Gynecology and Womens Health - Juniper Publishers
Breasts are subject to change. They react to hormonal
changes, they can hurt, and they also react to food, lifestyle and
stress. Breast health is very important and self-examination should not
be missed. By palpation and self-examination of the breasts, which are
heterogeneous due to cyclic exposure to hormones, it is impossible to
make any diagnosis. However, self-examination of women is extremely
important after menstruation when there are less physiological "bumps"
than during the cycle. It is very important that women know their
breasts well so that they can notice when something new appears in them.
Depending on age and anamnesis, it is extremely important to go for a
mammogram and compare images and perform comparative ultrasound
examinations. Any new change should be discussed with doctor.
Keywords: Breasts; Abnormalities; Pain; Cancer; Health
Breast conditions are common in women [1]. Estimates
are that 90% of women show benign breast tissue changes when examined
microscopically. The ultimate goal is to empower women to take control
of their breast health by knowing what their breasts look and feel like
and to use fundamental health and wellness principles such as diet and
exercise to create a healthy environment in the body. Women who
regularly perform breast self-exams may note changes in the breasts
during the menstrual cycle. The breasts become more lumpy and tender as
menses approaches and less lumpy and less tender after menses.
The female breasts are each composed of about twenty
lobes of glandular tissue embedded in fibrous and adipose tissue [2].
The lobes are arranged circumferentially much as petals on a flower.
Each lobe consists of clusters of glands (terminal ductules or acini) in
which milk is made during pregnancy, and a series of intralobular ducts
connecting the acini and the stromal tissue in which the acini and
ducts are located. Taken together these three components are called the
terminal duct lobular unit (TDLU). The ducts of the TDLU converge to
form large ducts that extend to the nipple. The ductules and ducts of
the lobular system are bilayered. The luminal epithelial cells lining
the ducts are the source of milk during lactation and also of much
breast pathology, the most important being carcinoma. The outer layer is
myoepithelial in nature and characteristically is lost in invasive
breast cancer. Preservation versus loss of the bilayered nature of the
lobular system is an important diagnostic criterion in separating benign
from malignant breast disease.
The breasts are modified sweat glands that have
become specialized to secrete milk. Before puberty, breast tissue in
both sexes consists only of branching ducts and fibrous tissue without
glandular tissue or fat. In the female, the breasts enlarge at puberty
in response to estrogen and progesterone produced by the ovaries,
whereas the unstimulated male breasts retain their prepubertal form.
Postpuber Independent Researcher, Herzegovinatal changes in the female
include proliferation of glandular and fibrous tissue and accumulation
of adipose tissue within the breasts. Variations in the size of the
postpubertal breasts of nonpregnant women are primarily the result of
variations in the amount of fat and fibrous tissue in the breasts rather
than differences in the amount of glandular tissue.
Once menses is established, the breast undergoes a
periodic premenstrual phase during which the acinar cells increase in
number and size, the ductal lumens widen, and breast size and turgor
increase slightly [3]. Many women have breast tenderness during this
phase of the menstrual cycle. Menstrual bleeding is followed by a
postmenstrual phase, characterized by a decrease in size and turgor,
reduction in the number and size of the breast acini, and a decrease in
diameter of the lactiferous ducts. Cyclic hormonal influences to the
breast are quite variable.
In response to progesterone during pregnancy, breast
size and turgidity increase considerably. These changes are accompanied
by deepening pigmentation of the nipple–areolar complex, nipple
enlargement, areolar widening, and an increase in the number and size of
the lubricating glands in the areola. The breast ductal system branches
markedly, and the individual ducts widen. The acini increase in number
and size. In late pregnancy, the fatty tissues of the breasts are almost
completely replaced by cellular breast parenchyma. After delivery with
the rapid drop in progesterone and estrogen levels, the breasts, now
fully mature, start to secrete milk. With cessation of nursing or
administration of estrogens, which inhibit lactation, the breast rapidly
returns to its pre pregnancy state, with marked diminution of cellular
elements and an increase in adipose deposits.
Following menopause, which typically occurs during
the fifth decade of life, the breast undergoes a gradual process of
atrophy and involution. There is a decrease in the number and size of
acinar and ductal elements, so that the breast tissue regresses to an
almost infantile state. Adipose tissue may or may not atrophy, with
disappearance of the parenchymal elements.
The two mammary glands, or breasts, are accessory
organs of the female reproductive system that are specialized to secrete
milk following pregnancy [4]. They overlie the pectoralis major muscles
and extend from the second to the sixth ribs and from the sternum to
the axilla. Each breast has a nipple located near the tip, which is
surrounded by a circular area of pigmented skin called the areola. Each
breast is composed of approximately 9 lobes (the number can range
between 4 and 18), which contain glands (alveolar) and a duct
(lactiferous) that leads to the nipple and opens to the outside. The
lobes are separated by dense connective and adipose tissues, which also
help support the weight of the breasts. During pregnancy, placental
estrogen and progesterone stimulate the development of the mammary
glands. Because of this hormonal activity, the breasts may double in
size during pregnancy. At the same time, glandular tissue replaces the
adipose tissue of the breasts.
Following childbirth and the expulsion of the
placenta, levels of placental hormones (progesterone and lactogen) fall
rapidly, and the action of prolactin (milk-producing hormone) is no
longer inhibited. Prolactin stimulates the production of milk within a
few days after childbirth, but in the interim, a dark yellow fluid
called colostrum is secreted. Colostrum contains more minerals and
protein, but less sugar and fat, than mature breast milk. Colostrum
secretion may continue for approximately a week after childbirth, with
gradual conversion to mature milk. Colostrum is rich in maternal
antibodies, especially immunoglobulin A (IgA), which offers protection
for the newborn against enteric pathogens.
Production of human breast milk among healthy mothers
who deliver full-term infants occurs in three phases-colostrum,
transitional milk, and mature milk [5]. Colostrum is a thick, yellow
substance produced during the first several days postpartum. Healthy
mothers produce approximately 80-100mL daily. Colostrum is rich in
calcium, antibodies, minerals, proteins, potassium, and fat-soluble
vitamins. This milk has immunologic qualities that are vital to the
infant, and it possesses gastrointestinal properties to facilitate
secretion of meconium. Production of colostrum is followed for the next
5-6 days with transitional milk, which provides essential components
more closely resembling mature breast milk. Most women will notice a
significant change evidenced by the fullness of their breasts and the
change in the consistency of the milk. True milk is white and sometimes
has a bluish tint. The consistency is similar to that of cow’s milk with
a sweet taste. Mature breast milk, produced beginning at or near
postpartum day 10, produces key components, discussed in the next
section.
Numerous factors may affect the supply of breast
milk, including anxiety, medications, maternal nutritional status,
amount of sleep, exercise, breastfeeding frequency, tactile stimulation,
and fluid intake. Breastfeeding mothers should be encouraged to consume
generous amounts of fluids and express breast milk every 2-3 hours. The
hormonal feedback loop that controls the production and release of
prolactin and oxytocin is initiated by suckling or other tactile
stimulation of the breast. The greater the amount of suckling or other
tactile breast stimulation, the greater the milk supply.
Because breast-feeding delays the onset of
menstruation after pregnancy, a phenomenon that is easily observed, it
has often been regarded as a form of birth control [6]. It is, however,
only a relatively short-term one. Modern studies in developing countries
show that mothers who breastfeed for an extended period do not begin
menstruating until an average of ten months after delivery as compared
with three months for mothers who do not breast-feed for a long period.
It also takes breast-feeding mothers longer to conceive a child after
their most recent birth event, perhaps because fertility is not at its
height. This sterility is based on the assumption that the infant has
little solid food and is entirely dependent on breast-feeding. If solid
foods are offered, the window of nonfertility is lessened. Some
practices associated with breast-feeding, however, might have lengthened
this window. Many peoples including the Greeks and the Romans held that
sexual intercourse spoiled the milk and, because some of these same
cultures believed that children should be nursed at least for three
years, long periods of abstinence would have been associated with
breast-feeding. Other factors are involved as well. The onset of
menstruation, even with lactating women, is closely associated with
levels of nutrition and physical well-being. A comparative study of
Bostonian and Taiwanese women who breast-feed indicated that a higher
percentage of Boston women had begun to menstruate within six months of
weaning than had Taiwanese women. The best advice today for women who
are breast-feeding and who are also engaging in sexual intercourse is to
use one of the methods of contraception available as well.
Embryologically, the breasts develop from columns of
cells called mammary ridges, which extend along the anterior body wall
from the armpits to the upper thighs [2]. Most of the ridges disappear
in the course of prenatal development except for the parts in the
midthoracic region, which give rise to the breasts and nipples.
Sometimes people have extra breasts or nipples. These are most commonly
found in the armpits or on the lower chest below and medial to the
normal breasts, but they may appear anywhere along the course of the
embryonic mammary ridges (the milk line). Extra nipples and breast
tissue may be a source of embarrassment to the individual, but usually
they do not cause other problems.
Nonproliferative (benign) cystic changes in breast
tissue, often called benign cystic disease or benign fibrocystic change
(FCC), is a common condition that bears no increased risk for
development of cancer. FCC occurs in about one-third of women from the
age of twenty to the menopausal period, after which the condition
recedes. It is characterized by focal areas of proliferation of
glandular and fibrous tissue in the breast associated with localized
dilatation of ducts, resulting in the formation of various-sized cysts
within the breast. Cystic change appears to be caused by irregularities
in the response of the breast tissue to the normal cyclic variations of
each menstrual cycle. Clinically, a breast cyst may feel very firm and
may appear to be a solid tumor. Ultrasound examination of the breast is
often helpful in distinguishing a cystic from a solid mass in the
breast. Often, if the physician believes the mass to be a cyst rather
than a solid tumor, an attempt is made to aspirate the cyst. A needle is
introduced into the breast under local anesthesia. If a cyst is
present, the fluid is aspirated and the mass disappears. If no fluid can
be obtained, surgical excision is performed.
Mastalgia is a symptom complex of breast pain and
tenderness, with or without nodularity [7]. Among presenting breast
complaints in primary care, mastalgia is at least as common, if not more
common, than finding a lump. Most women are concerned about cancer.
However, in a study of 987 women whose only complaint was breast pain,
1% had a malignancy on mammogram. Mastalgia is either cyclic or
noncyclic, and the management depends on this categorization.
Reassurance, after appropriate evaluation, that the pain is not due to
cancer will be sufficient for most women; roughly 15% will require
additional treatment.
Approximately two-thirds of women presenting with
breast pain have cyclic mastalgia, which is bilateral pain varying in
intensity throughout the menstrual cycle with the premenstrual time
often the most painful. It is thought to be hormonally mediated although
studies of circulating levels of progesterone, estrogen, prolactin, or
quantity of hormone receptors have yielded conflicting results; however,
altered hormone receptor sensitivity remains a possibility. The usual
age at presentation is 33 to 35 years; the condition also has been
reported by postmenopausal women on hormone therapy. Noncyclic mastalgia
is usually unilateral, typically occurs in women over the age of 40
years, and is not temporally related to the menstrual cycle.
Postsurgical breast pain may occur at the site of an
incision, particularly if the lines of Langer have been crossed.
Mondor’s disease (phlebitis of the thoracoepigastric vein) may be
related to a history of breast surgery, trauma, or radiation.
Costochondritis (Tietze syndrome) reportedly accounts for approximately
7% of noncyclic mastalgia. Ruptured breast implants may also be a cause
of localized breast pain. Although subclinical operable breast cancer
may present with noncyclic breast pain of recent onset, it is rare that
pain is the only presenting symptom in malignancy.
Breast carcinoma occurs in both sexes [2]. It is a
rare tumor in men, whose breast tissue is not subjected to stimulation
by ovarian hormones, but it is the most frequently diagnosed cancer in
women and ranks second as a cause of cancer deaths (exceeded only by
lung cancer). Breast cancer incidence rates declined drastically in the
early part of the 21st century with the recognition that combined
estrogen-progesterone therapy to reduce the symptoms associated with
menopause (hormone replacement therapy) was a major risk factor for
breast cancer. Additional modifiable risk factors include being
overweight, physically inactive, consuming alcohol, or being a heavy
smoker. Hormonal factors also influence the risk of breast carcinoma.
Women who have never borne children or had their first child after age
thirty are at increased risk, as are women who have had early onset of
menses (menarche) or late menopause (that is, have had a long menstrual
history). High breast tissue density (increased glandular relative to
fat tissue) as measured on mammography also may indicate increased risk,
but this may be due to the difficulty of early detection in such
breasts rather than to heightened risk. There is some tendency for
breast carcinoma to run in families, and a woman is at higher than
normal risk if her mother or sister has had a breast carcinoma.
Inherited mutations can lead to striking increases in breast cancer
susceptibility. Two genes (BRCA1 and BRCA2), although rare in the
population (less than 1 percent), account for up to 10 percent of all
female breast cancer and up to 20 percent of breast cancer that occurs
in families. In summary, the etiology of breast cancer is multifactorial
and involves genetic background, hormonal status, and poorly defined
environmental factors. Significant differences in breast cancer
frequencies are found in different populations and socioeconomic groups.
Mammography has led to the understanding that breast cancer originates
in “in situ disease,” which is restricted to the ducts and lobular
system and is not (yet) capable of metastasis. Ductal carcinoma in situ
(DCIS), the precursor lesion to most breast cancers, is now diagnosed
with fivefold greater frequency as a result of screening mammography.
With time, in situ disease leads to populations of neoplastic cell that
can traverse the ductal basement membrane, invade the surrounding
tissue, and metastasize to distant sites. Because it is unclear which
cases of DCIS will progress to invasive disease, DCIS is treated
aggressively with excision and sometimes radiation and hormonal therapy.
The process of progression is accompanied by loss of the myoepithelial
cell layer surrounding the ducts and lobules of the TDLU.
Substantial evidence supports the use of routine
screening mammography; however, recommendations relating to timing and
frequency vary by different agencies and countries [8]. About one-third
of the abnormalities detected on screening mammograms will be found to
be malignant when biopsy is performed. The probability of cancer on a
screening mammogram is directly related to the Breast Imaging Reporting
and Data System (BIRADS) assessment, and workup should be performed
based on this classification. The sensitivity of mammography varies from
approximately 60% to 90%. This sensitivity depends on several factors,
including patient age, breast density, tumor size, tumor histology
(lobular versus ductal), location, and mammographic appearance. In young
women with dense breasts, mammography is less sensitive than in older
women with fatty breasts, in whom mammography can detect at least 90% of
malignancies. Smaller tumors, particularly those without
calcifications, are more difficult to detect, especially in dense
breasts. The lack of sensitivity and the low incidence of breast cancer
in young women have led to questions concerning the value of mammography
for screening in women 40-50 years of age. The specificity of
mammography in women under 50 years varies from about 30% to 40% for
nonpalpable mammographic abnormalities to 85% to 90% for clinically
evident malignancies. Currently, the American College of Radiology
recommends annual mammography screening for women aged 40 and older and
the American Cancer Society recommends screening average-risk women
annually starting at the age of 45 and offering mammography to women who
choose to do so starting at the age of 40. Thus, clinicians should have
an informed discussion with patients about screening mammography
regarding its potential risks (eg, false positives, overdiagnosis) and
benefits (eg, early diagnosis), taking into consideration a patient’s
individual risk factors.
Breast self-examination (BSE) was traditionally
advocated as a method of self-screening [9]. Over the years, evidence
has demonstrated that self-examination does not reduce breast
cancer-related mortality and is associated with an increased rate of
benign biopsies. Beginning in 2009, the USPSTF (US Preventive Services
Task Force) specifically recommended against clinicians teaching the
practice of breast self-examination (awarding that service a “D” grade),
concluding with a moderate or high certainty that BSE did not have a
net benefit for patients.
The new mantra being advocated, in place of the
traditional practice of BSE, is the concept of “breast self-awareness,”
which is being promoted by essentially all organizations, including the
ACOG (American Congress of Obstetricians and Gynecologists), ACS
(American Cancer Society), and NCCN (National Comprehensive Cancer
Network). Rather than a methodically and routinely performed self-exam,
this recommendation emphasizes the importance of patients being aware of
the way their breasts normally appear and feel. The patient is
encouraged to be aware of any change that may occur in their own body
and to discuss these changes with their physician. A breast finding
brought to a clinician’s attention by the patient may be appropriately
followed up with either reassurance, clinical breast exam, and/or
imaging.
The first step in breast self-examination is to look
for any visible changes in front of the mirror. These can be a change in
skin color, a change in the size of a breast, a change in texture, skin
indentation, etc. It is also necessary to look at the nipples and see
if they have changed shape or color in any way. Most breast changes are
benign in nature and patients should not be immediately frightened if
they notice changes in the breast. It is necessary to go to the doctor
without panic and excessive fear. Without delay.
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