Operational Medicine Medical Education and Training

Breast Problems

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 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. During breast examinations, this area should be palpated.

 

Breast Problems

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Breasttail250.jpg (12296 bytes)

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.

Although this image shows a supernumerary breast low in the abdomen, the two most common places for them are in the axilla and directly underneath the normal breast.

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

Supernumerary Nipples

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.

Adolescent Breast Problems

There is considerable individual variation in age at which this development occurs.

Asymmetrical breast growth during adolescence is the rule rather than the exception. Reassurance is given that the asymmetry usually evens out by the time of full maturation.

Mammary hypertrophy can be a distressing symptom. Because growth and development continues for a long time, surgical intervention, if contemplated is postponed 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.

Pregnancy Changes

During pregnancy, a number of changes occur over time which prepare the breast for lactation. These images demonstrate these changes:

  • Early in the first trimester, the breasts and nipples become tender. The tenderness persists until the end of the 1st trimester, at which time the tenderness disappears.

  • By the end of the first trimester, enlargement of the breast and nipple is noticeable.

  • By the third trimester, the breast and nipple have experienced further enlargement and the Montgomery's glands around the periphery of the areola become more pronounced.

  • The nipples gradually darken, becoming dark brown or black by full term.

Continue to the PowerPoint Lecture...

From:

Operational Obstetrics & Gynecology
2nd Edition
NAVMEDPUB 6300-2C

Bureau of Medicine and Surgery
Department of the Navy

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