 Beneath the skin are glandular, fibrous, and
Differences in Areola Pigmentation
The pigment of the nipple and areola vary among
people of different races, getting darker as skin tone
darkens.
Whites have light-colored nipples and areola, usually
pink or light beige
People with darker complexion, such as Blacks and
Asians, have medium brown to almost black nipples
and areola
Male Concerns
Keep in mind that men also need breast examinations
and that the incidence of breast cancer in males is
rising. Men with breast disorders may feel uneasy or
embarrassed about being examined because they see
their condition as being unmanly. Remember that a
man needs a gentle, professional hand as much as a
woman does.
Male breast cancer and gynecomastia:
Be sure to examine a man’s breasts thoroughly during
a complete physical assessment. Don’t overlook
palpation of the nipple and areola in male patient;
assess for the same changes you would in a woman.
Breast cancer in men usually occurs in the areolar
area.
Gynecomastia is abnormal enlargement of the male
breast. It may be a benign finding, or it may be
caused by medications, cirrhosis, malnutrition,
neoplasms, illicit drug use, alcohol consumption, or a
hormonal imbalance
Breasts in boys and older men:
Adolescent boys may have temporary stimulation of
breast tissue caused by the hormone estrogen, which
is produced in males and females. Breast
enlargement in boys usually stops when they begin
producing adequate amounts of the male sex
hormone testosterone during puberty. Older men
may experience gynecomastia as a result of age-
related hormonal alterations or an adverse effect of
certain medications
 Each breast has a centrally located nipple of
pigmented erectile tissue ridged by an areola
that’s darker than the adjacent tissue
SUPPORT STRUCTURES
fatty tissue that vary with age, weight, gender,
hereditary and other factors such as pregnancy
 A small triangle of tissue, called the TAIL OF
SPENCE, projects into the axilla
 Attached to the chest wall musculature are
fibrous bands, called COOPER’S LIGAMENTS,
that support each breast
           
LOBES AND DUCTS
 In women, each breast is surrounded by 12 to
25 glandular lobes containing alveoli that
produce milk
 The lactiferous ducts from each lobe transport
milk to the nipple
 In men, the breast has a nipple, an areola, and
mostly flat tissue bordering the chest wall
                      
LYMPH NODES
 The breast also hold several lymph node chains,
each serving different areas
 The pectoral lymph nodes drain lymph fluid
from most of the breast and anterior chest
 The brachial nodes drain most of the arm
 The subscapular nodes drain the posterior
chest wall and part of the arm
 The midaxillary nodes, located near the ribs
and the serratus anterior muscle high in the
axilla, are the central draining nodes for the
pectoral, brachial, and subscapular nodes
 In women, the internal mammary nodes drain
the mammary lobes
 The superficial lymphatic vessels drain the skin
 In both men and women, the lymphatic system
is the most common route of spread of cells
that cause breast cancer
 A woman’s breasts make many transformations
throughout the life cycle
 Their appearance starts changing at puberty
and continues changing during the reproductive
years, pregnancy, and menopause
                
CHANGES DURING PUBERTY
 Breast development is an early sign of puberty
in girls
 It usually occurs between ages 8 and 13
 Menarche, the start of the menstrual cycle,
typically occurs about 2 years later
  Development of breast tissue in girls younger
than age 7 in Caucasians and age 6 in blacks
may be abnormal, and the patient should be
referred to a health care practitioner
 Breast development usually starts with the
breast and nipple protruding as a single mound
of flesh, commonly called the breast bud stage
 The shape of the adult female breast is formed
gradually
 During puberty, breast development is
commonly unilateral or asymmetrical
CHANGES DURING THE REPRODUCTIVE YEARS
 During the reproductive years, a woman’s
breasts may become full or tender in response
to hormonal fluctuations during the menstrual
cycle
 During pregnancy and lactation, breast changes
occur in response to hormones from the corpus
luteum, the placenta, and the pituitary gland
 The areola becomes deeply pigmented and
increases in diameter
 The nipple becomes darker, more prominent,
and erect
 The breasts enlarge because of the proliferation
and hypertrophy of the alveolar cells and
lactiferous ducts
 As veins engorge, a venous pattern may become
visible
 In addition, striae may appear as a result of
stretching, and Montgomery’s tubercles may
become prominent
                
CHANGES AFTER MENOPAUSE
 After menopause, estrogen levels decrease,
causing glandular tissue to atrophy and be
replaced with fatty deposits
 The breasts become less dense and smaller than
they were before menopause
 As the ligaments relax, the breasts hang loosely
from the chest
 The nipples flatten, losing some of their erectile
quality
 The ducts around the nipple may feel like firm
string
 You’ll typically begin your health history by
asking the patient about her reason for seeking
care
 You’ll then want to ask the patient questions
about her personal and family medical history
as well as her current health
 Common complaints about the breasts include
breast pain, nipple discharge and rash, lumps,
masses, and other changes 
 Complaints such as these – whether they come
from women or men – warrant further
investigation
 To investigate these complaints, ask about the
symptom’s onset, duration and severity
 What day of the menstrual cycle do the signs
and symptoms appear, if applicable?
 What relieves or worsens them?
 Ask the patient if she has ever had breast
lumps, a biopsy, or breast surgery, including
enlargement or reduction
 Also ask if she has a history of breast disease or
trauma
 If she has had breast cancer, fibro-adenoma, or
fibrocystic disease, ask for more information,
such as whether she underwent surgery,
chemotherapy, or radiation treatment
 Inquire about the patient’s menstrual cycle,
including what age it started, and record the
date of her last menses
 If the patient has been pregnant, ask how many
pregnancies and live births she has had
 How old was she each time she became
pregnant?
 Did she have complications?
 Did she breast-feed?
 Ask the patient if any family members have had
breast disorders, especially breast cancer
 Also ask about the incidence of other types of
cancer
 Having a close relative with breast cancer
greatly increases the patient’s risk of having the
disease
 Teach the patient how to examine her breasts
and the importance of regular breast
examinations and mammograms

Evaluating Breast Lump
If you find a breast lump during your assessment,
note the following characteristics. All breast lumps
should be further evaluated with a mammography,
ultrasound, fine-needle aspiration, or core biopsy
CHARACTERISTICS BENIGN MALIGNANT
Appearance Breasts show Breast is
no change dimpled, scaly,
or puckered,
with an
 orange-peel examination
appearance or 20 to Monthly, 7 Not Every 3
accentuated 39 to 10 days recommended years
veins after
Consistency  Lump is firm Lump is firm menses
to soft and hard begin
Demarcation  Lump is well Lump is poorly 40 Monthly, 7 Yearly  Yearly 
demarcated defined and to 10 days
Mobility  Lump is easy Lump is fixed in older after
to move breast tissue menses
begins
Tenderness  Breast is Breast may be  Some breast changes are a normal part of aging,
usually non non tender or so be sure to ask the patient how old she is
tender but tender, based  If she has noticed a breast change, ask her to
may be tender on describe it in detail
before advancement  Exactly where on the breast is the change?
menstruation of cancer When did it occur? Does she have pain,
Nipple changes Nipple shows Nipple may be tenderness, discharge, or rash?
no changes inverted,  Has she had changes or pain in her underarm
retracted, or area?
itchy with  Does the problem come and go, or is it always
bloody, yellow, present?
green, or clear  Ask the patient what drugs she uses regularly,
discharge such as birth control pills, contraceptive
Number  Single or Usually a single patches, or vaginal ring with estrogen
multiple lumps lump  Hormonal birth control methods can cause
may be in one breast swelling and tenderness
or both  Ask about her diet, especially caffeine intake
breasts  Caffeine has been linked to fibrocystic disease
Location  Lump may Lump ma occur of the breasts
occur anywhere in  Ask the patient whether she is under a lot of
anywhere in breast, but stress, smokes, or drinks alcohol
breast more  Discuss the possible link between those factors
commonly and breast cancer
occurs in upper  Note the patient’s weight
outer quadrant  If the patient is overweight, explain the link
between increased weight and breast cancer
development, and refer her to information on
Scheduling Breast Examinations weight control
The American Cancer Society recommends the  Having a breast examination can be stressful for
schedule shown here for regular breast examinations. a woman
Depending on their needs, some patients may follow  To reduce your patient’s anxiety, provide
schedule that have been modified by their doctors. privacy, make her as comfortable as possible,
Women with a family history of or a genetic and explain what the examination involves
predisposition for breast cancer – as well as women  If possible, perform the examination 7 to 9 days
who have a personal history of cancer – may need the onset of menses in a premenopausal patient
earlier or more frequent screening tests and  Before examining the breasts, make sure the
examinations. Women at high risk for breast cancer room is well lighted
should also have an annual magnetic resonance  Have the patient disrobe from the waist up and
imaging scan sit with her arms at her sides
 Keep both breasts uncovered so you can
Age Breast self- Mammography Clinical observe them simultaneously to detect
examination breast differences
  
BMI and Breast Cancer Risk
Extra weight can be bad for your patient’s health in
more ways than one. Women who have a body mass
index (BMI) of 30 or higher have an increased risk of
developing breast cancer, especially after
menopause. This is because fat tissue produces small
amounts of estrogen, and higher levels of estrogen
increases the risk of breast cancer. The outlook is
even worse for women with a BMI of 40 or higher
who develop breast cancer, they’re three times more
likely to die from the disease
INSPECTION
 Breast skin should be smooth, un-dimpled, and
the same color as the rest of the skin
 Check for edema, which can accompany
lymphatic obstruction and may signal cancer
 Note breast size and symmetry
 Asymmetry may occur normally in some adult
women, with the left breast usually larger than
the right
 Inspect the nipple, noting their size and shape
 If a nipple is inverted, dimpled, or creased, ask
the patient when she first noticed the
abnormality
 Lifelong nipple inversion may be normal, but
any changes of the nipple call for further
evaluation
 Next, inspect the patient’s breasts while she
holds her arms over her head, and then again
while she has her hands pressed against her
hips
 Having the patient assume these positions will
help you detect skin or nipple dimpling that
might not have been obvious before
 If the patient has large or pendulous breasts,
have her stand with her hands on the back of a
chair or the examination table and lean forward
 This position helps reveal subtle breast or nipple
asymmetry
PALPATION
 Before palpating the breasts, ask the patient to
lie in a supine position, and place a small pillow
under her shoulder on the side you’re
examining
 This causes the breast on that side to protrude
 Have the patient put her hand behind her head
on the side you’re examining
This spreads the breast more evenly across the
chest and makes finding nodules easier
 If her breasts are small, she can leave her arm
at her side
 To perform palpation, place your finger pads
flat on the breast and compress the tissue
gently against the chest wall, palpating outward
from the nipple with a circular, wedged, or
vertical strip method
 For a patient with pendulous breasts, palpate
down or across the breast with the patient
sitting upright
 As you palpate, note the consistency of the
breast tissue
 Normal consistency varies widely, depending in
part on the proportions of fat and glandular
tissue
 Check for nodules and unusual tenderness 
 Tenderness may be related to cysts, normal
hormonal changes, infection, or very rarely,
cancer
 However, nodularity, fullness, and mild
tenderness are also premenstrual symptoms
 Be sure to ask your patient where she is in her
menstrual cycle
 A lump or mass that feels different from the
rest of the breast tissue may indicate a
pathologic change and warrants further
investigation by a practitioner
 If you find what you think is an abnormality,
check the other breast, too
 Keep in mind that the infra-mammary ridge at
the lower edge of the breast is normally firm
and may be mistaken for a tumor
 If you palpate a mass, record these
characteristics:
o Number of masses
o Size in centimeters
o Shape – round, discoid, regular, or
irregular
o Consistency – soft, firm, or hard
o Mobility
o Delineation – well defined or not well
defined
o Degree of tenderness
o Location, using the quadrant or clock
method
 If the patient complains of a spontaneous nipple
discharge (and isn’t pregnant or lactating) or
has any other abnormal findings on her history
or physical examination, perform a thorough
examination of the nipple
  Compress the nipple and areola to detect
discharge
 If discharge is present, assess the color,
consistency, and quantity of the discharge
 If possible, obtain a cytologic smear
 To obtain a smear, put on gloves, place a glass
slide over the nipple, and smear the discharge
on the slide
 Spray the slide with a fixative, label it with the
patient’s name and the date, and send it to the
laboratory, according to your facility’s policy
 To examine the axillae, use the techniques of
inspection and palpation  thumb and fingers and palpate inside the
 With the patient sitting or standing, inspect the
skin of the axillae for rashes, infections, or
unusual pigmentation
 Before palpating, ask the patient to relax her
arm at her side
 Support her elbow with one of your hands
 Cup the fingers of your other hand, and reach
high into the apex of the axilla
 Place your fingers directly behind the pectoral
muscles, pointing toward the midclavicle
  To do this, have the patient relax her neck
Palpating the Breast
Use your three middle fingers to palpate the breast
systematically. Rotating your fingers gently against
the chest wall, move in concentric circles. Make sure
you include the tail of Spence and the subareolar area
in your examination
EXAMINING THE NIPPLE
If a lump was discovered in the breast, examine the
nipple for discharge
Gently squeeze the nipple between your thumb and
index finger. Note the color, amount, and consistency
of any discharge     part of the breast, including the axilla
Palpating the Axilla
To palpate the axilla, have the patient sit or lie down.
Wear gloves if an ulceration or discharge is present.
Ask her to relax her arm at her side, and support it
with your nondominant hand.
Keeping the fingers of your dominant hand together,
reach high into the apex of the axilla. Position your
fingers so they’re directly behind the pectoralis
muscles, pointing toward the midclavicle. Sweep your
fingers downward against the ribs and serratus
anterior muscle to palpate the midaxillary or central
lymph nodes. Explain to the patient that it’s normal
for this exam to be mildly uncomfortable.
ASSESSING THE AXILLARY NODES
 First, try to palpate the central nodes by
pressing your fingers downward and in toward
the chest wall
 You can usually palpate one or more of the
nodes, which should be soft, small, and
nontender
 If you feel a hard, large, or tender lesion, try to
palpate the other groups of lymph nodes for
comparison
 To palpate the pectoral and anterior nodes,
grasp the anterior axillary fold between your
borders of the pectoral muscles
 Palpate the subscapular or posterior nodes,
stand behind the patient and press your fingers
to feel the inside the muscle of the posterior
axillary fold
ASSESSING THE CLAVICULAR NODES
 If the axillary nodes are abnormal, assess the
nodes in the clavicular area
muscles by flexing her head slightly forward
 Stand in front of her and hook your fingers over
the clavicle beside the sternocleidomastoid
muscle
 Rotate your fingers deeply into this area to feel
the supraclavicular nodes
 The menstrual cycle, certain prescription drugs,
pregnancy, and other conditions can cause
breast changes, therefore, you might have
trouble differentiating abnormal changes from
those that are normal
 A breast nodule, or lump, may be found in any
 Breast nodules may range in clinical significance
from the benign lumps of Breast dimpling
o The puckering or retraction of skin on
the breast
 Results from abnormal attachment of the skin
to underlying tissue
 It suggests an inflammatory or malignant mass
beneath the skin surface and may represent a
late sign of breast cancer
Dimpling and Peau d’ Orange
DIMPLING
Dimpling usually suggests an inflammatory or
malignant mass beneath the skin’s surface. The
illustration shows breast dimpling and nipple
retraction caused by a malignant mass above the
areola                          
PEAU D’ ORANGE
Peau d’orange is usually a late sign of breast cancer,
but it can also occur with breast or axillary lymph
node infection. The skin’s orange-peel appearance
comes from lymphatic edema around deepened hair
follicles
                                      
                                 
 Nipple retraction, the inward displacement of
the nipple below the level of surrounding breast
tissue, may indicate an inflammatory breast
lesion or cancer
 It results from scar tissue formation within a
lesion or large mammary duct
 As the scar tissue shortens, it pulls adjacent
tissue inward, causing nipple deviation,
flattening, and finally retraction
 Nipple inversion is the lack of protrusion of the
nipple
 It typically occurs in puberty
In an adult woman, it may impede breast
feeding and predispose the patient to mastitis
and abscess formation
 Nipple discharge can occur spontaneously or
can be elicited by nipple stimulation
 It’s characterized as intermittent or constant,
unilateral or bilateral, and by color, consistency,
and composition
 It can be a normal finding; however, nipple
discharge can also signal serious underlying
disease, particularly when accompanied
by other breast changes
 Significant causes include endocrine disorders,
cancer, certain drugs, and blocked lactiferous
ducts
 Breast pain commonly results from benign
breast disease, such as mastitis or fibrocystic
breast disease
 It may occur during rest or movement and may
be aggravated by manipulation or palpation
 Breast tenderness refers to pain elicited by
physical contact
 Prominent veins in one breast may indicate
cancer in some patients; however, they’re
considered normal in pregnant women because
of engorgemen

This chart shows you some common groups of findings for the chief signs and symptoms of the breasts and axillae,
along with their probable causes.
SIGN OR SYMPTOM AND
FINDINGS
BREAST DIMPLING
Firm, irregular, nontender lump
Nipple retraction, deviation,
inversion, or flattening
Enlarged axillary lymph nodes
Heat
Erythema
Swelling
Pain and tenderness
Flulike signs and symptoms,
such as fever, malaise, fatigue,
and aching
BREAST PAIN
Tender, palpable lymph nodes
Fever
Nipple discharge
Breast pain and enlargement of Breast cancer
Breast Abnormalities
COMMON SIGN OR SYMPTOM AND FINDINGS COMMON CAUSE
CAUSE
BREAST NODULE Adenofibroma
Breast cancer Single nodule that feels firm, elastic, and
round or lobular with well-defined margins
Extremely mobile, “slippery” feel
No pain or tenderness
Size varies from pinpoint to very large
Grows rapidly
Usually located around the nipple or the
lateral side of the upper outer quadrant
Mastitis Hard, poorly delineated nodule
Fixed to the skin or underlying tissue Breast cancer
Breast dimpling
Nipple deviation or retraction
Located in the upper outer quadrant (50% of
cases)
Nontender
Serous or bloody nipple discharge
Edema or peau d’orange of the skin
overlying the mass
affected breast abscess Axillary lymphadenopathy
Redness and warmth in the
affected breast History of trauma to fatty tissue of the
breast (patient may not remember such Fat necrosis
Unilateral breast pain or trauma)
tenderness Tenderness and erythema
Serous or blood nipple Bruising
discharge, usually only from one Hard, indurated, poorly delineated lump
duct that’s fibrotic and fixed to underlying tissue
Small, soft, poorly delineated Intraductal or overlying skin
mass in the ducts beneath the papilloma Nipple retraction
areola

Small, well-delineated nodule Smooth, round, slightly elastic nodules or

Localized erythema generalized “lumpiness” without a discrete Fibrocystic breast
Induration mass disease
Increased size and tenderness just before
NIPPLE RETRACTION menstruation
Unilateral nipple retraction and Sebaceous cyst Clear, watery (serous), or sticky nipple
inversion (infection) discharge
Hard, fixed, nontender breast Bloating
nodule Irritability
Nipple itching, burning, or Abdominal cramping
erosion Breast cancer
Watery or bloody nipple
discharge (typically unilateral)
Altered breast contour
Dimpling or peau d’orange
Tenderness, redness, and
warmth

Unilateral nipple retraction,

deviation, cracking, or flattening
Firm, warm, erythematous,
tender, swollen area
Possible fatigue, fever, chills,
and other flulike symptoms
Mastitis