Assessment

HISTORY. Elicit a reproductive history. Women with a fibrocystic breast condition often have a history of spontaneous abortion, shortened menstrual cycles, early menarche, and late menopause. Patients are frequently nulliparous and have not taken oral contraceptives. Cyclic, premenstrual breast pain and tenderness that last about a week are the most common symptoms. With time, the severity of the breast pain increases, and onset occurs 2 to 3 weeks before menstruation. In advanced cases, the breast pain can be constant rather than cyclic.

Fibrocystic breast changes usually occur bilaterally and in the upper outer quadrant of the breast. A woman may appear with gross nodularity or with one or more defined lumps in the breast. The abnormality may be described as a hardness or a thickening in the breast. The areas are usually tender and change in size relative to the menstrual cycle (becoming more pronounced before menstruation and decreasing or disappearing by day 4 or 5 of the cycle). Approximately 50% of patients have repeated episodes of breast cysts.

PHYSICAL EXAMINATION. The breasts should be inspected in three positions: with the patient's arms at her side, raised over her head, and on her hips. Instruct the patient to "press in" with her hands on the hips to contract the chest muscles. Compare her breasts for symmetry of color, shape, size, surface characteristics, and direction of nipple. Women with deep or superficial cysts or masses may have some distension of breast tissue in the affected area, but often, no changes are noted on examination. Dimpling, retraction, scaling, and erosion of breast tissue indicate more serious breast conditions, and none of these disfigurations is usually found in fibrocystic breast condition.

Palpate the breasts in both the sitting and the supine positions. Use the pads of the three middle fingers to palpate all breast tissue, including the tail of Spence, in a systematic fashion. Breast cysts are filled with fluid and feel smooth, mobile, firm, and regular in shape. Superficial cysts are often resilient, whereas deep cysts often feel like a hard lump. Cystic lesions vary from 1 to 4 cm in size, can appear quickly, are often bilateral, and occur in mirror-image locations.

350 Fibrocystic Breast Condition

To conclude palpation of the breasts, gently squeeze the nipple. About one-third of women with advanced fibrocystic change experience nipple discharge. Nipple discharge in benign conditions is characteristically straw-yellowish, greenish, or bluish in color. A bloody nipple discharge often signals the presence of ductal ectasia or intraductal papillomatosis and should be further evaluated.

PSYCHOSOCIAL. Finding a lump or irregularity in the breast is distressing. The almost "overnight" appearance of cysts can make a woman doubt the validity of a recent negative physical examination or mammogram. In addition, the pain associated with advanced fibrocystic changes can be debilitating. Assess the patient's prior experience with breast problems and her use of coping strategies.

Diagnostic Highlights

General Comments: Diagnostic testing is needed to rule out malignancy, as well as confirm the diagnosis. Some 80% of breast lumps are found to be benign.

Test

Normal Results

Abnormality with Condition

Explanation

Fine-needle aspiration (FNA)

Not applicable

Green, brown, or yellow fluid obtained

Confirms diagnosis; bloody fluid is suspicious and should be sent to pathology

Mammogram

No tumor noted

Well-rounded mass with a discrete border noted (cyst); vague asymmetrical radiodensity (white)

Confirms diagnosis

Ultrasound

No abnormalities seen

Will show a fluid-filled mass, which is consistent with a cyst (not a solid mass, which is consistent with a malignant lump)

Confirms diagnosis

Biopsy

Benign

Benign

Is done if a lump remains after an FNA, to diagnose cancer

^ PLANNING AND IMPLEMENTATION Collaborative

The physician will attempt a fine-needle aspiration (FNA) of a breast mass that appears to be cystic. Once the fluid is removed, the cyst collapses and the pain is relieved. Medical therapies may be used in an effort to decrease breast nodularity and relieve breast pain and tenderness.

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