At puberty, the female breast develops, under the influence of hormones. 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 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.

A breast examination consists of inspection and palpation of the breasts to identify abnormalities. Some breast examinations are focused on specific issues while others are more general. Although there are many good ways to examine the breasts, one of them will be presented here.

Visually Inspect

Inspect the breasts visually, looking for:

• Visible masses (change in contour)

• Skin dimpling

• Nipple retraction

• Redness

• While generally symmetrical, many breasts are somewhat asymmetrical in respect to size, shape, orientation, and position on the chest wall.

Raise Arms

• Have her raise her arms while you continue to watch.

• An underlying malignancy can fix the skin in place. Raising the arms will accentuate these changes.

Palpate

With the patient's arm raised over her head, palpate for lumps, masses or thickenings.

• Breast tissue is normally somewhat nodular or "lumpy," particularly in the upper outer quadrant

Use the middle third of your fingers feel for lumps.

• The palm of the hand is too insensitive to detect subtle changes in  breast texture.

• The fingertips are too sensitive and will focus on the normal granularity of the breast tissue rather than the more worrisome masses.

Move your hand in a circular motion while pressing into the breast substance.

• Making these small circles will help you identify mass occupying lesions.

• With smaller breasts, palpation with one hand will give good results.

• When breasts are larger or pendulous, it may be useful to use two hands, compressing the breast tissue between them.

Check the axilla for masses or palpable lymph nodes.

Check for any palpable masses or lymph nodes in the supraclavicular area.

Stripping the ducts toward the nipple will cause any secretions to be expressed.

• Usually, a drop or two of clear, milky or slightly green-tinged can be expressed.

• Rust colored or bloody discharge is a danger sign that needs followup.

• Large amounts of nipple discharge also need further evaluation.

For further information, read:

Breast Problems, in Operational Obstetrics & Gynecology

Management of Common Breast Problems, in the General Medical Officer Manual

Female Health Issues

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Operational Medicine 2001

Health Care in Military Settings

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