Self-Reported Breast Implant Illness: The Contribution Of Systemic Illnesses And Other Factors To Patient Symptoms Part 2
Aug 21, 2023
Perimenopause/Aging
Females entering perimenopause may develop a constellation of symptoms that may mirror self-reported BII complaints. Common symptoms include mood changes, anxiety, depression, difficulty concentrating, joint or muscle aches, sleep disturbance, and other symptoms.33 The typical perimenopausal symptoms of hot flashes or night sweats are not seen in all females undergoing these changes,34 and, therefore, perimenopause may not be recognized as a source of the problem in patients who are concerned that their breast implants are causing their symptoms. Patients with preexisting anxiety and depression who develop early perimenopausal symptoms and who are active on social media may attribute the normal physiological and hormonal changes of reduced estrogen levels in perimenopause as evidence of self-reported BII.
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Early perimenopause can present with symptoms associated with decreasing estrogen levels. These symptoms may mirror some of the most common symptoms associated with self-reported BII. These very early changes may precede more recognizable symptoms such as hot flashes and may be misinterpreted as a breast-related issue. In patients in which breast implants are associated with capsular contracture or other pain-related conditions related to the implants, the overlay of perimenopause and breast issues may create a false diagnosis of BII.
The natural process of aging, accelerating in menopause, can also produce many of the symptoms reported by patients with self-reported BII.35 These changes are consistent with the reduction of serum estrogen levels and the physiological effects of chronologic aging. The most common symptoms reported in menopause include vasomotor symptoms, sleep disturbance, fatigue, mood disorders including depression, cognitive changes including memory loss, joint pain, and hair loss. Most females demonstrate one or more age-related menopausal symptoms, whether or not there are breast implants present. This makes it unclear what part of a self-reporting BII patient’s symptoms may be attributable to the hormonal changes associated with perimenopause or menopause, rather than a specific effect from breast implants. Plastic surgeons should keep in mind the normal, physiological progression of aging and consider the symptoms of aging and menopause when evaluating patients with potential BII complaints. Further study of aging and systemic symptoms in the presence of breast implants is warranted. Table 2 presents that perimenopause/aging can present with symptoms much like self-reported BII, with the exception that the skin changes in perimenopause are more associated with dryness and pruritis rather than a skin rash.28
ADVERSE EFFECTS OF PRESCRIPTION MEDICATIONS TAKEN FOR CHRONIC ILLNESSES
Side effects of prescription medications are extremely common and may mirror other disease conditions. Currently, 51% of the US population takes at least one medication for a chronic health condition.36 Patients presenting with breast implants with or without breast-specific symptoms may manifest systemic side effects of prescription drugs which may mimic reported BII symptoms. For example, migraine medications, which are used for migraine disorders and taken routinely by millions of females, are associated with the common side effects of mood change, brain fog, fatigue, difficulty concentrating, memory issues, and other side effects.37
The most frequently prescribed medications for chronic conditions affecting females include antidepressants, thyroid medications, and migraine medications.38,39 These 3 distinct groupings of medications can produce side effects including anxiety, memory problems, insomnia, and other symptoms which are similar to those self-reporting BII symptoms. The most frequently prescribed agent for females below 50 years of age in the United States are antidepressants which also may be used to treat anxiety.39 These medications frequently require dosing adjustments and are associated with many known side effects.40 Patients with hypothyroidism are typically treated with Synthyroid (Abbvie, North Chicago, IL), which requires dosing optimization by monitoring thyroid-stimulating hormone (TSH) levels.41 Side effects of Synthroid are common until a steady state of TSH is reached and maintained. Migraine disease is commonly treated with triptans, such as sumatriptan or rizatriptan, while chronic migraine may be treated with topiramate (Topamax). Triptans work by binding to vascular serotonin receptors in the brain and producing vasoconstriction, while topiramate has gamma-aminobutyric acid and glutamate receptor activity.42 Both of these medication classes often produce significant side effects which may overlap with self-reported BII symptoms, including fatigue, memory issues or “brain fog,” and anxiety.43,44 Reviewing patient medications or referral to the prescribing physician to evaluate a prominent side effect from prescription medication is an important role for the plastic surgeon and may help rule out symptoms that are not related to the presence of breast implants.
Three of the most common prescription medication classes for chronic illnesses in females 30 to 55 years of age are presented in Table 3. The most common symptoms in self-reported BII patients are presented along with the common side effects which may be experienced by patients taking prescription medications in these drug classes.
Consumption: Cigarette Smoking, Marijuana Use, and Dietary Contributions to Systemic Symptoms
Several studies suggest an association between smoking and diet and self-reported BII symptoms. Wixtrom et al noted a higher incidence of marijuana use in females self-reporting BII symptoms compared to controls as well as the fact that more females with BII symptoms smoked cigarettes than controls.45 Cigarette smoking is known to be associated with increased rates of fatigue and depression46 and is known to increase the risk of joint pain and cartilage loss within joint structures.47 Marijuana use has been shown to produce “brain fog,” cognitive decline, anxiety, depression, fatigue, and hair loss with regular use.48-50 The studies reporting adverse reactions to smoking in the literature do not evaluate the presence of breast implants as a variable; however, the fact that these changes occur in both males and females worldwide makes it unlikely that the symptoms associated with smoking are dependent on the presence of breast implants. Further study of the association between the adverse symptoms of smoking and the presence of breast implants is needed.
Diet has also been reported to be associated with self-reported BII symptoms. Gluten sensitivity and wheat allergy were found to be statistically higher in patients with self-reported BII symptoms compared to patients undergoing silicone implant exchange or mastopexy in a recent prospective study.45 Nonceliac gluten sensitivity can present with many of the symptoms of autoimmune celiac disease, although the mechanism of this condition is unclear.51 It is more common in females, typically in the fourth decade of life, with prevalence varying from 1% up to 13% of the general population. Symptoms may include fatigue, headache, anxiety, abdominal pain, irritable bowel syndrome symptoms, and depression.52,53 Wheat allergy was also found to be elevated in patients with self-reported BII. Wheat allergy is mediated through immune food allergy mechanisms, primarily affecting the skin, gastrointestinal tract, and respiratory tract, and does not overlap extensively with BII symptom complaints.54
CONCLUSIONS
Systemic illnesses often produce symptoms similar to those described by patients with self-reported BII. Patients may be concerned that their breast implants are causing them illness when in fact they may have symptoms from a chronic illness, not yet diagnosed. In some patients, a combination of a known systemic illness and symptoms related to their breast implants may create a synergism, exacerbating overall symptoms. Patients with breast implants may also have a known, diagnosed, chronic illness but do not associate those symptoms with their diagnosed condition. Other factors, such as anxiety disorders, medication side effects, perimenopausal, and age-related changes, can also produce symptoms that patients may assume are implant related. Patients who have implant-associated problems such as capsular contracture or breast pain and who also have systemic symptoms from an unrelated illness or other factors may believe that they have BII because they have symptoms that are both systemic and local. In these cases, patients may only have a local problem, correctable with a revisional breast procedure.
The current paper focused on several of the most common systemic illnesses and factors affecting females in the 30- to 55-year-old age group which may be contributing to symptoms that patients with breast implants may experience. There are many potential systemic illnesses and many additional factors which may produce similar symptoms. The purpose of the work presented here is to encourage plastic surgeons and other medical specialists to consider the range of potential contributing factors to presenting symptoms so that patients concerned about self-reported BII can be appropriately evaluated and counseled.
Plastic surgeons should be patient advocates and carefully evaluate patient symptoms and concerns. It is the right of any of our patients to ask for an explanation, regardless of the reason. We must be good listeners, provide scientifically based answers to patient questions and concerns, and remain an advocate for our patients. It is also helpful to explain and show patients typical results of explantation, especially if there is little breast tissue present following explantation, and to outline reconstructive options. It is also suggested that if a patient has symptoms suggestive of a systemic illness which may be masked as self-reported BII, a thorough history and physical examination be performed by an internist or rheumatologist to rule out other conditions as outlined in this paper, before explantation.
In conclusion, systemic illness and other factors may play a major role in producing some of the symptoms that patients attribute to their breast implants. Plastic surgeons should be aware of the many potential causes of systemic symptoms and conduct a thorough interview with patients discussing their medical history, medications, and presenting symptoms. If a patient presents with self-reported BII symptoms and is concerned about the potential changes or deformity associated with implant removal, it may be helpful to refer the patient to the appropriate specialist to rule out other etiologies for systemic symptoms. This may help reduce the need to remove breast implants which may not be the cause of systemic symptoms in some patients.
Disclosures
The author declared no potential conflicts of interest concerning the research, authorship, and publication of this article.
Funding
The author received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.
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