OBSTETRICS

Breast-feeding and benign breast disease

S. Bernardi 1 , A. P. Londero 2 , S. Bertozzi 1 , L. Driul 2 , D. Marchesoni 2 & R. Petri 1

1 Department of Surgery and 2 Clinic of Obstetrics and Gynecology, AOU ‘ SM della Misericordia ’ , Udine, Italy

Correspondence: S. Bertozzi, Department of Surgery, Piazzale SM della Misericordia, 15 - 33100 Udine, Italy. E-mail: sere_d.estate@libero.it

1992; McDivitt et al. 1992; Sarnelli and Squartini 1991; Kelsey and Gammon 1990).

It is known that breast-feeding and pregnancy are protective against malignant breast disease and are risk factors for BBD (Ma et al. 2010; Minami et al. 1998). In the literature, it is not clarifi ed if there is a correlation between breast-feeding and its duration with BBD. Moreover, we have only little information about BBD aetiol-ogy and correlation to women ’ s reproductive function, despite its high prevalence in the young female population. Th e objective of our study is to investigate the possible correlation between BBD and breast-feeding.

Materials and methods

Th e series in this study consisted of women who presented to the Senology Outpatients Facility in our Department of Surgery dur-ing 2008, and a random control group of women who delivered in our Clinic of Obstetrics and Gynecology during 2008. Th is study was conducted according to the declaration of Helsinki, and with internal review board approval.

Women were referred to our outpatients facility complaining of breast pain, discomfort or incidental clinical fi ndings. Among 355 women with a diagnosis of BBD, we chose to include those in their fertile age, under 40 years, with a histological diagnosis of BBD or a confi rmed BI-RADS 1 – 2 (at least twice). We stated these selection criteria to minimise the possible inclusion of malignant pathologies. A total of 105 BBD and 98 controls were available for data analysis.

Information on reproductive history (age at menarche, age at fi rst birth, age at last birth, history of abortion, parity, history of lactation for the last and previous children); medical history (histories of benign breast disease and gynaecological disease and family history of breast cancer); and other information (e.g. age, BMI, use of contraceptive or any other hormonal therapy) was collected by telephone interview, at routine outpatients visits or consulting clinical fi les of women aff ected by BBDs. In the control group, we collected the following information: age, parity, breast-feeding and its duration.

Women aff ected by BBD were regrouped into two major cate-gories according to their parity (nullipara and non-nullipara). We then divided the non-nulliparous group of women who breast-fed, into two sub-groups based on breast-feeding duration. In particular, we took into consideration as duration cut-off the 3rd quartile of cumulative breast-feeding duration (corresponding to 20 months) and the 3rd quartile of breast-feeding duration per child (i.e. 13 months).

We evaluated breast size with a scale ranging from 1 to 8: 1 � 65 cm; 2 � 70 cm; 3 � 75 cm; 4 � 80 cm; 5 � 85 cm; 6 � 90 cm; 7 � 95 cm and 8 � 100 cm. We considered gynaecological age as

Journal of Obstetrics and Gynaecology, January 2012; 32: 58–61

© 2011 Informa UK, Ltd.

ISSN 0144-3615 print/ISSN 1364-6893 online

DOI: 10.3109/01443615.2011.613496

Benign breast disease (BBD) is very common among women in their fertile age, but its correlation with breast reproductive function remains unclear. Our study aimed to investigate the relation between BBD and breast-feeding. We collected data on 105 women with BBD and 98 controls, focusing on their reproductive history and breast-feeding. We analysed data by R (version 2.12.1) considering p < 0.05 as signifi cant. The results showed that fi broadenoma represented the most frequent BBD (55%), followed by fi brocystic changes (19%), intraductal papil-loma (6%) and infl ammatory breast disorders (5%). The mean age was 31.5 years ( � 6.1), BMI 21.2 kg/m 2 ( � 3.4) and age at menarche 13.0 years ( � 1.5). Duration of breast-feeding was not signifi cantly diff erent between controls and BBD types ( p � NS). Selecting women with fi broadenoma breast-feeding duration directly correlated with the number of benign lesions ( p < 0.05), which remains signifi cant also by multivariate analysis. It wasconcluded that there seemed to be no diff erence in breast-feeding among BBDs types, but lactation may infl uence the number of fi broadenomas. Moreover, prospective studies would better defi ne the correlation between lactation and BBDs.

Keywords: Benign breast disease , fi broadenoma , fi brocystic changes , lactation

Introduction

Th e vast majority of lesions that occur in the breast are benign, but much concern is given to malignant ones because breast cancer is the most common malignancy in women in Western countries (Caleffi et al. 2004; Fitzgibbons et al. 1998; Sarnelli and Squartini 1991). Th e most frequent benign breast disease (BBD) is fi broadenoma (FA) (Dent and Cant 1989), which undergoes abnormal growth during the fertile age, mostly due to the oestrogen exposure, infl uenced by age, parity and hormonal status (Anderson et al. 1982).

Breast palpable mass and breast pain are the most frequently reported symptoms by women with BBD, sometimes aff ecting their quality of life.

With the use of modern imaging of the breast and the extensive use of needle biopsies, the diagnosis of BBD can be accomplished without surgery in the majority of patients.

Th e term BBD encompasses a heterogeneous group of lesions that may present a wide range of symptoms or may be detected as incidental microscopic fi ndings. Th e incidence of benign breast lesions begins to rise during the 2nd decade of life and peaks in the 4th and 5th decades, as opposed to malignant diseases, for which the incidence continues to increase aft er menopause, although at a less rapid pace (Kabat et al. 2010; Shaaban et al. 2002; Pfeifer et al. 1999; Fitzgibbons et al. 1998; Morrow 1992; London et al.

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Breast-feeding and benign breast disease 59

the diff erence between the chronological age and the age at menar-che. We included in the category of infl ammatory breast disorders, only women who had been referred to the surgeon consultant for the following reasons: acute mastitis; granulomatous mastitis; foreign body reactions and recurring sub-areolar abscess. In the category of other BBDs, we grouped the following instances: iso-lated cysts; diabetic fi brous mastopathy; lipomas and adenomas. We defi ned BBDs as previously reported (Guray and Sahin 2006).

Data were analysed by R (version 2.12.1), considering p � 0.05 as signifi cant. Monovariate analysis was performed by t -test, one way ANOVA, Wilcoxon test or Kruskal – Wallis test, in case of continuous variables, and χ 2 -test or Fisher ’ s exact test, in case of categorical variables. Monovariate linear regression analysis and monovariate and multivariate logistic regressions were also performed.

Results

We included 105 women, younger than 40 years of age, aff ected by BBD, and 98 controls without BBD, and reported the charac-teristics of the population aff ected by BBD (Table I). Th e mean women ’ s age was 31.5 years ( � 6.1); age at menarche 13.0 years ( � 1.5); and gynaecological age 18.4 years ( � 6.4) (Table I). In the control group, the mean age was 32.3 years ( � 4.5), and no

signifi cant diff erence was observed in comparison with the BBD group ( p � NS).

Th e most common BBD was FA (55%), followed by fi brocys-tic changes (19%); isolated mastalgia (10%); intraductal papil-loma (6%); infl ammatory breast disorders (5%) and other BBDs (5%). Selecting only non-nullipara, FA and fi brocystic changes remained the most prevalent BBDs, but infl ammatory breast dis-orders were signifi cantly more common (8%) than in nullipara (3%) (Table II). We found a mean BMI of 21.2 kg/m 2 ( � 3.4) and a mean breast size of 2.8 ( � 1.0), that signifi cantly infl uenced BMI itself (eff ect 0.119; CI.95 0.051 – 0.185; p � 0.05).

We had 43 women (41%) with a positive familial history of breast pathology, which was malignant in 31 cases (72%) and be-nign in the other 12 cases (28%). In our study, 63 women (60%) used contraception and 44 (41%) had at least one pregnancy, with a mean age at fi rst pregnancy of 26.5 years ( � 5.4). Th e 86% of these mothers breast-fed for a mean cumulative time of 14.8 months ( � 13.1) and a mean time for each single pregnancy of 9.7 months ( � 8.9).

Th e chronological and the gynaecological age results were signifi cantly greater in women who had ever had a pregnancy ( p � 0.05), and show a direct correlation with parity.

We found a non-signifi cant diff erence in breast-feeding dura-tion between BBDs and controls (Figure 1); but we saw a non-signifi cant longer breast-feeding duration in women who suff ered from infl ammatory breast disorders (Figure 1).

Considering only FA, which represents a benign proliferative breast disorder without atypia, among women who breast-fed, there is a direct correlation between the breast-feeding duration and the number of benign lesions ( p � 0.05) (Tables III and IV), which remains signifi cant also by multivariate logistic regression analysis (Table IV).

Table I. Population characteristics.

Age (years) ∗ 31.5 � 6.1

Age at menarche (years) ∗ 13.0 � 1.5

Gynaecological age (years) ∗ 18.4 � 6.4

Weight (kg) ∗ 59.0 � 10.0

Height (cm) ∗ 166.6 � 6.3

BMI (kg/m ² ) ∗ 21.2 � 3.4

Cumulative lactation (years) † 12 (4 – 20)

Lactation per child (years) † 9 (3 – 13)

Age at 1st pregnancy (years) ∗ 26.5 � 5.4

Contraceptive use ‡ 60% (63/105)

Contraception time (years) ∗ 5.7 � 5.0

Parity ∗ 0.6 � 0.9

Nulliparity ‡ 58% (61/105)

Maximal lesion size (mm) ∗ 22.8 � 12.28

Breast size ∗ 2.8 � 1.0

Mastalgia ‡ 47% (49/105)

Pruritus ‡ 1% (1/105)

Nipple discharge ‡ 6% (6/105)

Previous breast surgery ‡ 39% (41/105)

Data are presented as: ∗ mean � SD, † median (IQR), ‡ prevalence.

Table II. BBDs prevalence in the general population, in nullipara and in pluripara women.

General population

( n � 105)

Nullipara

( n � 68)

Pluripara

( n � 37)

p value n (%) n (%) n (%)

Fibroadenoma 58 55 40 59 18 49 NS

Fibrocystic changes 20 19 13 19 7 19 NS

Infl ammatory

breast disorders

5 5 2 3 3 8 � 0.05

Data are presented as percentage and signifi cance is calculated between nullipara and pluripara with χ 2 -test or Fisher ’ s exact test.

Figure 1. Comparison of breast-feeding duration among BBDs and controls (median, interquartile range and Kruskal – Wallis test).

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60 S. Bernardi et al.

Discussion

Duration of breast-feeding it was not signifi cantly diff erent be-tween controls and BBD types, but duration of lactation is signifi -cantly correlated to the number of lesions in FA.

In our population, the most common BBDs were FA and fi bro-cystic changes. However, according to the literature, infl ammatory breast disorders were signifi cantly more common among women who had a pregnancy than in nullipara, being usually managed with antibiotics and, in the case of abscess, with percutaneous drainage with good aesthetic results (Romero et al. 2007; Amir and Pakula 1991).

Mastalgia is reported by 47% of women, and represents an isolated symptom in 10% of cases, in the absence of any other evi-dent breast disorder. In their fertile age, a great number of women are aff ected by mastalgia, probably depending on a combination of hormonal stimuli on the mammary gland, which cause pain by periodically increasing breast tension (Goyal 2011).

Focusing on the correlation between BBD and breast-feeding, our data reveal no signifi cant diff erences based on breast-feeding duration (Figure 1). However, selecting only women with fi -broadenoma, there seems to be a direct correlation between the breast-feeding duration and the number of benign lesions, which remains signifi cant also by multivariate analysis.

To our knowledge, we describe this correlation for the fi rst time. In the previous literature, we found a positive correla-tion between lactation duration and BBDs of proliferative type ( Minami et al. 1998), but not between lactation history and BBDs in general (Minami et al. 1998).

We know that hyperplastic lobules, histologically identical to clinical FA, are present so commonly as to be regarded as normal, and can probably be found in all breasts if they are sought with suffi cient care. All the cellular elements of FA are normal, and epithelium and myoepithelium maintain a normal relationship (Courtillot et al. 2005), but FAs are a proliferative benign breast

disease and present a small increase in breast cancer (BC) risk (Santen and Mansel 2005; Minami et al. 1998).

Nulliparity and increased age at fi rst birth were clearly associ-ated with hormone receptor-positive tumours, but not with triple-negative BC (Yang et al. 2011). Among women with invasive BC, higher parity and the absence or short duration of breast-feeding were independently associated with triple-negative BC (Shinde et al. 2010). Th erefore, even if parity is a known protective factor against BC in general (Yang et al. 2011; Ma et al. 2010), it seems to play a role, as well as lactation, in triple-negative BC and BBD development. In our opinion, a better understanding of the infl u-ence of pregnancy on those pathologies could give us more infor-mation on their aetiologies.

Despite the retrospective nature of our study, the detailed in-formation available gave us the opportunity to explore new and interesting correlations in the fi eld of BBD and pregnancy. We also point out that, to give a strong answer to our question, a pro-spective study is required.

Conclusion

In conclusion, lactation may infl uence the number of fi broad-enomas, but we need more information to better clarify the aetiologies of BBD of proliferation type. In fact, we need to bet-ter understand why people aff ected by some BBD will develop cancer more frequently than the general population. Moreover, prospective studies would better defi ne the correlation between lactation and BBDs in terms of disease evolution and impact on breast-feeding and that is of paramount importance for the newborn.

Declaration of interest: Th e authors report no confl icts of inter-est. Th e authors alone are responsible for the content and writing of the paper.

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Table III. Comparison of nullipara with pregnant women who cumulatively breast-fed more or less than 20 months, and who breast-fed more or less than 13 months/child.

Nullipara

Breast-feeding

� 20 months � 20 months p value � 13 months � 13 months p value

Age (years) ∗ 29.5 � 6.2 35.1 � 3.8 36.1 � 4.3 � 0.05 35.7 � 3.0 34 � 6.53 � 0.05

Gynaecological age (years) ∗ 16.1 � 6.4 22.3 � 4.1 23.2 � 4.1 � 0.05 22.8 � 3.5 21.1 � 6.07 � 0.05

BMI (kg/m ² ) ∗ 20.8 � 2.7 22.1 � 4.7 21.0 � 1.9 0.279 22.1 � 4.5 20.7 � 1.9 0.248

Breast size ∗ 2.6 � 0.8 3.1 � 1.4 2.5 � 0.4 0.230 2.9 � 1.3 4.0 � 1.4 0.139

Fibroadenoma † 59% (40/68) 46% (13/28) 56% (5/9) 0.540 53% (16/30) 29% (2/7) 0.300

Fibrocystic changes † 19% (13/68) 21% (6/28) 11% (1/9) 0.790 20% (6/30) 14% (1/7) 0.941

Infl ammatory breast disorders † 3% (2/68) 3.6% (1/28) 22% (2/9) � 0.05 3% (1/30) 29% (2/7) � 0.05

Lesion number ( � 2) † , ‡ 15% (6/40) 0% (0/13) 80% (4/5) � 0.05 13% (2/16) 100% (2/2) � 0.05

Data are presented as: ∗ mean � SD and as † prevalences (with absolute values). Signifi cance is calculated with χ 2 -test or one-way ANOVA. ‡ Only fi broadenomas.

Table IV. Correlation between � 2 locations of fi broadenoma and breast-feeding duration by mono- and multivariate logistic regression.

Monovariate regression Multivariate regression

OR 95% CI p value OR 95% CI ∗ p value

Months of

lactation

1.05 1.00 – 1.08 � 0.05 1.01 0.99 – 1.09 0.056

Months of

lactation/child

1.07 1.01 – 1.16 � 0.05 1.06 1.00 – 1.17 � 0.05

Data are presented as odds ratio (OR) and 95% confi dence interval (95% CI). ∗ In the multivariate model, we corrected for: age, parity, BMI, hormonal contraception usage and menarche.

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Breast-feeding and benign breast disease 61

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