Frequently Asked Questions
I was born with an extra nipple. Should I have it removed?
The most common variation to appear at birth is polymastia—an extra nipple or nipples. These can appear anywhere along the milk ridge. Usually the milk ridge—a throwback to the days when we were animals with many nipples—regresses before birth, but in some people it remains throughout life. Between one and five percent of extra nipples are on women whose mothers also had extra nipples. Usually they’re below the breast, and often women don’t even know they’re there, since they look like moles. Extra nipples cause no problems and usually don’t appear cosmetically unattractive, though they may lactate if you breastfeed. There’s nothing wrong with this, unless it causes you discomfort.
Unless the extra nipple or breast tissue causes you extreme physical discomfort or psychological distress, there’s no need to worry about it. If it does bother you, it’s easy to get rid of surgically under local anesthetic in your doctor’s office.
What is causing my breast pain and what can I do about it?
About 70% of women will experience breast pain (called mastalgia) at some point in their lives—and it is one of the most frustrating clinical problems for doctor and patient alike.
To start with, it is important to gain as much information as possible about the pain. When you go to your doctor, it would be helpful if you can explain whether the pain is cyclical, and therefore more likely to be related to hormonal changes or water retention at certain times in your menstrual cycle, or noncyclical, and therefore more likely to be due to direct pressure on a nerve in the neck or chest wall.
Other factors that may contribute to breast pain in some women include birth control pills, menopausal hormones, weight gain, and bras that do not fit properly. Women who experience breast pain beyond the first few days of breastfeeding should speak with their doctor or lactation consultant.
Some women experience pain that is due to water retention but does not seem to correlate with the menstrual cycle. This observation has led researchers to look for environmental or nutritional causes for the pain, but as of yet there are no clear answers. Currently, there is no evidence that certain vitamins can help control breast pain. Even so, some women say they have found some relief by taking vitamin B6, vitamin B1, and vitamin E.
A second hypothesis, called the “methylxanthine hypothesis,” promotes the idea the methylxanthine (caffeine) found in coffee, tea, chocolate, and cola, could be associated with water retention, proliferation of cells, and, in turn, breast pain. Although this is a plausible mechanism, controlled trials, in which women are randomly given caffeine tablets or a placebo and then asked about their breast pain, have not found caffeine to be associated with breast pain.
Some women have found wearing a good, supportive bra, like a sports bra, even at night, can help reduce breast pain. Others have tried reducing sodium intake, maintaining a low-fat diet, going on the birth control pill, and losing weight (if they are overweight).
A clinic in Cardiff, Wales, tested evening primrose oil, a natural form of gamolenic acid, and found it relieved the breast pain in 44 to 58% of the women with moderate to severe pain who tried it. Evening primrose oil can be purchased at health food stores as capsules containing 500mg of gamolenic acid. Six capsules should be taken twice a day. Because it can take awhile for the evening primrose oil to have an effect, it is recommended the initial trial period last four months. If after four months the pain has decreased, the evening primrose oil should be continued for another one to two months and then discontinued. This treatment should not be tried if you are pregnant or trying to get pregnant as it can cause miscarriage.
Another option is over-the-counter pain medication. Most likely, though, you will need to speak with your doctor about prescription medications that are more effective but are also associated with more side effects. The two most commonly used drugs to treat breast pain are bromocriptine (brand name Parlodel) and danazol (brand name Danocrine).
Parlodel lowers prolactin levels and has been found to be effective for cyclical breast pain in double-blind placebo-controlled randomized trials. Its side effects may include dizziness, upset stomach, headache, fatigue, vomiting, and constipation. You can decrease the chance that you will experience these side effects by starting on a low dose, going up in dosage incrementally, and using the lowest dose that is effective for you. Parlodel should not be used if you are on the birth control pill.
The steroid pain medication Danocrine has also been shown to be effective in controlled trials at reducing severe cyclical breast pain. It can be effective at very low doses, such as 100mg every other day. The side effects, which are seen primarily in women who take higher doses (600–800mg/day), may include a decrease in breast size; a deepening of the voice, hoarseness, or sore throat; weight gain; water retention and bloating; sweating; vaginal dryness, burning, itching, or bleeding; depression; irritability; and changes in the menstrual cycle. Also, Danocrine cannot be taken if you are on the birth control pill, pregnant, or breastfeeding. The drug tamoxifen, which is a hormonal treatment for breast cancer, also has been shown to be effective in reducing breast pain. The recommended dose is 10mg/day. It is usually given as a three-month trial, which is repeated if the pain recurs after the tamoxifen is stopped.
If no underlying cause can be found for noncyclical breast pain, and if the pain is in a specific area of the breast, trigger point injections with local anesthetic and, if necessary, steroids may be effective.
It is difficult to conduct research on breast pain because oftentimes the pain will just resolve on its own. It is not rare for a woman to have one episode of severe pain during her lifetime. It often lasts for a few months, begins to decrease and ultimately go away.
That’s why doctors will want to know how long you have had symptoms and will typically not prescribe medication until you have been experiencing the pain for three months or longer and have found the other methods of relieving pain not to be effective.
My breast is horribly itchy. What should I do?
Nipple itching can be very aggravating, but it is not dangerous. If you have been checked for Paget’s disease and it is not present, your doctor may prescribe a strong steroid cream or an oral anti-itch medication. You might also see a dermatologist for advice on a good anti-itch medication that will not also cause excessive drowsiness. Oil of evening primrose, which is used to treat breast pain, may also be helpful, as well as soy or flaxseed oil. Make sure you are wearing a bra that is not made of a material that is aggravating the itching; cotton is the best choice. You may also want to switch to a laundry detergent that is chemical-free, as that may be contributing to the problem as well. In addition, dryer additives (sheets of softeners) often have chemicals in them that make people itch.
My nipple suddenly became inverted. Is this normal?
Although nipple inversion can be a symptom of breast cancer, it can also be totally benign.You should note whether your nipple is inverted all the time, or if it spontaneously goes in and out under various conditions.
Once you’ve noticed your inverted nipple, you should see a breast specialist for a clinical breast exam, a mammogram, and perhaps an ultrasound of the area behind the nipple. If the exams are all negative, then this may be just a case of benign nipple retraction. Benign nipple retraction does not have to be treated, but it is still important to have it examined by a physician. Surgery can be done to correct it, but it is not always successful, will make future breastfeeding impossible, and may lessen nipple sensation.
Should I do a monthly breast exam?
Studies have not shown that women who do monthly breast exams are less likely to die of breast cancer than women who do not. The most important thing is to be familiar with your breasts so that, when getting dressed or in the shower, you’ll know what’s normal for you and recognize a change.
To start this process, look at your breasts. Stand in front of a mirror and look at yourself. See how your breasts hang and get a sense of how they project. If you’re young they’ll tend to stick out; if you’re older they’ll tend to be more droopy. Feel the inframammary ridge, where the breast folds over itself, and the underlying muscles, the pectorals. Look at your nipple—what color is it? Does it have hairs or little bumps on it? If so, that’s perfectly normal. You might want to swing your arms around and watch how your breasts move, or don’t move, with the motion. Put your hands on your hips; flex your muscles; stretch your arms up. How do your breasts look with each change of position?
It’s important to do this nonjudgmentally. Your aim is to learn about your body. Forget everything you’ve learned about what breasts are supposed to look like. These are your breasts and they look fine.
The next step is to feel your breasts. It’s best to do this soaped up in the shower or bath so your hands slip very easily over your skin. Put the hand of the side you want to explore behind your head. This shifts the breast tissue beneath your armpit to over your chest wall. Since the tissue is sandwiched between your skin and your chest bones you have good access to it. If you’re very large-breasted, you may want to do it lying down, in the bathtub or even in bed. You should roll on one side and then the other to shift the breast closer to your chest wall, so you can get a better feel for it.
Breast tissue generally has a texture that is finely nodular or granular, like large seeds. A lot of this more or less bumpy feeling is the normal fat that intermingles with the breast tissue.
Lumpy breasts are caused by the way the breast tissue forms itself. In some women, the breast tissue is fine and thus not perceived as “lumpy.” Others clearly have lumpy breasts, which can feel somewhat like cobblestone paving. Still others are somewhere between the extremes—just a bit nodular. There’s nothing unusual about this—breasts vary as much as any other part of the body. Your breasts might be a little more nodular near your armpit or at the top, for example, and the pattern may be the same in both breasts or may occur only in one. You’ll find, if you explore your breasts, there’s a general, fairly consistent pattern. It’s important to become acquainted with your breasts and get a sense of what your pattern is.
What is a fibroadenoma?
A fibroadenoma is a smooth, round, nonmalignant lump that feels hard, like a marble, and moves around easily within the breast tissue. It is often found near the nipple but can grow anywhere in the breast.
Fibroadenomas usually develop during puberty and the teenage years, as the breasts are getting used to hormonal cycling, but they can occur at any age, up until menopause. In most cases, a woman has only one fibroadenoma; it’s removed, and she never gets another. However, some women get multiple fibroadenomas over their lifetime, or get more than one at a time.
Fibroadenomas can vary in size from as small as 5mm to as large as a lemon-sized 5cm. A doctor can usually tell simply by feeling the lump that it’s a fibroadenoma. To be certain, she can collect a few cells through a fine needle aspiration or a core biopsy and send them off to the lab. Fibroadenomas are usually distinct on a mammogram or ultrasound test. They are harmless in themselves and don’t need to be removed as long as we’re sure they are fibroadenomas.
Some doctors will insist on removing all fibroadenomas on the theory that a cancer might be present. It’s not a very sensible attitude, especially if a core biopsy has proven the lump is a fibroadenoma, because of both the rarity and the lack of danger.
Because adolescents are less likely to get breast cancer than are older women, their fibroadenomas do not need to be removed, unless they want them to be. If the doctor and the patient want the fibroadenoma removed, it can be easily done under local anesthetic. The surgeon simply makes a small incision, finds the lump, and takes it out. Another option is to have a minimally invasive procedure in which the fibroadenoma is frozen in place under ultrasound guidance. It is almost painless because the cold is numbing, and it takes about a half hour in a doctor’s office. Within about a year or two the fibroadenoma disappears.
Fibroadenomas in no way predispose you to cancer, and they don’t turn into cancer. They’re a nuisance, and they can scare you into thinking you might have cancer, but that’s the worst thing about them.
Is nipple discharge normal?
Most nipple discharge is benign and not related to an abnormality. Discharge can range in color from white to yellow to green and even bluish green. This is known as physiologic discharge and is not associated with breast cancer. If the discharge is clear and thick, like mucus, this should be investigated as thoroughly as if it were bloody.
A key question is whether the discharge is spontaneous, or whether it occurs only when the nipple is squeezed. It is less of a concern if the discharge occurs only when the nipple is squeezed, since most women can elicit discharge if they squeeze their nipple.
If the discharge is spontaneous, you should consider going directly to see a breast specialist, meaning a surgeon who specializes in breast diseases. The specialist will perform a clinical breast exam and, if appropriate, a mammogram and an ultrasound. The discharge should also be examined to see if it contains blood.
If the breast exam is negative but the discharge tests positive for blood, a ductogram should be done. This is a procedure in which dye is inserted through the duct and then X-rays of the duct system are taken. A ductogram allows the surgeon to identify which duct system is bleeding and determine whether there is a blockage in the duct that might be causing the discharge. (Think of a pipe that is rusty on the inside and gets blocked; when the rust breaks off it will come out the end of the pipe, making the water discolored.) It is best to have the ductogram done at a breast imaging center that has experience in doing this type of breast X-ray. Your doctor may also suggest that you have a ductoscopy, which involves threading a very tiny catheter into a milk duct through the nipple to see what is causing the discharge.
It is possible the surgeon will find you have an intraductal papilloma—a benign growth. This is most often identified by the presence of a spontaneous bloody nipple discharge. On rare occasions the discharge can be because you have pre-cancer called ductal carcinoma in situ (DCIS). But this really is rare. Only four percent of spontaneous bloody nipple discharge is found to be related to breast cancer. Even so, it is important and necessary to have the discharge examined by your physician.
It is also worth noting that smoking, hypertension, birth control pills, and some tranquilizers can influence nipple discharge because they stimulate prolactin, the hormone that influences lactation. So if you smoke, take the pill or tranquilizers, or have hypertension, you should mention this to the breast specialist.
What is ductoscopy?
Ductoscopy, also referred to as mammary endoscopy, involves inserting a small fiberoptic scope into the ductal openings of the nipple to look at the lining of the ductal system on a monitor or screen. This provides a window into the ductal system to help identify abnormalities. The procedure can be performed in an operating room or an outpatient setting.
Ductoscopy is not used as a risk assessment tool. Most often, it is performed on a woman who is experiencing a spontaneous nipple discharge that is either bloody or clear and thick, like mucus. By inserting the scope into the duct with the discharge, the clinician is able to see what is causing the problem. This discharge is typically the result of a benign growth called a papilloma, and with the ductoscope the surgeon can see the papilloma and determine the best place to make an incision to remove it.
The procedure takes a relatively short period of time to perform and causes minimal discomfort. Typically, when done in the outpatient setting, a numbing cream is applied to the nipple anywhere from 30 minutes to 2 hours prior to the procedure. The nipple is then cleaned and made numb with a local anesthetic. A small probe is inserted into the duct that will be examined to dilate the ductal opening. Then, the scope is put inside the duct. Once the scope is inside the ductal system, it can be visualized on a monitor that is connected to the scope. Some patients report some pain in the nipple or at the surface of the nipple. Others report a feeling of fullness or pressure in the breast, which usually subsides in less than two days. There are generally no lasting after effects of the ductoscopy procedure.
Researchers are currently investigating whether using ductoscopy during a lumpectomy can help ensure the surgical margins surrounding the tumor are free of cancerous cells. They are also exploring other ways in can be used to diagnose and treat breast cancer.
What is fibrocystic disease?
Fibrocystic disease is basically a meaningless umbrella term, a basket into which doctors throw every breast problem that isn’t cancerous. The symptoms it encompasses are so varied and so unrelated to each other that the term is wholly without meaning. To an examining doctor, fibrocystic disease can be swelling, pain, tenderness, lumpy breasts (a condition not to be confused with breast lumps), nipple discharge, and basically any noncancerous thing that can happen in or on the breast.
To a pathologist, fibrocystic disease is any one of about 15 microscopic findings that exist in virtually every woman’s breasts and never reveal themselves except through a microscope. They cause no trouble and they have no relation to cancer—or to anything else, except the body’s natural aging process. Only one of these microscopic findings is a danger sign: It’s called atypical hyperplasia, and combined with a family history of breast cancer, it can suggest an increased breast cancer risk.
You probably went to the doctor because you were having a problem with your breasts. You should talk with your doctor about that specific problem, not the meaningless term fibrocystic disease.
What should I do about a breast cyst?
Cysts occur typically in women in their 40s and early 50s, and are most common in women approaching menopause. Younger women or postmenopausal women rarely get cysts. A gross (large) cyst is a fluid-filled sac, very much like a blister. It is smooth on the outside and squishy when felt. However, cysts feel like typical cysts only when they are close to the breast’s surface. Cysts that are deeply embedded in the breast distend the tissue, pushing it forward, so they can feel like hard lumps.
Usually a woman will get one or two cysts in her entire life. But a few women get many cysts, and those can return often. In this case, the chances are good they’ll continue to get them until menopause. In the interest of caution, recurring multiple cysts ought to be aspirated every three to six months. While the cysts themselves are harmless, they shouldn’t be ignored.
A cyst may also show up as an area of density on a routine mammogram. An ultrasound test can confirm if it’s a cyst or a solid lump. In this case, as long as the cyst doesn’t bother you, there’s no need to have it aspirated. There’s only a one percent incidence of cancer in cysts, and when a cyst is malignant it is a seldom-dangerous cancer called intracystic papillary carcinoma, which usually doesn’t spread beyond the lining of the cyst.
Alternatively, your doctor may aspirate the cyst by puncturing it with a very fine needle. Sometimes a doctor will aspirate a cyst and won’t get any fluid for a number of reasons. The lump may not be a cyst but another kind of nonmalignant solid lump. Or the doctor may have missed the middle of the cyst, which is relatively easy to do, especially when the cyst is small. Operating on a cyst should be a last resort—it simply isn’t necessary in any but the most unusual situation.
It isn’t true that aspirating a cyst is dangerous in a woman who may have breast cancer; the process of aspiration won’t spread the cancer over the needle’s track as feared. Any dominant lump should be aspirated before it is biopsied.
Cysts don’t increase the risk of cancer, but every lump should be checked out to be sure it isn’t dangerous.
Do breast enhancement pills and creams work?
Manufacturers of breast supplements proudly proclaim their products will “feed,” “develop,” “nurture,” and “beautify” a woman’s breasts. And in case you have doubts, they provide first-person testimonials and scientific statements to bolster the belief these products do, indeed, work. But do they? Is there any basis for these claims?
The answer: There is no evidence that any of the current dietary supplements marketed for breast enhancement are effective or that the science they use to support their claims is credible.
Companies can make these claims because there is no federal entity that oversees “holistic” or “homeopathic” products. As a result, these products do not need to be approved by the US Food and Drug Administration or even proved effective before they can be sold.
Breast enhancement products typically exploit common misunderstandings about what herbs and “phytoestrogens” can and cannot do. Product advertisements typically claim that since a woman’s estrogen is what naturally causes her breasts to grow, phytoestrogens like soy, red clover, flaxseed, black cohosh, saw palmetto, and wild Mexican yam will do the same. But that is not how soy and other phytoestrogens work. These products actually have an antiestrogenic effect on the breast in premenopausal women. (In postmenopausal women they appear to have more of an estrogenic effect.) This means that even if these products contained what the manufacturers claim they do (and they don’t always), they would not be able to make a woman’s breasts grow.
Further, and more importantly, if these products could enhance breast size, they would actually be dangerous. That’s because if they did work, the estrogen they were exposing women to could, in fact, increase their risk for breast cancer.
The bottom line: Your breast size is as genetically determined as your hair color or your height. About one-third of your breast is fat tissue; the other two-thirds or so is breast tissue. If you gain weight, the fat in your breast will grow along with the fat in other parts of your body and your breasts will become larger. In turn, if you lose weight, you will lose fat in your breasts and your breasts will become smaller. Since you can’t make yourself lose or gain weight in one specific part of your body, you can’t gain weight only in your breasts. The only real option for enhancing breast size, other than certain types of bras or silicone breast implants, is exercises that build the chest muscles that support your breasts. These exercises won’t actually change your breast size, but they may make your breasts look larger.
I am almost in menopause but still sometimes have breast tenderness. Why?
Breast tenderness can be worrisome and upsetting, but it usually doesn’t signify anything serious. Even so, if you haven’t had a breast exam or a mammogram within the last year, and you have any focused areas of pain or recent changes in breast sensitivity, you should check with your clinician.
The tenderness is likely due to hormonal changes. Levels of estrogen and progesterone fluctuate wildly throughout perimenopause, and breast tissue responds. Breasts often get tender when estrogen levels rise, and during perimenopause there are times when estrogen levels are much higher than they were during our reproductive years.
While it would be nice to have a sure cure for breast tenderness, we don’t. Although many people talk about eliminating caffeine as a first step, studies haven’t shown this to be helpful. Some physicians, who believe that the pain comes from water retention, recommend diuretics (“water pills”). But there is little evidence that these medications help. Others have suggested everything from ginseng tea, vitamin A, vitamin B complex, and antibiotics, to a firm support bra. Meditation and visualization techniques can be effective in reducing pain, and they may help relieve cyclical breast pain.
The prescription drugs danazol (brand name Danocrine) and bromocriptine (brand name Parlodel) have been shown to have some benefit, but they should be used as a last resort. Unless your breast tenderness is intolerable, the potential relief from these drugs won’t be a reasonable trade-off for the side effects and the expense of drug treatment.
There is some good news. Once you are past menopause, the tenderness should subside if you don’t take estrogen.