In this interview, JJ Virgin asks a breast specialist to walk through the clinical management of a perimenopausal woman who discovers a breast lump. The specialist explains that many breast changes in this age group are related to hormonal fluctuations (fibrocystic changes) and advises a watch‑and‑wait approach tied to the menstrual cycle, noting that irregular cycles in perimenopause may prompt earlier evaluation. The diagnostic work‑up begins with a clinical exam to distinguish solid from cystic lesions, followed by imaging—diagnostic mammogram and targeted ultrasound. Cystic lesions are usually benign and can be aspirated in‑office; solid lesions require tissue diagnosis via fine‑needle aspiration or image‑guided core biopsy. Pathology results (benign, atypia, or cancer) dictate subsequent steps. The conversation ends with a question about how to manage cancer treatment while the patient is simultaneously experiencing perimenopausal symptoms, highlighting the need for coordinated symptom control during therapy.
Someone, uh, let's, let's give you a hypothetical patient. She's just in perimenopause and not on anything yet, starting to have those symptoms of perimenopause, finds a lump. Walk us through, be like, if she were your patient, what would she be going through? Like how should she be handled?
Okay. So the first thing to know is that Many women have the so-called lumpy, bumpy breasts or fibrocystic breasts. And in the second part of someone's menstrual cycle, when progesterone is produced, sometimes people will actually feel their lumpiness in a more discrete way, meaning someone can think they feel a lump. It may actually be due to the hormonal changes of the cycle. So the first thing that I tell someone to do is let's wait and see what happens with your next menstrual cycle. Now, the problem in the perimenopause is sometimes cycles are spacing out. So if they don't get a cycle in a few weeks, I'm gonna want them to come in and get that lump evaluated. Um, when someone has an evaluation of a lump, first thing is it usually includes a clinical exam. To determine whether something is likely solid or cystic. Cysts are, by and large, almost 100% of the time benign. A cyst can be aspirated even in the office. And if fluid is obtained, you can see if that goes, that lump goes away, bring someone back again for a follow-up exam, make sure it goes away. Many people don't do aspirations in their office and they send someone for imaging. Imaging includes getting a diagnostic mammogram to target into that area and a diagnostic ultrasound. Ultrasounds are really helpful, mainly in telling if a lump that's there is solid or cystic. Again, if it's a cyst, it's benign. With benign cysts, like people who have these so-called fibrocystic changes, they get these discrete cysts and we don't aspirate them because they can come back. We aspirate them only if they're really big and really painful. If it's a solid lump, that needs to be evaluated. So people will get some sort of tissue diagnosis. If you can feel it, they get what's called the fine needle aspiration. If you had sent someone for a mammogram and it was only seen on mammogram, they can get mammogram-guided biopsies. And then everything depends on what that biopsy shows. You know, it can be benign tissue, it can be atypical tissue, and it can be cancer. And depending on those results determines sort of what's the next steps and, and where they're going to go from there.
And if it's cancerous, so now they're going in for cancer treatment while they're having all their perimenopausal symptoms, there are— how do you keep them from going absolutely crazy? With the two things going on at once?
Yeah, that's a great question. Again, one of the things I always want to see is what's the treatment going to involve? Because there are many, many different types of treatments that people get. They get different types of surgery, lumpectomy, mastectomy. Some people get radiation. If they have hormone-positive disease, they're going to be recommended Hormonal therapies. There are different side effects with tamoxifen versus aromatase inhibitors. To use an aromatase inhibitor, you have to be menopausal. That means if you're perimenopausal, they're going to throw you into menopause by giving you shots to shut your ovaries down, or we sometimes surgically remove the ovaries. If you're hormone negative, you may get chemotherapy. So a lot depends. I always work closely with my breast team to understand, okay, What are the steps that are going to happen? And then I can more aptly guide someone. So if I know that their treatment is going to include something like an aromatase inhibitor, we're going to be aggressive at talking at that initial visit of, you're likely going to have a worsening of your temperature dysregulation. Let's go through the different options that we can give you if that starts to become a problem. I know when you're on an aromatase inhibitor that you're probably gonna have horrific vaginal dryness cuz those drugs shut down all estrogen production in the body. Let's talk about what you can do to be proactive at preventing some of that. So there's a number of over-the-counter things that people can try, and the recommendations actually from organizations like the NCCN are to try over-the-counter things first before we talk about the use of vaginal estrogen. I'm going to talk to them about their diet. I'm going to talk to them about their sleep. When you're diagnosed with cancer, people tend to have a lot of anxiety. So we're going to talk of ways of doing stress reduction. We're going to talk if we need supplements when it comes time for sleep. To try and keep their mind from going. So there's a lot of things that I think we can talk to people about beforehand that allows them to be a little bit better prepared for all of these treatment-induced side effects.
