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Definitions, Structure and Function
Chapters 14,20,21,&22
Key Definitions
 Gynecomastia: abnormal enlargement of one or two
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breasts in men.
Supernumerary breast: extra breast tissue, sometimes
with a nipple.
Dysmenorrhea: painful menstration
Dyspareunia: painful intercourse
Gravida: # of pregnancies regardless of outcome.
Parity: # of deliveries, regardless of outcome.
Menarche: age at which menstruation begins.
Key Definitions
 Menopause: age at which menstruation ends.
 Puberty: secondary sexual characteristics appear,
reproductive ability develops.
 Androgens: male sex hormones.
 Circumcision: surgical removal of the prepuce
(foreskin)
 Phimosis: abnormal tightness of the prepuce.
 Hypospadias: opening of the urethral meatus on
ventral surface of the penis.
Structure and Function
Surface Anatomy
 Lie anterior to the pectoralis major & serratus ant. mus.
 Between the second and sixth ribs
 From lateral side of sternum to the midaxillary line.
 Tail of Spence: projects up and laterally into the axilla.
 Nipple is located below the center of the breast (milk
duct openings)
 Areola: surrounds the nipple, contains small elevated
sebaceous glands called “Montgomery’s glands/tubercles
” (secrete protective lipid material during lactation).
 2.5-10 cm in diameter
One breast may be slightly larger than the other, this is normal.
Quadrants of Left Breast
 Breast may be divided
into 4 quadrants
 UIQ
 LIQ
 LOQ
 UOQ extends into axilla
 note Tail of Spence
Internal Anatomy
The breast is composed of:
1. Glandular tissue
2. Fibrous tissue including suspensory ligaments (Cooper’s
Ligament) provide support for breast tissue. In Cancer these
become contracted and cause dimpling.
3. Adipose tissue (fat)
4. Breasts are supported by a bed of muscles:
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2.
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4.
5.
Pectoralis major & minor
Latissimus dorsi
Serratus anterior
Rectus abdominus
External oblique
15-20 lobes
Each with 20-40
Lobules (contain alveoli)
Each empties into
Lactiferous dusts to
Lactiferous sinuses.
(reservoir behind nipple)
Milk Line
Ectodermal Galactic Band
 Develops during 5th week of
fetal devmt
 Most of the band atrophies
except in the thoracic area
 Incomplete atrophy results in
the development of extra
nipples known as
supernumerary nipples
Lymphatic Drainage
 The breast has extensive lymphatic drainage.
 More than 75% drain into the ipsilateral axillary nodes.
 Central axillary nodes, pectoral, subscapular and lateral
nodes.
 Internal mammary nodes
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Sm group flow up into infraclavicular, chest, abdomen or across to breast
Developmental Considerations
 Diagram of breast development-note changes p 416
 at puberty - breast development begins between ages 8 & 10 –
stimulated by estrogen release during puberty- with the
appearance of breast buds - onset of menses usually follows in
2-3 years – asymmetry in breast development is not abnormal.
 during pregnancy and lactation - enlarge several times normal
size, colostrum after the fourth month
 maturity - after menopause - as estrogen secretion declines the
tissue atrophies and is replaced with fatty deposits - reduction
in breast size results - breasts become flabbier and hang more
loosely from the chest wall as the ligaments relax
Male Breast
 During adolescence, temporary enlargement is common
(gynecomastia)
 Unilateral
 Provide reassurance
 Gynecomastia reappears in the aging male and may be due
to testosterone deficiency.
Health History
 Patient profile
 Age
 Gender
 Race
 Common chief complaints
 Breast mass, tenderness, discharge
 Assess characteristics
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Location
Quality
Quantity
Associated manifestations
Aggravating factors
Alleviating factors
Timing
Health History
 Past health history
 Medical
 Breast specific vs. nonbreast specific
 Surgical
 Medications
 Allergies
 Injuries and accidents
 Family history
 Breast cancer
 Benign breast disease
Health History
 Social history
 Alcohol use
 Tobacco use
 Work environment
 Home environment
 Economic status
 Ethnic background
 Health maintenance activities
 Diet
 Exercise
 Use of safety devices
 Health check-ups
 Monthly breast self-exam
 Mammogram
Equipment
Towel, drape, centimeter ruler, teaching aid for breast
self-exam
General approach
Inspection
Patient positions
Subjective Data
Breast
 Pain
 Lump
 Discharge
 Rash
 Swelling
 Trauma
 Hx of breast disease
 Surgery
 Breast self-exam,
mammogram
Axilla
 Tenderness
 Lump or swelling
 rash
Assessment
Inspect specific areas
 Breasts
 Axillae
 Areolar areas
 Nipples
 Contour (see pg 422 for illustrations)
 Lesions or masses
 Exudates
Assessment
 Normal Findings for Inspection:
 Breast and axillae are flesh colored
 Areolar areas and nipples are darker in pigmentation
 Moles and nevi are normal variants
 No thickening or edema
 Minor size variation in the breasts and areolar areas
 Breast on dominant side usually is larger
 Nipples should point upward and laterally, may point outward &
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downward
Breasts, areolar areas, nipples should be symmetrical
Breasts are convex, without flattening, retractions, or dimpling
Free from masses, tumors, primary or secondary lesions
No discharge from nipples in nonpregnant, nonlactating female
Palpation
 Sequential manner
 Supraclavicular and infraclavicular nodes
 Breasts with arms at side, arms raised over head
 Axillary lymph node region
 Breasts with pt in supine position
Palpation
while
sitting
Palpate
Supraclavicular &
Infraclavcicular
lymph nodes
Bimanual palpation
while sitting
Palpation of Axillary
Nodes while sitting
Palpation
while
supine
Palpation Methods
-Wedge
-Concentric lines
-Parallel lines
Palpation of
Glandular tissue
Palpation of
Areola
Palpation of
Nipple
Normal Findings for Palpation
 Palpable lymph nodes less than 1 cm in diameter usually
are clinically insignificant
 Palpation should not elicit pain
 Consistency of breast tissue is highly variable depending
on age, time in menstrual cycle, and proportion of adipose
tissue
 Breasts are usually nodular or granular before menses
 Variation with breast augmentation—breasts feel firm
throughout
Evaluation of Breast Mass
Characteristics
 Location
 Definition
 Size
 Mobility
 Shape
 Tenderness
 Number
 Erythema
 Consistency
 Dimpling or retraction
 Lymphadenopathy
 P. 429
Risk Factors for Breast Cancer
 Age > 50
 Personal history of breast cancer
 Mother, grandmother, or sister with breast cancer
 Menarche at an early age
 Menopause at advanced age
 Obesity
 Alcohol intake > 3 servings per day
 American or European descent
 Urban dweller
(continues)
Risk Factors for Breast Cancer
 Estrogen replacement therapy (ERT), Hormone (HRT)
 Nulliparous
 First birth after age 30
 Higher education and socioeconomic status
 Atypical hyperplasia
 Significant mammographic breast density (indicates a
grter amt of glandular tissue)
 BRCA 1 or BRCA 2 gene mutation
Jarvis p.416
•Mutation of BRCA1
and BRCA2 genes
•Previous positive
breast biopsy or
irrradiation
•Menopause after 50s
•White race
•Long term use of HRT
•No breast feeding
•Physical inactivity
Breast Cancer
 Second major cause of death from cancer in women
 identify risk factors
 70% of breast cancers occur with only age and gender as
identifiable risk.
 5 year survival rate for localized breast cancer is 98%.
 If cancer has spread regionally, the rate is 76 to 88%.
Breast Self-Exam
 Video in lab
 See handout last pages
 Teach during palpation stage of assessment
 Check for dimpling, retraction, breast flattening, discharge
 Also report redness, inflammation, masses, puckering,
sunken areas, asymmetrical nipples direction, bleeding,
lesions
Benign Breast Disease
•Cyclic Swelling
•Pain, cyclic: non-cyclic
•Nodularity, cyclic: non-cyclic bilaterally
mobile, feel rubbery like water balloons
•Dominant lumps
•Nipple discharge
•Infections/inflammations
50% have some form of benign breast
Disease.
Rule out cancer with biopsy
Sometimes difficult to detect cancer
lumps
Cancer
•Solitary, unilateral non-tender mass
•Single focus (one area)
•Solid, hard, dense and fixed to
tissues or skin as cancer becomes
invasive
•Borders irregular and poorly delineated
•Grows constantly
•May have pain or be painless
•Most common in upper outer quadrant
30-80 yrs
Advanced cancer=firm or hard irregular
axillary nodes
skin dimpling, nipple retraction, elevation
and discharge
Diagnosed by biopsy
Fibroadenoma
•Solitary non-tender mass
•Category of benign breast disease
•Solid, firm, rubbery, and elastic
•Round, oval, or lobulated
•1 to 5 cm
•Freely movable, slippery
Most common between 15 to 30
Up to age 55
Grows quickly and constantly
Diagnosed by biopsy
Diagnostic Techniques
 Mammography
 X ray
 Ultrasonography
 Magnetic resonance imaging
Gerontological Variations
 Breast tissue atrophies
 Decreased glandular tissue, resulting in
granular feel
 Breasts become smaller, pendulous, and
wrinkled
 Ductal tissue becomes more palpable;
feels stringy
Breast Self-Examination (BSE)
 Performed once a month
 Performed on a fixed date each month, or 8 days after
menses
 Avoid completing during menstruation or ovulation
 Use calendar for monthly reminder
 Include significant other in examination process
Breast Self-Examination (BSE)
 Bed (B): Supine position
 Use palmar surface of fingers
 Place right arm over head and palpate
right breast
 Move in concentric circles from the periphery inward
 Squeeze the nipple to examine for discharge
 Use same procedure to check left breast
Breast Self-Examination (BSE)
 Standing (S)
 Repeat previous process in standing position
 Stand before mirror, arms at side
 Assess for symmetry, retractions, dimpling, inverted
nipples, or nipple deviation
 Repeat with arms above head
 Repeat with hands pressed into hips
Lying Down & Standing BSE