female breasts
accessory reproductive organs whose function is to produce milk for nourishing the newborn
surface anatomy
-breasts
-tail of spence
-nipple
-areola
internal anatomy
-glandular tissue
-coopers ligaments
-adipose tissue
breasts
-lie anterior to the pectoralis major and serratus anterior muscles
-located bw the 2nd and 6th ribs
-extend from side of the sternum to the midaxillary line
Tail of Spence
-the superior lateral corner of breast tissue
-projects up laterally into the axilla
Nipple
-just below that center of the breast
-rough, round, usually protuberant
-surface looks wrinkled with tiny milk duct openings
-more darkly pigmented than rest of breast (pink - brown)
Areola
-surrounds nipple
-1-2 cm radius
-contain sebaceous glands=
MONTGOMERY'S GLANDS
-has smooth muscle fibers that cause nipple erection
-more darkly pigmented than rest of breast (pink - brown)
Breast is Composed of
1) Glandular Tissue
2) Fibrous Tissue (including suspensory ligaments)
3) Adipose Tissue
Glandular Tissue
-contains 15-20 LOBES radiating from the nipple
-the lobes are composed of LOBULES
-within each lobule are CLUSTER of ALVEOLI that produce milk
-each lobe empties into a LACTIFEROUS DUCT
-the lactiferous ducts form a COLLECTING DUCT SYSTEM converging towa
Cooper's Ligaments
-the suspensory ligaments
-fibrous bands
-extend vertically from surface to attach on chest wall muscles
-support the breast tissue
-become contracted in cancer of breast
=pits or dimples in overlying skin
Adipose Tissue
-lobes are embedded in the adipose tissue
-layers of subcutaneous and retromammary fat
-form most of the bulk of the breast
Tail of Spence
-extends from the upper outer quadrant
-cone-shaped breast tissue that projects up into the axilla
-close to the pectoral group of axillary Lymph Nodes
Most common site of breast tumors
-upper outer quadrant
Lymph Nodes of the breast region
-feel pearly, stringy
-breast has extensive lymphatic drainage
-more than 75% of the lymph drains into the ipsilateral (same side) axillary nodes
-four groups of axillary nodes:
1. Central Axillary Nodes
2. Pectoral (anterior)
3. Subscapular (posterior)
4
Central Axillary Nodes axillary node
-high up in middle of the axilla
-over the ribs and serratus anterior muscles
-receive lymph form the other three group of nodes
*and from here drainage flows up to the infraclavicular and supraclavicular nodes
Pectoral (anterior) axillary node
-along lateral edge of pectoralis major muscle
-just inside the anterior axillary fold
Subscapular (posterior) axillary node
-along lateral edge of scapula
-deep in the posterior axillary fold
Lateral axillary node
-along humerus
-inside upper arm
Embryonic and Infant considerations
-during embryonic life there are Ventral Epidermal Ridges/Milk Lines
*these curve down from the axilla to the groin
-breast develop along the ridge, the rest of the ridge usually atrophies
-SUPERNUMERARY NIPPLE: an extra nipple, somewhere along the track
Adolescent Considerations
-at puberty, estrogen stimulates breast changes
-enlargement due to fat deposition
-duct system grows branches
-masses of small, solid cells develop at the duct endings
=potential alveoli
Onset of Puberty in females
-puberty is occurring earlier that classically used norms
-avg. 8-10 years now
-avg. used to be at 10-11 years
Tanner Staging
-5 stages of breast development
-when staging, look at Posture and Nipple (not size)
-follow the classic description of sexual maturity rating
1. Preadolescent- only a small elevated nipple
2. Breast Bud Stage- small mound of breast and nipple develops; a
time span during Tanner Stages
-stage 2-5 takes average of 3 years (range is 1.5-6)
-during this time pubic hair develops
-axillary hair appears 2 years after onset of pubic hair
-breast development precedes MENARCHE by about 2 years
-Menarche occurs during tanner stage 3 or 4...usuall
Breast texture changes within the Hormone Cycle
-nodularity increases from mid cycle up to menstruation
-3-4 days before menstruation: breast feels full, tight, heavy, and sore
-days 4-7 of menstrual cycle: breast volume is smallest
Pregnant Women Considerations
-breast changes start during 2nd month
-an early sign of pregnancy for most women
-expansion of ductal system and supporting fatty tissue
-development of true secretory alveoli
-breast enlarge
-feel more nodular
-nipples are larger, darker and more erecti
Colostrum
-after the fourth month of pregnancy
-thick, yellow fluid
-precursor for milk
-contains same amount of protein and lactose but practically no fat
-breast produce colostrum for the first few days after delivery
-rich with antibodies to protect newborn agai
Aging Female considerations
-decreased ovarian secretion of estrogen and progesterone after menopause
-breast glandular issue to atrophy
-replaced with fibrous connective tissue
-fat envelope atrophies
=begins in middle years
=marked in the 8th and 9th decade
-this all causes decrea
the Male Breast
-rudimentary structure
-think disk of undeveloped tissue underlying the nipple
-well developed areola
-nipple is relatively small
-temporary enlargement during adolescence
=GYNECOMASTIA
*usually unilateral and temporary
*may reappear in the aging male
*ma
Subjective Data the Breast and Axilla Health
BREAST:
1. pain
2. lump or thickening
3. discharge
4. rash
5. swelling
6. trauma
7. history of breast disease
8. Surgery
9. self-care behaviors: perform breast self-examination, last mammogram
AXILLA:
1. tenderness, lump, or swelling
2. rash
Mastalgia
-occurs with trauma, inflammation, infection, and benign breast disease
Cyclic Pain
-common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease
lump
-may not be serious if present for many years and exhibiting no change
-should still be explored
-recent changes or new lumps should be approached with suspicion
discharge
-clear nipple discharge caused by hormone changes (i.e. oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers
-discharge with a lump is significant
-discharge with blood or blood-tinged is always signifi
Galactorrhea
spontaneous flow of milk from the breast unassociated with childbirth or nursing
Paget's Disease
-intraductal carcinoma
-starts with small crust on nipple apex, then spreads to areola
Eczema or other Dermatitis
-rarely start at nipple unless due to breastfeeding
-usually stats at areola or surrounding skin then spreads to nipple
trauma to breast
-lump from injury is due to local hematoma or edema and should resolve shortly
-trauma may cause a woman to feel the breast and find a lump that really was already there and unrelated to the trauma
risk for breast cancer
-if family history of pre-menopause breast cancer, this increases the risk
-presence of benign breast disease makes the breast more difficult to examine bc the general lumpiness conceals a new lump
Mammoplasty
augmentation or reduction
mammography and rate of CBE (clinical breast exam)
-screening x-ray examination of the breasts
-CBE every 3 years for women 20-39 years old
-CBE and Mammogram ANNUALLY for women 40 and older
additional subjective data/history for the Pregnant female
-inverted nipples may need special care in prep for breast feeding
Breast Cancer risk factors (nature)
-second major cause of death from cancer for women
->50 years old
-mutation of BRCA1 and BRCA2 genes
-previous biopsy with atypical hyperplasia or breast disease w/o atypia or usual hyperplasia
-previous breast irradiation
-menarche before age 12
-menopau
Breast Cancer risk factors (nurture)
-nulliparity
-first child after age 30
-recent oral contraceptive use
-postmenopausal hormonal therapy (especially combined estrogen-progesterone therapy)
-not breast feeding
-> or equal to 1 alcoholic bev a day
-obesity (especially after menopause)
-high
objective data for the breast examination
-preparation
-inspect breasts:
general appearance
skin
lymphatic drainage areas
nipple
maneuvers to screen for retraction
-inspect and palpate the axillae
-palpate the breasts
-teach the Breast Self Examination
Preparation
-sitting up facing examiner
-use sensitive and matter-of-face approach
-equipment: small pillow, cm ruler, pamphlet or teaching aid for BSE
General Appearance
-note symmetry of size and shape
-slight symmetry in size is common
-often left breast is slightly larger than right
-sudden increase in size of one breast signifies inflammation or new growth
Skin
-smooth of even color
-note localized redness, bulging, dimpling
-note skin lesion or focal vascular pattern
-normally no edema
*edema exaggerates hair follicles
*"pig-skin" or "orange-peel" look
-not normal to have unilateral dilated superficial veins
Skin of Pregnant Breasts
-fine blue vascular network is visible
-pale linear striae, or stretch marks, follow pregnancy
Lymphatic Drainage
-observe axillary and supraclavicular regions
-note any bulging, discoloration, or edema
Nipple
-should be symmetrical
-on same plane
-usually protrude, some are flat or inverted
-nipples tend to stay in their original condition
-note dry scaling, fissure, ulceration, bleeding, discharge
-distinguish between a recently retracted nipple from one that
Supernumeray nipple
-a normal and common variation
-an extra nipple along the embryonic "milk line"
on thorax or abdomen
-congenital
-5-6cm below breast near midline
-has no associated glandular tissue
-looks like a mole, but upon close inspection it looks like a tiny nipple
Maneuvers to Screen Retraction
-direct woman to change position while you check for breasts for skin retraction
-lift arms slowly over head
-both breasts should move up symmetrically
-next have pt push her hands onto her hips and to push her two palms together
-these maneuvers contract
Inspect and Palpate the Axillae
-examine axilla while woman sits
-note any rash or infection
-lift woman's arm and support it so that her muscles will be loose and relaxed
-use R hand to palpate L axilla
-reach fingers high into axilla, move them firmly down in four directions
-move wom
four directions of palpation of axilla
Move your fingers in four directions:
1) down the chest wall in a line from the middle of axilla
2)along the anterior border of the axilla
3) along the posterior border
4)along the inner aspect of the upper arm
Supernumerary Breast
-rare
-additional glandular tissue is present
Position to Palpate the Breasts
-supine position
-tuck small pad under side to be palpated
-raise her arm over her head
-this is to flatten the breast tissue and displace it medially
-significant lumps will then feel more distinct
How to Palpate the Breasts
-use pads of first three fingers
-make gentle rotary motion on the breast
-vary pressure so palpating light, medium and deep tissue in each location
Breast Palpation techniques
1) Vertical Strip Pattern: currently recommended as the best to detect breast mass
2) Spokes-on-a-wheel pattern: palpating from the nipple and out to the periphery
3) Concentric circles pattern: concentric circles out to the periphery
***take care to palp
Vertical stip pattern
-start high in the axilla
-palpate down just lateral to the breast
-proceed in overlapping vertical lines ending in the sternal edge
breast of nulliparous women vs postpartum women
-firm, smooth, elastic
-after pregnancy, tissue feels softer and looser
premenstrual breasts
-engorgement due to progesterone
-slight enlargement
-tenderness to palpation
-generalized nodularity
-lobes feel prominent and margins more distinct
inframammary ridge
-transverse ridge of compressed tissue in the lower quadrants
-especially noticeable in large breasts
-not do be confused with a normal lump
nipple palpation
-note induration or subareolar mass
-with thumb and forefinger gently depress the nipple tissue into the well behind areola
-tissue should move inward easilly
-if reports spontaneous discharge, press areola inward with index finger, repeat in different di
pendulous breast palpation
-use bimanual technique
-woman must lean forward in sitting position
-support inferior part of breast with one hand
-use other hand to palpate the breast tissue against your supporting hand
if pt reports self-discovered lump
-examine unaffected breast first
*learn baseline of normal consistency
-note the 10 characteristics of the lump/mass
characteristics of lump/mass
1. location- use breast as clock face, describe distances in cm, or make a diagram
2. Size- cm, three dimensions of width, length, thickness
3. Shape- oval, round, lobulated, indistince
4. Consistency- soft, firm, hard
5. Movable- freely movable or fixed
Teach Breast Self Examination
-best to do right after menstrual period or 4th-7th day of the menstrual cycle
-this is when breasts are the smallest and least congested
-must be done at same time each month
-emphasize the absence of lumps, not the presence of them
-start in shower, the
Factual material while teaching BSE
-majority of women will never get breast cancer
-the great majority of breast lumps are benign
-early detection of breast cancer is important; if the cancer is not invasive, the survival rate is close to 100%
the male breasts
-more abbreviated, but do not omit
-combine exam with that of anterior thorax
-inspect chest wall, note skin surface, lumps, swelling
-palpate nipple area for lump or tissue enlargement
-should feel even, no nodules
-palpate axillary lymph nodes
-normal h
Gynecomastia
-enlargement of this breast tissue
-makes it clinically distinguishable from other tissues in chest wall
-feels like a smooth, firm, movable disk
-occurs normally during puberty
-usually only affects one breast and is temporary
-reassure adolescent that t
Neonate breasts
-may be enlarged and visible due to maternal estrogen crossing the placenta
-may secrete clear or white fluid (witch's milk)
-not significant
-resolved within a few days to a few weeks
prepubertal child
-note position of nipples, should be symmetric, just lateral to the midclavicular line, between fourth and fifth ribs
-nipple is flat, and areola is darker pigmented
the adolescent
-usually begins on average btw 8-10 years
-expect some asymmetry during growth
-distinguish breast development from extra adipose tissue in obese children
-record stage of development using Tanners's staging
-teach adolescent normal developmental stages a
pregnant female
-delicate blue vascular pattern visible over breasts
-breasts and nipples increase in size
-jagged linear stretch marks/striae may develop
-nipples become darker and more erectile
-areola widen, darker, and contain small, scattered, elevated Montgomery's
Montgomery Glands
-small, scattered, elevated glands on the pregnant females breasts
Lactating female
-colostrum changes to milk around 3rd postpartum day
-breasts may engorge, enlarge, reddened, shiny, feel warm and hard
-frequent nursing helps drain the ducts and sinuses and stimulate milk production
-nipple soreness is normal
-nipples may look red and
the aging female
-breasts look pendulous, flattened, and sagging
-nipples may be retracted but can be pulled outward
-feel more granular
-terminal ducts around nipple feel more prominent and stringy
-thickening of inframammary ridge at lower breast is normal, feels more p
risks of the aging female
-women over 50 y/o have increased risk of breast cancer
-problems with arthritis, ROM, and vision decrease self care
-BSE aids include talcum powder to help fingers glide over skin