There are so many conditions of the breast that go poorly understood because of the emphasis on detecting breast cancer early. While finding breast cancer early is indeed of utmost importance, this column is devoted to the other conditions that are significantly encountered in the breast.

Breast size: There is often some difference in the size of a woman’s breast. This is often magnified because of a woman’s concern that this means something is wrong or that she looks “funny”. Even though there are rare cases of women with only one breast developing, most commonly there is only a slight variation in the size, usually only noticed by the woman herself. This is benign when it has “always been that way” and unless it gets to be a psychological barrier for the woman, does not need to be addressed. Plastic surgery is the answer when the difference is significant for the woman.

Breasts that are too large is another problem that sometimes is significant. Some women are just genetically programmed to have breasts that are painfully large. This tendency is not dependent on being “fat” but carrying extra weight can aggravate the condition. Women can be miserable. It can affect a woman’s choice of activities, causing women to avoid playing tennis, jogging, or other vigorous activities. Some women develop deep tender grooves over their shoulders from bra straps digging in and/or they suffer from chronic neck and upper back pain that can cause daily misery. It is a woman’s judgement call to decide when this condition needs to be addressed surgically. Many of my patients are grateful to have had the surgery and never look back. However, scarring can be a problem especially in keloid-formers and successful breast feeding can be made impossible. It is a big decision.

Breast lumps: Benign lumps can be divided into solid or cystic lesions. Many breast cysts that I see in my practice are discovered by the patient. They appear all of a sudden resulting in a visually obvious, tender lump. We usually go ahead with draining the cyst in the office. If it goes away completely with draining, the fluid is clear to milky, and the cyst does not recur, nothing further needs to be done. Some women are prone to this problem and are very familiar with this plan. Other cysts are not noted until a mammogram is done. Often, an area of density on the mammogram will turn out to be a cyst or simple fluid collection when examined by ultrasound. As long as all the cyst criteria are benign, i.e. thin-wall, single cavity, clear, etc., nothing further needs to be done. Anytime the cyst is complicated in appearance, recurrent, or filled with bloody fluid, biopsy should be considered.

The most common solid lump in the breast is something called the fibroadenoma. These can be seen even in the teenage years. They have specific criteria associated with them and sometimes are just observed over time. I lean towards recommending removal for lesions of any size for several reasons. First, patients worry if we are wrong and there is something in their body that will “get them”. Second, these lesions can grow and the bigger it is when removed, the larger the scar or breast defect may be. Third, follow-up can be difficult because of distortion from the lesion.

After a blow to the breast, especially after something like a shelf or table corner hit, or a car accident with seat belt bruising, the breast can undergo fat necrosis in that area, forming a firm nodule that eventually softens but may lead to some long-term distortion.

Nipple discharge: This is very common. When it comes from both nipples, is milky, and is not associated with pregnancy, it can represent an abnormal increase in Prolactin hormone and should be evaluated. Bizarre nipple discharge that is green or black is associated with fibrocystic change in the breast and usually only comes from one nipple at the time. Despite the strange appearance, this is a non-worrisome process. Bloody nipple discharge can be associated with a benign growth in a milk duct called a papilloma. Still, any bloody drainage should be further evaluated to exclude a cancer as the cause.

Commonly, many of the above symptoms are seen in women with fibrocystic change. Up to 40% of women have this condition that can promote the development of cysts, densities that can make the breast feel like beanbags, and colorful nipple discharge. Forty percent, that is a lot of women. All of the conditions mentioned here are very common. Benign changes including swelling before a period or any of the changes mentioned above will often be encountered by a woman. The above descriptions are provided to let women know that most changes don’t represent cancer. One should not be afraid! It is certainly prudent however to see your doctor about any change you notice that is different for you. Particularly, bloody drainage, lumps, or thickened areas should prompt a visit. Let your physician help to determine what evaluation should be done to help you rest assured.

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