Case Study: Pseudoangiomatous Stromal Hyperplasia (PASH) of the Breast – Molly Jarchow, ND
Case Study: Pseudoangiomatous Stromal Hyperplasia (PASH) of the Breast
Molly Jarchow, ND
Understanding PASH, its diagnosis, and holistic approaches to managing hormonally sensitive breast conditions.
This case study examines a 41-year-old patient diagnosed with Pseudoangiomatous Stromal Hyperplasia (PASH), highlighting the diagnostic process, hormonal influences, and personalized treatment strategies to optimize breast and hormonal health.
Patient Presentation and History
Personal and Family History
A 41-year-old female presented with concern about a lump in her left breast first noticed 6 weeks prior. The mass had not changed in size, was non-tender, and was unaccompanied by other breast symptoms except bilateral cyclical mastalgia. She had no history of breast masses or breast cancer.
Her personal medical history included polycystic ovary syndrome (PCOS) and Hashimoto’s thyroiditis, both well-controlled with a lower-carbohydrate and gluten-free diet and an active lifestyle. She was homozygous for the MTHFR A1298C mutation. She had not used hormonal contraceptives for over 20 years. Still, she had applied high-dose bioidentical progesterone cream for many years in her 20s to induce withdrawal bleeds due to PCOS-related anovulation. This use ceased more than a decade ago after her cycles became regular. She had never been pregnant and took no medications.
Her supplements included intermittent use of an active B complex, NAC, inositol, Rhodiola, fish oil, and vitamin D. She had no prior mammograms, but a breast ultrasound 22 months earlier was normal.
Family history revealed breast cancer in her maternal grandmother (diagnosed in her 70s) and paternal aunt (diagnosed in her 40s with recurrence in her 50s). Her paternal grandmother died from colon cancer in her 70s.
Presenting Symptoms
On physical examination, a 1cm, smooth, firm mass was palpable in the left breast approximately 2 cm from the nipple at 1 o’clock position. There were no skin abnormalities, nipple discharge, or palpable lymph nodes. The patient was referred for a diagnostic breast ultrasound.
Diagnostic Evaluation
Image findings
Breast ultrasound revealed a 1.2 x 1.7 x 1.3 cm suspicious, vascular, hypoechoic mass in the left breast with strong posterior shadowing and irregular borders, corresponding to the palpable mass… No lymphadenopathy or fibrocystic changes were noted. The right breast ultrasound was normal.
A breast surgeon confirmed these findings on repeat ultrasound, describing a 1.25×1.16×1.36cm hypoechoic, vascular, solid mass with shadowing. An ultrasound-guided core needle biopsy was recommended. The patient declined the placement of a metallic clip (which can be made of titanium, stainless steel, or gold), which is standard in such procedures, citing her preference to avoid foreign objects in her body. The clip is utilized for easy identification in future imaging.
Despite the concerning ultrasound findings, several features suggested the mass was benign pseudoangiomatous stromal hyperplasia (PASH). The mass was vaguely palpable and not hard, could “disappear” on ultrasound when the probe angle changed, and tissue samples from the biopsy lacked visible blood, which is uncommon in vascular cancers.
Due to her family history, the patient underwent genetic testing with an expanded hereditary cancer panel assessing 77 genes.
Biopsy and Genetic Testing Results
The final diagnosis from the biopsy revealed “benign breast parenchyma with focal fibroadenomatous change with mild usual ductal hyperplasia and associated pseudoangiomatous stromal hyperplasia, negative for atypia and malignancy.” Genetic testing showed no pathogenic variants…
Final Diagnosis & Understanding PASH
Characteristics of PASH
Pseudoangiomatous stromal hyperplasia (PASH) is a benign stromal proliferation in the breast that mimics vascular lesions due to slit-like pseudospaces in the stroma, devoid of red blood cells.1 First described in 1986, it is still considered uncommon, although it is an incidental finding in up to 23% of breast biopsies.2
PASH often presents as a non-tender thickening or nodule, similar to a fibroadenoma, and is believed to be hormonally influenced. Pre- and peri-menopausal females are most commonly affected, though cases of PASH have been documented in men with gynecomastia, postmenopausal women on hormone therapy, and adolescents.1
Histological staining shows high levels of progesterone and estrogen receptors in PASH stromal cells, and the condition can recur after excision. OCP use, hormonal stimulation, and certain medications, including those that interact with the cytochrome p450 enzymes influencing estrogen and progesterone detoxification, may increase the incidence of PASH.3
Differential Diagnoses
PASH may be mistaken for mammary angiosarcoma or phyllodes tumor1, but histological confirmation via core needle biopsy rules out malignancy… PASH does not increase breast cancer risk but can coexist with malignant lesions, warranting further evaluation if a lesion grows rapidly.
In 2018, The American Society of Breast Surgeons collaborated with the American Board of Internal Medicine on their “Choosing Wisely” campaign, creating recommendations for benign breast disease, including PASH. They concluded that surgical excision is not recommended for PASH if it is not bothersome to the patient as long as it remains stable without suspicious findings on the ultrasound.4
Although reassuring when a breast mass is confirmed as benign, a hormonally sensitive condition like PASH provides an opportunity for the prevention of future health issues by investigating underlying hormonal imbalances.
Hormonal Testing and Key Findings
Bloodwork Results
Bloodwork was ordered for 7 days post ovulation to assess luteal hormones, which revealed an elevated estradiol of 218 pg/mL (56-214 luteal), normal progesterone of 19.1 ng/mL (2.6-21.5 luteal), and an elevated AM cortisol of 22.1 mcg/dL (4-22 for 7-9 AM). Her total and free testosterone, fasting blood sugar, insulin, HgbA1C, Vitamin D, and complete thyroid panel were all normal.
Urine Hormone Metabolite Testing
A urine cortisol and hormone metabolite test was also ordered for 7 days post ovulation. It showed elevated 24-hour free cortisol that followed a normal daily pattern of elevated estradiol with much higher 2-OH-E1 levels than 2-Methoxy-E1 levels, indicating poor phase 2 detoxification, likely in part due to her MTHFR mutations. Androgens, progesterone, melatonin, nutritional and oxidative stress markers were normal.
Treatment Approach and Lifestyle Recommendations
Stress Reduction Strategies
Stress reduction techniques were recommended for her elevated cortisol levels, including replacing some of the hours of high-intensity exercise each week with yoga, eliminating caffeine, and switching to Ashwagandha rather than Rhodiola to lower high cortisol levels.
Supporting Estrogen Detoxification
She was encouraged to take her active B complex daily and to add magnesium glycinate and trimethylglycine to support healthy methylation and phase 2 detoxification. She increased her brassica vegetable intake to two large servings daily and added other fiber-rich foods to encourage healthy estrogen detoxification.5 She also researched her personal care products through the EWG skin-deep website, purchased an advanced water filter, and stopped using non-stick pans when cooking to decrease xenoestrogen exposure.
Follow-up and Ongoing Monitoring
Although her breast mass remained palpable but stable, her cyclical mastalgia resolved within 3 months.
Ultrasound Results
Six months later, she had a follow-up ultrasound with her breast surgeon, which revealed no growth of her PASH mass and no additional areas of concern.
Long-Term Hormone Optimization
Annual screening breast ultrasounds were recommended for ongoing monitoring in addition to a baseline mammogram. Luteal serum and urine hormone metabolism tests will also guide diet and supplement recommendations to optimize hormone detoxification as she moves deeper into perimenopause.
- Yoon KH, Koo B, Lee KB, et al. Optimal treatment of pseudoangiomatous stromal hyperplasia of the breast. Asian J Surg. 2020;43(7):735-741. doi:10.1016/j.asjsur.2019.09.008
- Bowman E, Oprea G, Okoli J, et al. Pseudoangiomatous stromal hyperplasia (PASH) of the breast: a series of 24 patients. Breast J. 2012; 18 (3): 242-7. doi:10.1111/j.1524-4741.2012.01230.x
- Hattingh G, Ibrahim M, Robinson T, Shah A. The effect of hormones on an uncommon breast disorder pseudoangiomatous stromal hyperplasia: a case report and literature review. J Surg Case Rep. 2020;2020(12):rjaa514. Published 2020 Dec 26. doi:10.1093/jscr/rjaa514
- Rao R, Ludwig K, Bailey L, et al. Select Choices in Benign Breast Disease: An Initiative of the American Society of Breast Surgeons for the American Board of Internal Medicine Choosing Wisely® Campaign. Ann Surg Oncol. 2018;25(10):2795-2800. doi:10.1245/s10434-018-6584-5
- Fowke JH, Longcope C, Hebert JR. Brassica vegetable consumption shifts estrogen metabolism in healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2000;9(8):773-779.