are found helpful to reduce pain in several studies. Vitamin E in a dose of 400 IU daily also help some patients to get rid of the symptoms at least partly. None of these treatments are proved to to be effective beyond doubt till date.

Premenstrual Syndrome (PMS)

What is Premenstrual syndrome? or, PMS?

A very common condition affecting the women mostly in their 30s and 40s. They notice premenstrual worsening of their physical wellbeing and mood. The symptom may vary month to month; being minimal in one month severe in other and moderate discomfort in some months. Some women also notice that the symptoms are less when they are on combined contraceptive pills. 3% of the affected women get these symptoms regularly and they may be so severe, that it cause major disruption to their lives. This syndrome is also known as Premenstrual tension or. PMT

What are the symptoms of PMS or PMT?

Tension, irritability, depression, bloating sensation, heaviness and tenderness in the breasts, headache, craving for carbohydrates, lack of sexual drive or, libido are the common symptoms. Many other bizarre symptoms may appear. To know whether one has PMS or, not it is essential to keep a diary of events. This diary will help the treating doctor to differentiate PMS with other disorders and will be helpful to find any psychological disturbance, she may be having. If she is having her symptoms worst premenstrual, she will have at least one week symptom free period after her menstruation.

How to treat Premenstrual syndrome (PMS)?

Reassurance is very important and she must understand this is not going to produce any serious disease or, cancer in future. Cooperation from the spouse and children is required to cope up with life. Find self help group support in the area. Improvement of diet, proper exercising, Yoga and rest, avoiding tobacco and alcohol will help. Herbal remedies though not tested properly some find them helpful. Try sage and fennel for irritability. Pyridoxine (Vitamin B6) 10 mg orally daily, either continuously or during the discomfort may help to elevate the mood and relive headache.

For severe cyclical pain in the breasts, cyclical mastalgia:

Avoid eating saturated fats as they increases the affinity of the oestrogen receptors for oestrogen.

Gamolenic Acid 160 mg orally 12 hourly

Bromcryptine 2.5 mg orally twice daily from 10^th to 26^th day of the cycle ( prescribed even when the prolactin level is within normal limit)

Danazol 100 – 200 mg 12 hourly orally for 7 days prior to menstruation.

Suppression of ovulation help in relieving symptoms in PMS

Yasmin a new entrant in combination pill is specially helpful to alleviate symptoms of PMS by suppressing ovulation.

Oestrogen Implants with cyclical progesterone is also used.

Danazol can also be given to suppress ovulation, but has other side effects like pimple, hair fall, weight gain etc.

Diuretics Spironolactone 25mg orally 6 hourly is also prescribed from 16^th to 26^th day of the cycle ( 1^st day being the first day of menstruation) when there is excessive fluid retention.

Other than these alprazolam, mefenamic acid and other analgesics are used to treat PMS.

In intractable patients removal of uterus and ovaries may be done and results are 96% satisfactory. These women should receive oestrogen replacement (HRT) following their operation.

This article is also republished at India Study Channel

Secondary Dysmenorrhoea

Cyclical Pain Abdomen Related With Menstruation – Dysmenorrhoea

The commonest complain in my Out Patient Department I encounter from all age group of patients is cyclical pain associated with menstruation. The medical term for this condition is dysmenorrhoea. The condition is very common and most of the time, not always, it is nothing serious. In this article you will have some idea how and why such cyclical pain occurs and what one should do?

More than 90% of women some time or other, in their life experience pain during her menstruation. In clinical terms we have two types of dysmenorrhoea.

1. Primary dysmenorrhoea
   
2. Secondary dysmenorrhoea
   

Secondary dysmenorrhoea:

This kind of cyclical pain during menstruation is associated with some disease/ pathology in the genital organ i.e., uterus, fallopian tubes and ovaries. Secondary dysmenorrhoea develop years after the onset of menstruation. Here the pain begins 1 – 2 weeks prior to menstrual flow and persists till few days after cessation. The mechanism of secondary dysmenorrhoea is not fully understood and NSAID ( Nonsteroidal Antinflammatory Drugs) do not provide full relief. Treatment to this kind of dysmenorrhoea should be directed to the treatment of the underlying cause.

Here are the few common gynaecological cause of secondary dysmenorrhoea:

1. Adenomyosis
   
2. Endometriosis
   
3. Fibroid uterus
   
4. Pelvic congestion syndrome
   
5. Sub acute pelvic infection
   
6. Adhesions
   

Adenomyosis:

Though this is a disease of women in their forties, but frequently encountered in younger women nowadays. The normal site for endometrium is lining of the uterine cavity. In this disease endometrium is abnormally found in the musculature of the uterus. This make the uterus large and painful during menstruation. The affected woman complains painful heavy periods and pain during intercourse.

Diagnosis of adenomyosis is easily done from the symptoms, clinical findings and ultrasonography.

There is no medical treatment available at present for this condition. The affected organ uterus has to be removed by operation (Hysterectomy) after she completes her family. Till such time symptomatic treatment with analgesics are done.

Endometriosis:

Nowadays an extremely common condition affecting girls and women of almost all age group after 16 years! I will post a separate article on this condition to give a little in depth information. In this condition endometrium is found in different abnormal location inside the abdominal cavity and even the skin. In each cycle endometrium in these abnormal sites bleed along with the normal endometrium, lining the uterine cavity. This bleeding causes severe pain and varied kind of symptoms depending on the site of bleeding. Endometriosis is a major cause of infertility. Painful, sometimes incapacitating heavy menstruation, pain during intercourse are the major complains.

Diagnosis of endometriosis is done by clinical history, examination, ultrasonography and finally by diagnostic laparoscopy.

Definitive treatment of endometriosis is removal of ovaries and uterus. Unfortunately the disease is mostly found in young woman without any child. Different kind of hormonal treatment and conservative surgery are usually advised to them. Once they complete their family and still the symptoms persist removal of uterus and ovaries (hysterectomy) done.

Fibroid Uterus:

These are benign tumors in the uterine musculature. Though mostly remain symptomless, but sometimes obstructs the natural flow of menstruation and causes pain. The other symptoms are swelling of abdomen, excessive bleeding during and sometimes in between menstruation, repeated abortions, failure to conceive depending on the size and site of the tumor.

Diagnosis of fibroid uterus is done from complain of the patients, clinical examination and ultimately by ultrasonography.

Treatment of fibroid uterus: This depend on the symptoms, age and whether the woman has completed her family or not. If family is completed, in a symptomatic patient, the affected organ is removed surgically ( Hysterectomy). Otherwise removal of the tumors (conservative surgery) is done.

Pelvic congestion syndrome:

Common sufferers are the women in their reproductive age. This condition is most likely associated with emotional stress, which in turn increases the blood flow to the genital organs i.e. uterus, fallopian tubes and ovaries. This causes pain during menstruation, heavy bleeding and pain while intercourse ( dysparunea).

Diagnosis of pelvic congestion syndrome is done from history, clinical examination, ultrasonography, MRI, trans uterine pelvic venogram and laparoscopy.

Treatment depends on the age and the number of children the woman has. If her family is not completed conservative treatment with analgesics and different hormones are done. Once she completes her family and still suffers hysterectomy is done.

Subacute pelvic infections:

Inadequately treated infection of the uterus and its appendages, fallopian tubes and ovaries may persist and causes dysmenorrhoea, excessive bleeding and dysparunea. Proper treatment of the infection may solve the issue but in resistant cases hysterectomy is the answer.

Adhesions:

Adhesions may occur with the surrounding organs like urinary bladder, intestines, rectum and within the uterus and its organs i.e. ovaries and fallopian tubes. The cause of such adhesions may be repeated infections, sexually transmitted diseases or any abdominal or vaginal operations like MTP (Medical Termination Of Pregnancy).

The woman presents with dysmenorrhoea, dysparunea, difficulty in passing urine and stool. Diagnosis is done by laparoscopy . The minor adhesions are usually dealt with freeing the uterus and appendages by operation either by laparoscopy or open operation. In bad type of such adhesion removal of uterus is the only answer.

Cyclical Pain Abdomen Related With Menstruation – Dysmenorrhoea

The commonest complain in my Out Patient Department I encounter from all age group of patients is cyclical pain associated with menstruation. The medical term for this condition is dysmenorrhoea. The condition is very common and most of the time, not always, it is nothing serious. In this article you will have some idea how and why such cyclical pain occurs and what one should do?

More than 90% of women some time or other, in their life experience pain during her menstruation. In clinical terms we have two types of dysmenorrhoea.

a) Primary dysmenorrhoea
b) Secondary dysmenorrhoea

Primary dysmenorrhoea : It is a condition where the girl/ woman having cyclical pain at menstruation, and on investigation no disease is found in the genital organs. This is the commonest form of dysmenorrhoea see in young adults. These usually appears within one to two years after girls starts menstruating and usually lasts for few years and in most cases subside after having a baby. Sometimes it may also continue up to 40 years of age.

Typically the pain starts few hours before or, at the onset of menstruation and last for 48 to 72 hours. The main is similar to labor pain to some extent. The affected girl have cramps in lower abdomen along with backache . Most girls can tolerate this very easily and none of their daily activities are hampered due to this. In few others, it is severe enough to detain her from normal activities and may be associated with nausea, vomiting, dizziness, headache and even fainting attack in severe cases.

Pain sensitivity varies with the individuals. Some can tolerate pain better than others. This may be one of the causes for such condition in some girls. The intensity of the process of pain may also be greater in few of them. Whatever may be the reason, be assured that this is not any dangerous condition and in no way it is going to affect her future sex life or child bearing.

Why pain during menstruation happens?

Prostaglandin, a chemical is produced while a girl is menstruating is the culprit for these symptoms. It produces contractions in the uterine muscles and affect the other organs to produce different kind of symptoms. Girls who are having increased sensitivity to prostaglandins get more symptoms.

What to do when I am in pain during my period (menstruation)?

If this problem is bearable and not detaining you from any activity of yours, don’t worry at all. Have nutritious food and do regular exercises and enjoy your life. In case, you are incapacitated for few days each month, you should visit a gynaecologist. He will probably order a ultrasonography to exclude any other problem in your genital organ. If nothing found abnormal, which is true for most cases, nothing to worry about.

Treatment of Primary dysmenorrhoea:

Analgesics work by inhibiting the prostaglandins, the culprit chemical causing this. Any nonsteroidal anti-inflammatory drug (NSAID) for 2 – 3 days (deliberately I am not writing the name – get it prescribed by your doctor) will relieve the symptoms. The common mistake done by many general practitioners, medicine shops, and the patient is they prescribe or take antispasmodics like Buscopan. This will not help alone. You have to take NSAID along with it.

Know about Secondary dysmenorrhoea here.