Fibrocystic Breast Disease and Perimenopause
Frederick R. Jelovsek MD
"Are there any herbs or natural treatments, other than less caffeine to help in treatment of fibrocystic breast disease? And why do the cysts keep getting harder? Does HRT therapy aggravate the situation?
I am a 52 year old female, and was on HRT from 45 to 51 when cysts began to be more frequent and harder. I take vitamins and exercise on a regular basis. I would like to continue the HRT for other health benefits if it does not hinder the cysts. I am not currently taking anything prescribed by a doctor but am taking the herb black cohosh as my friends say it is helpful to them. ". Sasha
Fibrocystic breast disease is an improper name; it is really a condition made up of many different pathological changes which we do not fully understand. Perhaps it should be called a syndrome or fibrocystic breast condition. There are three cell components involved: the skin lining the breast milk ducts (epithelium), the glands of the breast and the supporting stromal cells or matrix of connective tissue that lends fibrous fullness to the breasts.
In general, estrogen stimulates growth of the ductal epithelium and growth of the supporting stroma or fibrous connective tissue. Progesterone or synthetic progestins make the glandular tissue grow. In pregnancy when both estrogen and progesterone are very high, the breasts are very full and almost hard. In menopause, without hormone replacement, the breasts are the opposite. They are collapsed and soft.
Does hormone replacement therapy worsen fibrocystic breast disease?
Yes. Hormone replacement (HRT) worsens fibrocystic breast conditions, especially if the HRT includes a progestin. It is interesting that some HRT is worse than others depending upon which progestin is used; cyproterone acetate and medroxyprogesterone acetate seem to produce higher incidences of fibrocystic change on x-ray (1). This goes along with the concept that both estrogen and progesterone (progestin) are needed to stimulate breast fibrocystic growth. It is also noteworthy that oral contraceptives earlier in life seem to lessen all benign breast conditions including fibrocystic changes (2, 3). This implies to me that certain progestins are worse than others because medroxyprogesterone acetate is not used in oral contraceptives. Remember that it is the combination of estrogen and progestin that gives the problem because medroxyprogesterone acetate alone does not seem to worsen the incidence of fibrocystic changes (4).
My first suggestion would be that if you have a problem with fibrocystic breast changes around the menopause, ask your doctor not to prescribe HRT containing medroxyprogesterone acetate (Provera®) such as Prempro® or cyproterone acetate. There are some newer hormone replacement therapy regimens that contain the same progestins as contained in birth control pills. such as Precept®.
A second suggestion that may or may not apply in your case is to be sure you are menopausal to the extent the ovaries are not functioning at all. This would be evident by a high serum FSH value. The reason I mention this is that there are many doctors who are recommending post menopausal hormone replacement during the perimenopause period. While there are pros and cons to this, if your body is still producing estrogens and progesterone, then adding an extra dose of HRT only makes the fibrocystic changes and pain worse.
Are there any herbal or natural treatments that can be used to less fibrocystic breast disease?
Vitamin E has been shown to produce a slight improvement in cyclical breast pain (5). There is also some suggestion that vitamin A may be able to play a role in decreasing fibrocystic changes (6). On the other hand, vitamin B6 and oil of evening primrose have not worked out very well to lessen breast pain from fibrocystic changes. One of the components of oil of evening primrose, however, called gamolenic acid, does show some promise (7)
I am not aware of any other herbal therapy that professes to improve fibrocystic changes. As far as I know, black cohosh has not been studied as to any effects on fibrocystic breasts or breast pain. It does function as a phytoestrogen and perhaps it blocks some of the estrogen receptors like tamoxifen does (8).
Within essential oil/aromatherapy, skin application of something that has carrot seed oil, rich in vitamins A, B1, B2 and C, may be a benefit. It is said to be useful in PMS although there are no medical studies I could find.
Why does caffeine seem to worsen the pain from fibrocystic breasts?
Coffee consumption does not increase the incidence of breast cancer (9) although it definitely worsens fibrocystic change (10). Discontinuing caffeine and all methlyxanthines such as in chocolate and theophyllin in some asthma medicines results in significantly less pain (11).
Remember that caffeine is also in tea, soft drinks and many over-the-counter meds so you should carefully examine everything you are ingesting to make sure caffeine is at zero.
Do birth control pills worsen or cause benign fibrocystic breast conditions?
They do not seem to. In fact the incidence of fibrocystic change seems to be less on oral contraceptives, especially at today's low doses (2, 3).
What treatments are there to lessen fibrocystic breast changes?
The most effective treatment of fibrocystic breast changes is an anti-estrogen called tamoxifen (12, 13). This drug is also used in the treatment of breast cancer. It is very likely that raloxifene (Evista®) which is very closely related to tamoxifen, also improves fibrocystic breast conditions. I have not seen any studies using raloxifen yet, however.
Danazol which is an androgenic hormone has also been used to improve pain associated with cystic change (14), but in a comparison trial, it was not as good as tamoxifen ( 15)
To summarize the steps you should take to lessen the pain and fullness from fibrocystic breast change:
- Make sure you are at zero caffeine by examining everything you ingest including asthma and pain medicines. For most women, this is the only treatment needed.
- Take the lowest estrogen and progesterone hormone replacement dose possible the keep menopause symtpoms under control. Do not use HRT containing medroxyprogesterone acetate.
- Use vitamin A and E supplements. Try the black cohosh to see if it helps.
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