• Characteristically cyclic and bilateral, with multiple cysts of varying sizes giving the breast a nodular consistency
• Pain or premenstrual breast pain and tenderness common, although condition is often without symptoms
• Occurs in 20 to 40% of premenopausal women
Benign fibrocystic breast disease (FBD), also known as diffuse cystic mastopathy, is usually a component of premenstrual syndrome (PMS). It is also considered a risk factor for breast cancer, though not as significant as the classic breast cancer risk factors: family history, early onset of menstruation, and late first pregnancy or no pregnancy.
FBD cannot be definitively differentiated from breast cancer on clinical criteria alone. Although pain, cyclic variations in size, high mobility, and multiplicity of nodules are indicative of FBD, you should see a physician immediately if you notice a lump of any kind. Noninvasive procedures, such as ultrasound, can help in differentiation, but at this time definitive diagnosis depends upon biopsy.
Causes
FBD is apparently the result of an increased estrogen-to-progesterone ratio. However, other hormones are also important. For example, the changes within the breast in FBD may be due to the hormone prolactin. Typically, significantly elevated levels of prolactin are found in women with FBD, though the levels are not so high as to cause menstruation to cease. The increase in prolactin is thought to be the result of higher estrogen levels.1
Therapeutic Considerations
For a more comprehensive discussion of the many factors involved in FBD, read the chapter “Premenstrual Syndrome” as well. The factors discussed here were chosen because they are not covered in depth in the PMS chapter and are particularly relevant to FBD.
According to population-based studies,2 experimental evidence,3–5 and clinical studies,3–5 there is strong evidence supporting an association between caffeine consumption and FBD. The methylxanthines caffeine, theophylline, and theobromine elevate the levels of compounds that promote overproduction within breast tissue of cellular products linked to FBD, such as fibrous tissue and cyst fluid.3–5
In one study, limiting methylxanthines (coffee, tea, cola, chocolate, and caffeinated medications) resulted in improvement in 97.5% of the 45 women who completely abstained and in 75% of the 28 who limited their consumption. Those who continued with little change in their methylxanthine consumption showed little improvement.3 According to this study, women may have varying thresholds of response to methylxanthines. However, three other studies have shown no association between methylxanthines and FBD.6,7,8 Stress may also play an important role.
A comparison between the diets of 354 women with benign proliferative epithelial disorders of the breast and those of 354 matched controls and 189 unmatched controls found an inverse association between dietary fiber and the risk of such disorders.9 An increased intake of dietary fiber may be associated with a reduced risk of both benign breast disease and breast cancer.
Breast disease has been linked to a low-fiber diet and constipation. There is an association between abnormal cell structure in nipple aspirates of breast fluid and the frequency of bowel movements.10 Women having fewer than three bowel movements per week have a risk of FBD 4.5 times greater than women having at least one bowel movement a day. The cause of this association is probably that the bacterial flora in the large intestine transform estrogen into various toxic metabolites, including carcinogens and mutagens. Fecal microorganisms are capable of synthesizing estrogens as well as breaking the bond between excreted estrogen and glucuronate, resulting in absorption of bacteria-derived estrogens and reabsorption of previously excreted estrogen as free estrogen. Diet plays a major role in colon microflora, transit time, and concentration of absorbable metabolites.
Women on a vegetarian diet excrete two to three times more conjugated estrogens than women on an omnivorous diet.11 Furthermore, omnivorous women have a 50% higher average level of free estrogen reabsorbed from the intestinal tract. Bacterial beta-glucuronidase is a bacterially produced enzyme that breaks the bond between excreted estrogen and glucuronic acid. Not surprisingly, excess beta-glucuronidase activity is associated with an increased risk of estrogen-dependent breast cancer and may be a factor in FBD as well. Probiotic supplementation has been shown to lower fecal beta-glucuronidase and may help improve bowel function as well.12
Reducing the total fat content of the diet is also important. Reducing the total fat intake to 15% of total calories while increasing consumption of high-fiber foods has been shown to reduce the severity of premenstrual breast tenderness and swelling, as well as reducing the actual breast swelling and nodules in some women.13 Reducing the dietary fat intake to 20% of total calories has also been shown to result in significant decreases in circulating estrogens in women with benign breast disease.14
Because FBD is so often linked to PMS, the nutritional supplements recommended in the chapter “Premenstrual Syndrome” are appropriate here. It is especially important to promote the excretion of excess estrogen. FBD may be related to an increased sensitivity to estrogen, and because the liver is the primary site for estrogen clearance, adequate levels of B vitamins and lipotropic factors are necessary. Historically, naturopaths have used lipotropic factors such as inositol and choline to support the excretion of estrogen. Lipotropic factors promote the removal of fat from the liver. Lipotropic supplements usually are a combination vitamin-and-herbal formulation designed to support the liver’s functions of removing fat, detoxifying the body’s wastes, detoxifying external toxins, and metabolizing and excreting estrogens. These lipotropic products vary in formulation depending on the manufacturer, but they are all similar. Many now contain anticancer phytonutrients found in brassica-family vegetables, such as indole-3-carbinol (I3C), di-indoylmethane (DIM), and sulfurophane. These compounds help to break down cancer-causing forms of estrogens to non-cancer-causing forms, making them especially important in women with FBD.
Evening Primrose Oil
The only essential fatty acid to be studied in relation to fibrocystic breasts is evening primrose oil. When 291 women with cyclic and noncyclic breast pain were given 3,000 mg evening primrose oil for six months, almost half of the 92 women with cyclic breast pain experienced improvement, compared with one-fifth of the patients who received the placebo. For those women who experienced breast pain throughout the month, 27% (of 33 women) improved with evening primrose oil, compared with 9% on the placebo.15 In another study, 73 women with breast pain randomly received 3 g per day of EPO or a placebo. After three months, pain and tenderness were significantly reduced in both the women with cyclic breast pain and those with noncyclic pain. The women who took the placebo did not significantly improve.16 Other seed oils with gamma-linolenic acid should also be considered, including blackcurrant oil and borage oil. However, fish oils would probably be most effective. One study showed that red blood cells with higher levels of EPA and DHA—the two primary omega-3 fatty acids in fish—were associated with a significantly reduced risk for FBD.17
Vitamin E
Vitamin E (alpha-tocopherol) has been shown to relieve many PMS symptoms, particularly FBD, as evidenced by several double-blind clinical studies.18 Two studies demonstrated that vitamin E is clinically useful in relieving pain and tenderness, whether it is cyclical or noncyclical.19,20 The mode of action remains unclear. When larger numbers of women were studied, vitamin E did not fare so well, showing no significant effects either subjectively or objectively.21,22
Vitamin E may work best when part of a more comprehensive antioxidant plan. In one study, 66 women with FBD were given a combination of beta-carotene, vitamin E, vitamin C, and garlic powder. There was a reduction in the severity of breast pain, premenstrual syndrome, infrequent menses, and menstrual cramping as well as a reduction in symptoms of FBD in 75% of the women taking the combination, compared with 45% of women on a placebo.23
Experimentally induced iodine deficiency in rats results in mammary changes similar to human FBD.24 This suggests that iodine (specifically iodine caseinate) may be an effective treatment for FBD.25 It is theorized that an absence of iodine renders the epithelium more sensitive to estrogen stimulation. This hypersensitivity can produce excessive amounts of secretions, distending the breast ducts and producing small cysts and later fibrosis (hardening of the tissue due to the deposition of fibrin, similar to the formation of scar tissue). Iodine may help to arrest this process.26
Since 1975, three clinical trials with iodine have been performed on women with FBD. Results from these studies indicate that although treatment with high doses of iodides was effective in about 70% of subjects, it was associated with a high rate of side effects (altered thyroid function in 4%, iodinism in 3%, and acne in 15%).26 The dosage of iodine was quite high. We recommend that patients take iodine only under strict medical supervision, as taking too much iodine can lead to altered levels of thyroid hormone.
In addition to iodine, there is research showing that thyroid hormone replacement therapy may result in clinical improvement.27 Thyroid supplementation (0.1 mg Synthroid per day) decreases breast pain, serum prolactin levels, and breast nodules in supposedly normal thyroid patients. These results suggest that subclinical hypothyroidism, iodine deficiency, or both may be etiologic factors in FBD. For more information on subclinical hypothyroidism, see the chapter “Hypothyroidism.”
Chasteberry
A large open study (that is, a study without a control group) of 1,634 women with FBD as part of their premenstrual syndrome demonstrated that after three months of treatment, 81% of the patients being treated rated chasteberry (Vitex agnus-castus) as a good or very good treatment for FBD.28 In a double-blind study, 97 women with FBD had twice the decrease in intensity of pain after one or two treatment cycles as compared with a placebo.29 In another double-blind study comparing chasteberry with fluoxetine (Prozac) in PMS, 58% of patients being treated with chasteberry had an improvement in their FBD and 68% of patients had improvements in their psychological symptoms.30 And in the largest double-blind study, 170 women with PMS were given chasteberry or a placebo for three consecutive cycles. The improvement in breast pain was greater in the chasteberry group (52%) compared with the placebo group (24%).31
QUICK REVIEW
• Fibrocystic breast disease is most often a component of premenstrual syndrome.
• Elevated estrogen to progesterone ratio or both increased prolactin levels are thought to play a role in FBD.
• Eliminating caffeine and similar compounds has produced improvements in as many as 97% of women in clinical trials.
• Hypothyroidism and/or iodine deficiency may be a causative factor in fibrocystic breast disease.
• Vitex extract has been shown in several clinical trials to produce significant benefits in improving breast pain and FBD.
• Women who have fewer than three bowel movements per week have a 4.5 fold greater rate of fibrocystic breast disease than women who have at least one bowel movement a day.
TREATMENT SUMMARY
Given the close association of FBD with PMS, we encourage you to also see the chapter “Premenstrual Syndrome.”
Follow the guidelines in the chapter “A Health-Promoting Diet.” Consume a diet low in fat and high in fiber, whole grains, flaxseed, and soy foods and avoid saturated fats, sugar, caffeine, and alcohol. Soy isoflavone intake should be between 45 and 90 mg per day. Ground flaxseed at a dosage of 1 to 2 tbsp per day is also recommended.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin B6: 25 to 50 mg two times per day
Folic acid: 800 mcg per day
Vitamin B12: 800 mcg per day
Vitamin C: 500 to 1,000 mg per day
Vitamin E (mixed tocopherols): 100 to 200 IU per day
Magnesium (bound to aspartate, citrate, fumarate, malate, or succinate): 200 to 300 mg three times per day
Zinc: 15 to 30 mg per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• Evening primrose oil: 3,000 mg per day
• Specialty supplements, one of the following:
Lipotropic formula providing 1,000 mg betaine, 1,000 mg choline, and 1,000 mg cysteine or methionine
SAM-e: 200 to 400 mg per day
• One or a combination of the following:
Indole-3-carbinol: 300 to 600 mg per day
Di-indoylmethane: 100 to 200 mg per day taken with food
• Vitex (chasteberry): Usual dosage of chasteberry extract (often standardized to contain 0.5% agnuside) in tablet or capsule form is 175 to 225 mg per day; for liquid extract, typical dosage is 2 to 4 ml (1/2 to 1 tsp) per day.