Medical Female Breast Exam

Anatomy: The breast is made up of milk producing glands that are arranged into units known as lobules. These glands are connected via a series of ducts that ultimately join up to form a common drainage path, terminating at the nipple. The nipple is surrounded by a ring of pigmented tissue known as the areola. Fibro-elastic and fatty tissue provide support for the rest of the structure and allow the breast to maintain its distinctive shape. The breast lies on top of the pectoral muscle, which in turn rests on the thoracic cage. Rough boundaries of the breast are as follows:
Superior aspect of the breast is bounded by the clavicle
Inferiorly by the inframamary crease (“bra line”)
Medially by the sternum
Laterally by the axilla
Why and when should a breast examination be performed?
In the asymptomatic patient: The asymptomatic breast exam is generally performed only on women. This is because diseases of the breast, in particular cancer, occur far more commonly in women then men. Malignancies generally originate in either the glandular tissues that secrete milk or in the ductal structures that transport it to the nipple.
Examination can be done by the clinician (Clinical Breast Exam – CBE) or patient (Self Breast Exam – SBE). Those performed by the clinician are usually done on an annual basis, beginning at the age of 40, which coincides with time of increased risk for development of breast cancer. Other major breast cancer risk factors include: prior history of breast ca, family history in 1st degree relative (particularly if at a young age), increasing patient age and features that result in prolonged/uninterrupted exposure to estrogen (e.g. early age at onset menstruation, never having been pregnant, older age at first pregnancy, older age at menopause). SBE is often recommended on a monthly-to-every-few-months basis.
Interestingly, while both SBE and CBE are part of routine clinical care, there are no studies that demonstrate that either of these techniques, when performed as stand-alone examinations, actually improves clinical outcomes (i.e. detects cancer at an earlier stage, demonstrating positive impact on cancer related morbidity or mortality). In contrast, mammography (performed with or without CBE), has a strong body of evidence to support its routine use as a screening tool for early detection of malignancy.
In the symptomatic patient: The goal of the examination in the setting of symptoms is to better characterize the abnormality, identify underlying etiology, and direct additional evaluation and treatment. Breast related symptoms may include any of the following:
Discrete masses detected by the patient, often concerning for malignancy
Pain, which can be associated with a number of processes including: cyclical in a menstruating women (reflecting transient hormone induced changes in the breast tissue), occasionally malignancies.
Unusual nipple discharge, which may include:
Blood, concerning for malignancy
Milk when not pregnant. Suggestive inappropriate Prolactin secretion from the pituitary – may also be induced by certain medications
Other
Discoloration or change in the quality of the skin:
Redness suggests infection or inflammation – in the post partum patient, this is often due to mastitis, a diffuse inflammatory condition caused by congestion from inadequately expressed milk.
“Peau d’orange” quality – an “Orange Peel” like texture that’s caused by an uncommon, aggressive inflammatory malignancy
If a mass or other abnormality is identified, it’s location can be described as being in one of 4 quadrants (left upper, left lower, right upper, right lower) of the breast. Alternatively, it can be described relative to it’s position, imagining a clock face were superimposed on the breast.

It’s worth noting that breast symptoms may be caused by diseases elsewhere in the body. For example, as mentioned above, inappropriate milk production may be due to a pituitary tumor secreting Prolactin. Or breast development in men may signify underlying liver disease. Given this, breast symptoms may merit careful history and evaluation of other organ systems. As symptoms can occur in male or female patients (though overall, female >>> male), evaluation is indicated in either sex patient who presents with breast concerns.
Examination in Detail
Getting Started
Carefully explain what you are going to do – and why.
Room should be a comfortable temperature.
Patient should be in a gown – all undergarments (bras, shirts, etc) should be removed.
Have the patient remove their arms from the sleeves of the gown – though keep both breasts covered by laying the garment on top of their chest. Alternatively, the patient may put on the gown so that it opens in the front, which may make exposing one breast at a time a bit easier.
Patient should be lying flat on the table – It may help to have them place hand on side to be examined behind their head, allowing easier access to breast and axilla.
Uncover only the breast that you are going to examine.
Observe the breast, looking for evidence of skin or nipple dimpling/retraction, discoloration, obvious masses or asymmetry.
Observing the breasts while the patient sits up may increase your ability to detect asymmetry or other surface abnormalities, particularly if the person has large breasts.
Palpation of the Breast and Axilla: The goal of this exam is to examine the breast in a systematic fashion, such that all of the tissue is palpated. 3 methods are described below. The accuracy of the exam is increased by allowing adequate time. This will vary with breast size. Specifically, it will take more time to carefully evaluate larger breasts. Regardless of the method used to assure that the breast is examined in its entirety, palpation technique should be as follows:
Palpation Technique in Detail

Use the pads of the middle 3 fingers of one hand.
Press downward using a circular motion.
Apply steady pressure, pushing down to the level of the chest wall. Apply enough pressure to palpate to 3 levels of depth: first superficial, then medium, and then deep/to the level of the chest wall.
Make sure to palpate the nipple and areolar regions.
What precisely are you trying to identify? Normal breasts have a lumpy consistency, created by the mix of lobular, ductal and supporting tissue. The CBE (as mentioned above) is largely performed to identify masses consistent with malignancy. Most lumps are benign (e.g. fibroadenomas, cysts). Masses of concern tend to have the following characteristics: Feel different from the rest of the breast tissue (aka “dominant mass”), firmness, irregular/hard to define borders, fixed/stuck to adjacent tissue – and increase in size over time. As breast density decreases with age (lobular tissue replaced by fat), it is easier to identify masses in older patients.

Three Methods for systematic examination of the breast:

Method 1 – Vertical strips:
In this technique, you are breaking the breast into a series of vertical strips, each of which is evaluated sequentially, moving lateral to medial.
Start at the clavicle, adjacent to the axilla.
Move your hand down in a vertical line until you’ve reached the area below the breast. Actual palpation technique is as described above.
Then move a bit more medially, and examine while traveling up towards the top of the breast.
When you reach the clavicle, move medially and repeat until you’ve evaluated the entire breast.
There is a “tail” of breast tissue that extends from the lateral aspect of the structure towards the axilla. Make sure that you palpate this region as well.