Breast Disorders

Benign Breast Disorders

Breast cancer is uncommon in patients under 35 years. However, persistent asymmetry, unilateral nodularity, discrete measurable lumps or blood-stained discharge require investigation regardless of age. Patients should be referred for specialist evaluation particularly if symptoms are accompanied by a first degree family history of breast disease. Fine needle aspiration of discrete measurable lumps should only be performed by practitioners fully conversant with the technique. If the cyst does not disappear completely after aspiration, or if it repeatedly refills, the patient should be further assessed by a specialist. If no aspirate is yielded, or if it is blood-stained, referral is advised.

Benign Breast Pain is very common but clinical examination to exclude the presence of a lump is essential. Pain charts should be given to the patient at initial consultation for completion to establish if the pain is cyclical. Although the condition often resolves spontaneously, treatment is necessary where quality of life is affected.

Cyclical Breast Pain is an exaggeration of normal premenstrual tenderness and is often associated with nodularity. Simple measures such as analgesics, altering underwear or reducing dietary fat may bring relief. Danazol, a gonadotrophin release inhibitor with mild ancrcgenic side effects, isthought tcrei'e:ebreast pain through a direct action on the breast and indirectly via the hyoothalamic-pituitary axis. Doses of 200 to 300 mg daily started immediately after the period (to exclude pregnancy) should be given for one cycle. Then reduce to 100 mg daily for maintenance. Review after 6 months. Bromocriptine is a long acting dopamine agonist. It produces rapid symptomatic relief from cyclical breast pain by reducing the overall stimulation of the breast by prolactin. Treatment should be initiated with 1 mg daily taken at night to minimise the side effect of postural hypotension. Dosage may then be increased as necessary up to 2.5 mg twice daily and continued for 6 months.

Non-Cyclical Breast Pain, if localised, may be injected at the site of pain with 1 ml of local anaesthetic and 1 ml depot methylprednisolone acetate. To relieve non-cyclical diffuse breast pain, 6 weeks treatment with NSAIDs is recommended, while for pain associated with duct ectasia simple analgesia should be used. Second line treatment may include danazol or bromocriptine. Rarely persistent localised pain can be the only presenting symptom of breast cancer, so in patients over 50 years referral should be considered.

Treatments no longer recommended for breast pain include pyridoxine, diuretics and antibiotics.

Nipple Discharge related to cancer is generally bloody or serous in nature and often associated with a palpable abnormality. Galactorrhoea, however, may be due to concomitant drug therapy e.g. phenothiazines or due to a pituitary disorder in which case serum prolactin levels should be checked.

Lactational Inflammation should be treated immediately with a suitable antibiotic to prevent abscess formation.

Menopausal disorders

Hormone Replacement Therapy

A review of the balance of benefits and risks of HRT has shown that the benefits of HRT include the effective relief of menopausal symptoms and the prevention of osteoporosis in the long term. However, the use of HRT is associated with a duration-dependent increase in the risk of breast, endometrial and ovarian cancer. It also increases the risk of myocardial infarction and of venous thromboembolism, especially in the first year of therapy, and of stroke. It is recommended that HRT may be used for the treatment of menopausal symptoms that adversely affect quality of life, but it is used at the lowest effective dose for the shortest possible time. The patient should be reviewed at least once per year and the decision to continue treatment evaluated on the basis of any changes in her risk factors. In healthy women without symptoms, the balance of risks and benefits is generally unfavourable and HRT is not recommended.

HRT should not be used first-line for the prevention of osteoporosis in women over the age of 50, but can be used second-line when other treatments are ineffective or contraindicated.

HRT may be used in women with an early menopause for treating menopausal symptoms and preventing osteoporosis, but at aged 50. treatment should be reviewed and HRT considered a second-line choice.

The decision to start HRT should be made on an individual basis after consideration and discussion of the woman's risk factors. while the need for continued therapy should be reviewed at least once per year. Women on long term therapy should be encouraged to participate in national breast and cervical screening programmes and should be instructed in breast self-examination.

Topical vaginal administration of oestrogens in the form of creams, pessanes or a vaginal ring can be used as an alternative for patients who do not want systemic HRT to relieve local symptoms of post-menopausal atrophic vaginitis as the risk of systemic side effects is reduced. They may also be used as adjuncts to systemic HRT when lower urogenital tract symptoms prove refractory. Endometrial stimulation cannot be ruled out, so regular checks are advised and a progestogen should be considered particularly if treatment is to be extended beyond 3 months.

Selective Oestrogen Receptor Modulators (Serms)

Raloxifene is indicated for the treatment and prevention of osteoporosis in post menopausal women. A significant reduction in the incidence of vertebral, but not hip, fractures has been demonstrated. Raloxifene evokes differential oestrogenic and anti-oestrogenic responses in specific tissues. In bone it increases mineral density and protects against osteoporosis by acting as an oestrogen agonist. In the cardiovascular system, it reduces cholesterol levels to protect against the cardiovascular risks of the menopause by acting as an oestrogen agonist. In the endometrium and breast it behaves as an oestrogen antagonist so reducing the risks of endometria! or breast cancer. It may induce flushing and s associated with a similar increased :ncidence of thromboembolic events as HRT.

Bone Regulators


Alendronate, etidronate andrisedronate inhibit the osteoclasts that are responsible for bone resorption, thereby allowing the osteoblasts to lay down new bone tissue and increase bone mass. As a result. the risk of fracture in osteoporosis is reduced. Etidronate is taken cyclically for 2 weeks every 3 months. It increases bone mass, with a reduction in the rate of fractures. It is licensed for prevention and treatment of osteoporosis, including corticosteroid induced osteoporosis. Alendronate is considered to be approximately 100 fold more potent than etidronate. It is taken continuously on a daily basis and produces a significant increase in bone mass at all clinically important skeletal sites. It reduces the number of vertebral and non-vertebral fractures. Risedronate is also taken continuously on a daily basis. It is indicated for the treatment and prevention of postmenopausal osteoporosis and reduces the risk of both vertebral and non-vertebral fractures.

Calcitonin (salmon) is indicated for post-menopausal osteoporosis. It maintains bone mass by suppressing bone resorption. Its efficacy is thought to be related to its ability to inhibit the calcium pump that transports calcium out of bone cells into extracellular space.

Calcium requirements are raised during the years following the menopause. During the first 5 postmenopausal years women lose about 2 % of their bone mass per year, thereafter 1 % per year. Calcium supplements can be used to prevent bone loss when dietary intake is low. Evidence indicates that vitamin D3 is also important. A daily dose of has been shown to increase bone density and reduce the number of hip fractures and non-vertebral fractures.

Oral calcium can be given in the form of various calcium salts (carbonates, citrates, gluconates, lactates, phosphates). AII the salts are readily absorbed from the GI tract and there is little to choose between them. In patients with achlorhydria, calcium salts should be taken with food to maintain absorption.

Alternatively, calcium citrate may be preferable as its absorption is independent of gastric acid secretion. All calcium supplements can cause irritation of the GI mucosa and should be used with caution in patients with GI obstruction or ulcer.

Anabolic steroids may be used to prevent further bone loss in the elderly and to reduce the risk of hip fracture.


b-AGONISTS cause relaxation of uterine smooth muscle. They are given by i.v. infusion to suppress premature uterine activity in pregnant women followed by oral maintenance doses.

Lack of uterospecificity can produce significant cardiovascular side effects including myocardial ischaemia, fluid overload and potentially fatal maternal pulmonary oedema together with foetal tachycardia. Feelings f anxiety are also common.

Their effect on carbohydrate metabolism, causing a rapid and large rise in blood sugar, necessitates the use of extreme caution in diabetes, long term oral therapy may produce macrosomic babies.

Atosiban is a competitive oxytocin receptor antagonist. It inhibits tone and frequency of uterine contractions to delay preterm birth. It is more effective than b-agonists and is not associated with cardiovascular risk.

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