Breast Development

At puberty, the female breast develops, under the influence of estrogen, progesterone, growth hormone, prolactin, insulin and probably thyroid hormone, parathyroid hormone and cortisol. This complex process typically begins between ages 8 to 14 and spans about 4 years.

The breast contains mostly fat tissue, connective tissue, and glands that following pregnancy, will produce milk. The milk is collected in the ducts and transported to 15- 25 openings that exit through the nipple.

During the menstrual cycle, the breast is smallest on days 4-7, and then begins to enlarge, under the influence of estrogen and later progesterone and prolactin. Maximum breast size occurs just prior to the onset of menses.

The breast is not round, but has a “tail” of breast tissue extending up into the axilla (or armpit). This is clinically significant because abnormalities can arise there just as they can in other areas of the breast.

Breasts are never identical, comparing right to left. One is invariably a little larger, slightly different in shape, and located differently on the chest wall. The nipples are likewise never identical but show minor differences in size, location and orientation.

The breast is divided into quadrants to better describe and compare clinical findings. The upper outer quadrant is the area of greatest mass of breast tissue. It’s also the area in which about half of all breast cancers will develop.

Adolescent Breast Problems

During adolescence, several breast growth patterns can be troubling to the adolescent and her family. Among these are:

• Unusually early breast development
• Unusually delayed breast development
• Unusually large breasts (Mammary hypertrophy)
• Unusually small breasts
• Asymmetrical breast growth
• Breast lumps

Initial breast development occurs on average at age 9, with the appearance of a breast bud. The normal range for breast bud appearance is from ages 8 to 13. It is common for one bud to appear up to 6 months prior to the second bud appearing.

Breast growth is then progressive, with enlargement of the breast tissue, areala and papillae, and change in shape and contour. By age 18 breast development is usually complete.

Premature thelarche is breast development prior to the age of 8 in the absence of pubic hair development. We evaluate these children to rule out estrogen-producing ovarian tumors, ingestion of estrogen-containing compounds, and the rare, true precocious puberty.

Delayed thelarche reflects absence of any breast development by age 13.

Asymmetrical breast growth during adolescence is the rule rather than the exception. Reassure the patient that the asymmetry usually evens out by the time of full maturation. Even at maturity, breasts are rarely 100% symmetrical, so minor degrees of asymmetry are expected. Because the breasts are continuing to grow and change, we usually delay any surgical intervention for asymmetric breasts until after age 18.

Mammary hypertrophy can be a distressing symptom. Because growth and development continues for a long time, if we are contemplating surgical intervention, we generally delay this surgery until the breasts are fully mature.

Breast masses in adolescents are essentially 100% benign. Because of this, surgery (excisional biopsy or fine needle aspiration) is almost never warranted.

Further, the surgical disruption of architecture can be disfiguring as the breast continues to mature.

Supernumerary breasts

Supernumerary breasts are relatively common. They are found along the “milk line,” extending from the axilla to the groin.

Most of them are not noticed clinically until pregnancy occurs. Then, under the influence of the pregnancy hormones, the breasts enlarge in preparation for lactation. It is at this time that soft swellings along the milk line occur, representing supernumerary breasts. During lactation, the extra breasts may produce milk.

These are not dangerous and are generally ignored. If they prove to be a cosmetic problem, they can be removed surgically.

More common than supernumerary breasts are supernumerary nipples. Like extra breasts, these are located in the milk line and are not dangerous.

Unless they are large, they are usually not noticed until a pregnancy. At that time, like the normal nipples, they enlarge and darken.

Inverted Nipples

Usually nipples point outward. Sometimes, they invert. When they persistently point inwards, they are called inverted nipples. This can be unilateral or bilateral.

With stimulation and nipple erection, most inverted nipples will evert. Occasionally, they remain inverted despite all efforts to evert them.

Other than for cosmetics, nipple inversion is not usually a problem. For breast-feeding, most inverted nipples will evert. Even those that do not evert may still function normally enough to allow for satisfactory infant nursing.

Non-cyclic Breast Pain

Among the common causes of non-cyclic breast pain are trauma, infection, and chest wall pain underlying the breast tissue (muscle strain or overuse of the pectoralis major muscle). Breast cancer rarely causes breast pain in the early stages and is not usually suspected unless the symptoms persist. Hormonal causes include functional ovarian cysts and pregnancy.

Women complaining of non-cyclic breast pain should have a careful examination. Common areas of tenderness include the pectoralis muscle distribution over the anterior chest wall. In this case, the muscle itself will be sore and the breast, if palpated with two hands and not pressed against the tender muscle, will be non-tender. Pain or soreness in the pectoralis major muscle is frequently found among women who have recently engaged in strenuous physical activity, and it represents a muscle strain. Chest wall pain does not involve the nipple or areola, while cyclic breast tenderness usually does. Treatment is symptomatic, with rest, some stretching exercises, and non-steroidal anti-inflammatory medication such as ibuprofen or naproxen.

A second common area for chest wall pain is along the costal margin. Direct pressure on the costochondral cartilage, without compressing breast tissue, will duplicate the pain. Compressing the chest wall with your hands placed laterally to the breasts will also duplicate the pain. This costochondritis has similar etiologies to the pectoralis major muscle tenderness, and the treatment is the same. and if the pain persists, referral will likely be necessary.

Trauma can include vigorous coughing or vomiting. The resulting strong, sustained contractions of the intercostal muscles can lead to chest wall tenderness that may be perceived by the patient as breast pain.

Cyclic Breast Pain

During the days leading up to the menstrual flow, the breasts normally are somewhat engorged and may be somewhat tender. Following the onset of menstrual flow, these changes spontaneously resolve. If the tenderness is more than mild or is clinically bothersome, it is called cyclic breast pain or mastodynia.

If examined during this time, these women also often have significantly enhanced nodularity of the breast tissue. The combination of cyclic breast pain and symmetrically thickened nodularity of the breast tissue is often called fibrocystic disease (misnamed because it’s not really a disease) or fibrocystic breast changes.

While not dangerous, women with cyclic mastodynia find it annoying and in its most severe form, interferes with some normal activities.

Some women find that by reducing or eliminating their intake of caffeine (coffee, tea, cola drinks) and taking Vitamin E supplements (400 IU daily) has seemed to improve their symptoms. Whether such improvement is pharmacologic or placebo in nature is still under debate.

Any pharmacologic approach that suppresses ovulation will be very helpful in treating cyclic mastodynia. Among these, birth control pills are the simplest. Taking BCPs in the usual fashion generally improves the pain significantly. For those who still experience significant pain, continuous birth control pills will usually suppress the pain completely.

Also effective, by virtue of ovulation inhibition, are depot medroxyprogesterone acetate, Lupron, or Danocrine, the latter two usually justified only in severe cases due to their significant side effects.

Nipple Discharge

Normally, if the ducts are stripped toward the nipple, a drop or two of clear, milky, or greenish-tinged liquid will appear. This is not considered nipple discharge.This image demonstrates milk from a lactating woman. This is also considered normal.

If the nipples spontaneously leak discharge, staining the clothing, that is not normal, nor is it normal to have bloody nipple secretions.

Nipple discharge from both breasts indicates “galactorrhea.” While a few post partum women will continue to leak small amounts of milk for years following delivery, galactorrhea in general indicates the need for a serum prolactin measurement and possibly an MRI of the pituitary gland to look for prolactin- secreting pituitary adenomas. Hypothyroidism can also cause this problem, although it is rare.

Athletes may experience small amounts of galactorrhea from constant rubbing of the nipples against clothing.

Frequent sexual stimulation of the breasts may have similar effects. The serum prolactin measurement is best made after a few days of non-stimulation of the breast. Even after a breast exam, it is often helpful to wait 2 days before measuring the serum prolactin.

Persistent discharge from a single duct, particularly if bloody, rust-colored or multicolored, suggests the presence of an intraductal lesion, such as an intraductal papilloma. While these are often benign, they need further exploration with a general or breast surgeon.

Paget’s Disease

This crusty, flaking lesion is associated with an underlying breast malignancy, invasive or in-situ. The appearance may be suggestive of Paget’s disease, but the diagnosis is generally confirmed by nipple biopsy.

The onset of the lesion is often so gradual that by the time it comes to the attention of the physician, many months or years have passed since its’ onset.

Treatment depends on the character and extent of the underlying lesion.

Breast Lump

If a dominant mass is found in the breast which persists through the menstrual cycle, it is usually biopsied, either through fine needle aspiration or excisional biopsy, depending on the clinical circumstances.

Suspicious masses (large, irregular, hard, fixed in place, with redness and dimpling of the overlying skin and nipple retraction) are usually biopsied right away.

Most masses are benign, but for those found to be malignant, earlier intervention is thought by many to lead to improved chances of successful treatment.

Breast Cyst

Breast cysts present as smooth, non-tender masses. They will often disappear over the course of the menstrual cycle, but those that persist will need further evaluation.

Cyst aspiration is frequently attempted, using a small needle and syringe.

Aspiration of the cyst fluid is performed primarily to confirm the fact of the cyst and to decompress it.

Many physicians discard the cyst fluid unless it is bloody as cyst fluid cytologic examination is felt to be of little value.

Following decompression of the cyst, the patient returns for periodic follow-up to look for recurrence. Recurrent cysts in the same location are often subjected to excisional biopsy or fine needle aspiration biopsy.

Fat Necrosis

Fat necrosis presents as a breast mass with surrounding ecchymosis (bruise). It may be tender and a history of breast trauma is identified in half the cases. Even when significant trauma is not identified, it is felt to be the general cause of this condition.

This benign condition is self-resolving, but is of clinical importance because it mimics the dominant mass found in breast cancer.

Those cases with the typical presentation can be followed to make sure they completely resolve. Those cases that are not typical or if there is any doubt, can have a fine needle aspiration to confirm the diagnosis.

Fibroadenoma

These common, benign, solid, round or oval breast tumors are most common among women ages 15-35. They are rubbery in consistency, mobile and non-tender. They rarely grow larger than 2-3 cm.

The diagnosis is usually suspected on physical exam and confirmed with fine needle aspiration or excisional biopsy. When found in teenagers, they are often simply watched because of the very low risk of malignancy compared to the architectural disturbance caused by excisional biopsy.

Breast Cancer

Breast cancer is a relatively common cancer, representing about 30% of all cancers in women. In broad terms, treatment is successful in about 3 out of 4 patients in controlling or eliminating the cancer. In about one out of four, the cancer proves fatal.

The risk of developing breast cancer increases steadily with increasing age. It is rare among women under age 25 but affects nearly one in nine of those women reaching age 90.

Breast Cancer Detection Strategies

A number of factors are associated with an increased of developing breast cancer, including:

• Strong family history of breast cancer
• Menopause after age 55
• No term pregnancy prior to age 35

Despite the increased risk, most (about 80%) of breast cancer occurs in women not at increased risk for developing breast cancer. For that reason, efforts at early detection are not focused just on those with somewhat increased risks, but on all women. The primary strategy involves a three-armed effort: Periodic (annual) professional breast examination, monthly self- breast examination, and mammography at appropriate intervals.

The underlying assumption of all breast screening programs is that if we can detect a breast malignancy when it is very small, then the outcome will be better for the patient than if we discover the problem when it is bigger. Just how true that assumption is and the exact parameters of that truth are still under debate, as is the effectiveness of any of the breast cancer screening programs in improving outcome for women with breast cancer.

Breast Examination

Once a year, a woman’s breasts should be evaluated by a qualified health professional. Any significant abnormalities in texture, contour, skin, any palpable masses, retractions, dimpling or nipple discharge will require followup appropriate for the abnormality.

Professional breast exams are felt to be about 80% reliable in detecting significant breast abnormalities.

Self Breast Examination

Once a month, a woman should examine her own breasts, looking for changes in appearance, texture, or nipple discharge that was not previously present.

Examination technique is not obvious, but is a skill to be learned (and taught). Any new findings should be promptly reported to the woman’s physician or other qualified healthcare provider. Most breast cancers are first noted by the patient herself.

Some critics of self breast exams have observed that they may cause more problems than they solve. By the time a breast cancer is large enough for the woman to feel herself, it is not likely to be “early.” Further, most of the self-discovered breast lumps are benign and do not represent a threat. Nonetheless, they are often subjected to investigation, including biopsy and excision.

Mammography

The goal of mammography to to detect very early cancers or pre-cancerous changes before they have a chance to develop into a more advanced and dangerous stage. Mammography is felt to be about 80% effective in detecting significant breast abnormalities, but many of the ones that are missed by mammography can be detected by examination.

There is controversy over how frequently mammograms should be performed. If there is a clinical abnormality, mammograms can be used to gain additional information about the abnormality (a “diagnostic” mammogram). Many physicians recommend that “screening:” mammograms be performed every other year between ages 40 and 50, and annually thereafter. Some physicians dispute the usefulness of mammograms prior to age 50. Some physicians recommend mammograms more often if there is a strong family history of breast cancer. Some physicians dispute the value of screening mammograms after age 75 or 80. Some physicians dispute the value of screening mammograms at any time.

Breast Ultrasound

Breast ultrasound is used in some countries (although not commonly in the United States) to screen for breast cancer. It has the advantage that it is relatively inexpensive, quick, painless, and uses no radiation. It is particularly good at detecting cystic masses (better than mammograms). In skilled hands, it does a fair job of detecting malignancies.

Unfortunately, it is not as good at detecting malignancies as mammograms and so it is not usually used for primary screening in the U.S. It is commonly used in the U.S., however, as an adjunctive method to evaluate abnormalities palpated by the examiner or identified on mammograms.

Thermography

Thermography is a means of looking at the breast with an infrared (heat-sensitive) imaging device. It relies on the principle that cancers have increased metabolic activity, generating more heat, that can be detected with a thermographic process. While this has some theoretical advantages over other imaging techniques, in practice, thermography has not been demonstrated to be effective in early detection of significant lesions, and so is not generally used as a primary screening technique.

MRI

Magnetic Resonance Imaging is sometimes used in the diagnosis and management of breast cancer.

• It changes the surgical management in as many as 1 in 4 patients if performed pre-operatively.
• In high risk patients (those with a lifetime risk of greater than 20%), it seems to have greater sensitivity at detection of malignancies not found on routine mammograms, breast ultrasound, or professional breast

Unfortunately, MRI’s are significantly more expensive than other methods of detection, limiting their use for screening in the general population.