Breast
Anatomy and physiology
The breasts are modified sweat glands. The openings of the lactiferous ducts are on the apex of the nipple, which is erectile tissue. The nipple is in the fourth intercostal space in the mid-clavicular line, but accessory breast/nipple tissue may develop anywhere down the nipple line (axilla to groin) ( Figs 11.1 and 11.2 ). The adult breast is divided into the nipple, the areola and four quadrants (upper outer to lower inner), with an axillary tail (of Spence) projecting from the upper outer quadrant ( Fig. 11.3 ).
The size and shape of the breasts are influenced by age, hereditary factors, sexual maturity, phase of the menstrual cycle, parity, pregnancy, lactation and nutritional state. Fat and stroma surrounding the glandular tissue determine the size of the breast, except during lactation, when enlargement is mostly glandular. The breast responds to fluctuations in oestrogen and progesterone levels. Swelling and tenderness are common in the premenstrual phase. The glandular tissue reduces and fat increases with age, making the breasts softer and more pendulous. Lactating breasts are swollen and engorged with milk, and are best examined after breastfeeding.
The history
Benign and malignant conditions of the breast cause similar symptoms but benign changes are much more common. The most common presenting symptoms are a breast lump, breast pain, and skin and nipple changes. Men may present with gynaecomastia (breast swelling). Women are often worried that they have breast cancer, whatever breast symptom they have, and it is important to explore these concerns.
The history of the presenting symptoms is crucial. Find out the nature and duration of symptoms, any changes over time and any relationship to the menstrual cycle.
Ask about risk factors for breast cancer, in particular:
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previous personal history of breast cancer
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family history of breast or ovarian cancer and the age of those affected
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use of hormone replacement therapy
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previous mantle radiotherapy for Hodgkin’s lymphoma.
Common presenting symptoms
Breast lump
Not all patients have symptoms. Women may present with an abnormality on screening mammography or concerns about their family history.
Ask:
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Is it a single lump or multiple lumps?
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Where is it?
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Is it tender?
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Is there any associated nipple discharge?
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Is there any variation in symptoms during the menstrual cycle?
Breast pain (mastalgia)
Ask if the pain varies during the menstrual cycle. Breast pain may be cyclical or non-cyclical and it is important to establish its timing and severity, and to distinguish it clearly from chest-wall pain. Cyclical mastalgia is common, worse in the latter half of the menstrual cycle and relieved by menstruation. Non-cyclical mastalgia does not vary with the menstrual cycle.
Skin changes
Women may report changes in the breast skin or these may be noted on examination. Possible skin changes include:
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Simple skin dimpling: the skin remains mobile over an underlying cancer ( Fig. 11.4 ).
Fig. 11.4
Skin dimpling due to underlying malignancy.
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Indrawing of the skin: the skin is fixed to the cancer.
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Lymphoedema of the breast: the skin is swollen between the hair follicles and looks like orange peel ( peau d’orange ; Fig. 11.5 ). The most common causes of lymphoedema are infection or tumour and it may be accompanied by redness, warmth and tenderness. Investigate any ‘infection’ that does not respond to one course of antibiotics to exclude an inflammatory cancer. These are rare but aggressive tumours with a poor prognosis.
Fig. 11.5
Peau d’orange of the breast.
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Eczema of the nipple and areola: this may be part of a generalised skin disorder. If it affects the true nipple, it may be caused by Paget’s disease of the nipple ( Fig. 11.6 ), or invasion of the epidermis by an intraductal cancer.
Fig. 11.6
Paget’s disease of the nipple.
Nipple changes
Women may report changes to the nipple or these may be noted on examination. Changes include:
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Nipple inversion: retraction of the nipple is common and often benign. It can be the first sign of malignancy, however, in which case it is usually asymmetrical ( Fig. 11.7 ).
Fig. 11.7
Breast cancer presenting as indrawing of the nipple.
Note the bloody discharge on the underclothing.
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Nipple discharge: a small amount of fluid may be expressed from multiple ducts by massaging the breast. It may be clear, yellow, white or green in colour. Investigate persistent single-duct discharge or blood-stained (macroscopic or microscopic) discharge to exclude duct ectasia, periductal mastitis, intraduct papilloma or intraduct cancer.
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Galactorrhoea: this is a milky discharge from multiple ducts in both breasts, most commonly caused by one of several drugs. Rarely, it is due to hyperprolactinaemia. Galactorrhoea may persist for some time after breastfeeding. It often causes hyperplasia of Montgomery’s tubercles, the small rounded projections covering the areolar glands.
Gynaecomastia
Gynaecomastia is enlargement of the male breast and often occurs in pubertal boys. In chronic liver disease, gynaecomastia is caused by high levels of circulating oestrogens, which are not metabolised by the liver. Many drugs can cause breast enlargement ( Box 11.1 and Fig. 11.8 ).
The physical examination
Always offer a chaperone and record that person’s name; if the patient declines, note this. Male doctors should always have a chaperone. Ask the patient to undress to the waist and sit upright on a well-illuminated chair or on the side of a bed.
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Ask the patient to rest her hands on her thighs to relax the pectoral muscles ( Fig. 11.9A ).
Fig. 11.9
Positions for inspecting the breasts.
A Hands resting on the thighs. B Hands pressed on to the hips. C Arms above the head. D Leaning forward with the breasts pendulous.
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Face the patient and look at the breasts for:
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asymmetry
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local swelling
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skin changes
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nipple changes.
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Ask the patient to press her hands firmly on her hips to contract the pectoral muscles and inspect again ( Fig. 11.9B ).
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Ask her to raise her arms above her head and then lean forward to expose the whole breast and exacerbate skin dimpling ( Fig. 11.9C,D ).
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Ask her to lie with her head on one pillow and her hand under her head on the side to be examined ( Fig. 11.10 ).
Fig. 11.10
Position for examination of the right breast.
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Hold your hand flat to her skin and palpate the breast tissue. Using two hands is often helpful. Breasts are often tender so pressing too firmly can be very uncomfortable.
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View the breast as a clock face. Examine each ‘hour of the clock’ from the outside towards the nipple, including under the nipple ( Fig. 11.11 ). Examine all the breast tissue, comparing the texture of one breast with the other. The breast extends from the clavicle to the upper abdomen and from the midline to the anterior border of latissimus dorsi (posterior axillary fold). Define the characteristics of any mass (see Box 3.8 ).
Fig. 11.11
Clinical examination of the breast.
Palpating clockwise to cover all of the breast.
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Elevate the breast with your hand to uncover dimpling overlying a tumour that may not be obvious on inspection.
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Is the mass fixed underneath? With the patient’s hands on her hips, hold the mass between your thumb and forefinger. Ask her to contract and relax the pectoral muscles alternately by pushing into her hips. As the pectoral muscle contracts, note whether the mass moves with it and if it is separate when the muscle is relaxed. Fixation suggests malignancy.
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Examine the axillary tail between your finger and thumb.
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Palpate the nipple by holding it gently between your index finger and thumb. Try to express any discharge. Massage the breast towards the nipple to uncover any discharge, noting the colour and consistency, and the number and position of the affected ducts. Test any discharge for blood using urine-testing sticks.
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Palpate the regional lymph nodes, including the supraclavicular group. Ask the patient to sit facing you, and support the full weight of her arm at the wrist with your opposite hand. Move the flat of your other hand high into the axilla and upwards over the chest to the apex. This can be uncomfortable, so warn patients beforehand and check for any discomfort. Compress the contents of the axilla against the chest wall. Assess any palpable masses for:
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size
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consistency
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fixation.
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Examine the supraclavicular fossa, looking for any visual abnormality. Palpate the neck from behind and systematically review all cervical lymphatic chains (see Figs 3.27 and 9.22 ).
In the UK, breast cancer affects 1 in 9 women. The incidence increases with age, but any mass is potentially malignant until proven otherwise. Cancer of the male breast is uncommon and may have a genetic basis. In contrast, fibroadenomas are smooth, mobile, discrete and rubbery lumps that are common in women under 35 years of age. These are benign overgrowths of the terminal duct lobules.
Fibrocystic changes are rubbery, bilateral and benign, and most prominent premenstrually, but investigate any new focal change in young women that persists after menstruation. These changes and irregular nodularity of the breast are common, especially in the upper outer quadrant in young women.
Breast cysts are smooth, fluid-filled sacs, most common in women aged 35–55 years. They are soft and fluctuant when the sac pressure is low but hard and painful if the pressure is high. Cysts may occur in clusters. A large majority are benign, but investigate any cyst where there is a residual mass following aspiration or which recurs after aspiration.
Breast abscesses occur as one of two types:
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Lactational abscesses in women who are breastfeeding. These are usually peripheral in the breast.
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Non-lactational abscesses, which occur as an extension of periductal mastitis, under the areola, often with nipple inversion. They usually affect young female smokers. Occasionally, a non-lactating abscess may discharge spontaneously through a fistula, classically at the edge of the areola ( Fig. 11.12 ).
Fig. 11.12
Mammary duct fistula.
Investigations
Accurate diagnosis of breast lesions depends on clinical assessment, backed up by mammography and/or breast ultrasound and pathological diagnosis; this should ideally be done by core biopsy, although fine-needle aspiration cytology can also be helpful in assessing axillary lymph nodes (‘triple assessment’) ( Box 11.2 and Figs 11.13 – 11.14 ). Up to 5% of malignant lesions require excision biopsy for the diagnosis to be made. MRI is useful for investigating possible implant rupture or the extent of cancer in a mammographically dense breast, and for screening those with BRCA1 or BRCA2 gene mutations. In the UK, there are specific guidelines for the appropriate referral of patients with breast symptoms to specialist units.
| Investigation | Indication/comment |
|---|---|
| Ultrasound | Lump |
| Mammography | Should not be used in women under 40 unless there is a strong suspicion of cancer |
| Magnetic resonance imaging | Dense breasts, ruptured implant, BRCA1/2 mutation |
| Fine-needle aspiration | Should not be used to diagnose primary cancer but still useful for assessing lymph nodes |
| Core biopsy | To differentiate invasive or in situ cancer |
| Large-core vacuum-assisted core biopsy | Useful for large areas of diffuse change |
| Open surgical biopsy | Used as a last resort when multiple core biopsies have not provided a definite diagnosis |
Female reproductive system
Anatomy and physiology
The female reproductive organs are situated within the bony pelvis ( Fig. 11.15 ). They cannot normally be felt on abdominal palpation. A vaginal examination is required for their routine assessment.
The vulva ( Fig. 11.16 ) consists of fat pads, called labia majora, covered with hair. The labia minora are hairless skin flaps at each side of the vulval vestibule, which contains the urethral opening and the vaginal orifice. The clitoris is situated anteriorly where the labia minora meet and is usually obscured by the prepuce. Posteriorly the labia meet at the fourchette, and the perineum is the fibromuscular region posteriorly that separates it from the anus.
The vagina is a rugged tube 10–15 cm in length. There is an irregular mucosal ring two centimetres into the vagina that represents the remnants of the hymen (see Fig. 11.16 ). Bulging into the top of the vagina is the grape-sized fibrous uterine cervix, with the external cervical os on its surface ( Fig. 11.17 ). The fornices are the areas of the top of the vagina next to the cervix ( Fig. 11.18 ).
The uterus is a muscular pear-shaped structure, about the size of a large plum, situated in the midline and usually tilted anteriorly over the bladder ( Fig. 11.19 ). Its internal cavity is lined by endometrium that proliferates, secretes and breaks down during the menstrual cycle. The Fallopian tubes run laterally from the uterine fundus towards the ovaries (see Fig. 11.17 ). Their distal finger-like fimbriae collect the oocyte after ovulation.
The ovaries are about the size of a walnut and sit behind and above the uterus close to the pelvic side wall. At mid-cycle, one ovary will have developed a fluid-filled preovulatory follicle measuring around 2 cm in diameter. The female reproductive tract is in close proximity to the bladder, ureter and lower gastrointestinal tract (see Fig. 11.19 ).
The history
Identify the woman’s main symptoms, how these developed, their day-to-day impact, how she copes and her ideas, concerns and expectations of the encounter. Document any previous investigations and management. Check the history, even if an asymptomatic patient has come for a routine cervical smear.
Take a gynaecological history by asking about:
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(in pre- or perimenopausal women) last menstrual period (LMP) and whether it was normal; always consider that these patients might be pregnant
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past and present contraceptive use
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plans for fertility
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previous cervical smears, when taken, and any treatment required for abnormalities
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prior abdominal surgery, pelvic infection or sexually transmitted disease
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prior pregnancies and their outcomes
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current or previous hormone replacement therapy
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other medication with potential gynaecological effects (see later).
Common presenting symptoms
Abnormal vaginal bleeding
If women present with heavy periods, ask about:
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flooding: whether menstrual blood soaks through protection, increased requirements for sanitary protection
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passing of blood clots.
Women normally experience monthly menstruation from the menarche (average age 12) until the menopause (average age 51). Menstrual bleeding for 3–6 days normally occurs every 22–35 days (average 28). A menstrual cycle with bleeding for 4–5 days every 25–29 days is recorded as 4–5/25–29. Heavy menstrual bleeding (HMB, previously called menorrhagia) affects 20% of women over 35 and is defined as > 80 mL blood loss during a period (average 35 mL). As this is not quantified in routine practice, HMB is subjective. Anaemia implies heavy bleeding.
Unexpected bleeding suggests endometrial or cervical pathology. Ask when the bleeding occurs:
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between periods (intermenstrual, IMB)
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after intercourse (postcoital, PCB)
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more than 1 year after the menopause (postmenopausal, PMB).
Approximately 4% of women experience PMB, which must be investigated as 10% have endometrial cancer.
Lack of periods (amenorrhoea) in the absence of pregnancy implies ovarian dysfunction and affects 5–7% of woman in their reproductive years. Distinguish between:
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Primary amenorrhoea: periods have not started by age 16. Both ovarian function and the structure of the reproductive tract should be investigated.
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Secondary amenorrhoea: there have been no periods for ≥6 months but there was previous menstruation.
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Oligomenorrhoea: the menstrual cycle is longer than 35 days.
In early pregnancy, 30% of women experience vaginal bleeding. Establish if this is associated with lower abdominal pain. Although the pregnancy may continue normally, bleeding is associated with miscarriage and ectopic pregnancy. Further investigation is required, particularly if the bleeding is associated with lower abdominal pain.
Lower abdominal pain
Lower abdominal pain may arise from the reproductive organs or the urinary or gastrointestinal tract, or be musculoskeletal or neurological in origin ( p. 96 ). Psychological and social factors may also contribute to a woman’s experience of pain.
To differentiate between the possible causes of lower abdominal pain, ask about:
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site of the pain (unilateral, bilateral or midline)
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onset (sudden or gradual, cyclical/related to menstruation or not).
Ovarian pain is often unilateral and can be physiological ( Mittelschmertz is discomfort associated with ovulation). Ovarian cyst accidents involving torsion (twisting on the vascular pedicle causing acute ischaemia), haemorrhage or rupture can lead to acute severe pain.
Primary dysmenorrhoea is pain arising from uterine contraction that is most intense just before and during peak menstruation. Secondary or progressive dysmenorrhoea, due to underlying pathology such as endometriosis or chronic infection, often manifests as pain that lasts beyond the normal menstrual cycle. Infection, pelvic adhesions and endometriosis can cause generalised pain ( Box 11.3 ).
| Uterine pain | Ovarian pain | Adhesions or pelvic infection | Endometriosis | |
|---|---|---|---|---|
| S ite | Midline | Left or right iliac fossa | Generalised lower abdomen; more on one side | Variable |
| O nset | Builds up before period | Sudden, intermittent | Builds up, acute on chronic | Builds up, sudden |
| C haracter | Cramping | Gripping | Shooting, gripping | Shooting, cramping |
| R adiation | Lower back and upper thighs | Groin; if free fluid, to shoulder | – | – |
| A ssociated symptoms | Bleeding from vagina | Known cyst, pregnancy, irregular cycle | Discharge, fever, past surgery | Infertility |
| T iming | With menstruation | May be cyclical | Acute, may be cyclical | Builds up during period |
| E xacerbating factors | – | Positional | Movement, examination | Intercourse, cyclical |
| S everity | Variable in spasms | Intense | Intense in waves | Variable |
Dyspareunia is pain during intercourse. Ask if it is felt around the vaginal entrance (superficial) or within the pelvis (deep). Pain due to involuntary spasm of muscles at the vaginal entrance (vaginismus) may make intercourse impossible. Persistent deep dyspareunia suggests underlying pelvic pathology. Dyspareunia can be due to vaginal dryness following the menopause.
Iliac fossa pain in early pregnancy is commonly associated with a corpus luteum cyst of the ovary but may indicate a tubal ectopic pregnancy. Ruptured ectopic pregnancy results in generalised abdominal pain, peritonism, haemodynamic instability and referred pain in the shoulder.
Abdominal distension and bloating
Pelvic masses can cause non-specific symptoms like abdominal distension, bloating or urinary frequency due to pressure on the bladder. They may also be asymptomatic and picked up during routine abdominal or vaginal examination. Uterine masses include pregnancy and benign leiomyoma tumours (fibroids). Large ovarian cysts can also be midline and malignant ovarian cysts are associated with ascites.
Vaginal discharge
This may be normal and variable during the menstrual cycle. Prior to ovulation, it is clear and abundant, and stretches like egg white; after ovulation, it is thicker, does not stretch and is less abundant. Abnormal vaginal discharge occurs with infection. Ask about:
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consistency
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colour
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odour
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associated itch, pain or dysuria.
The most common non-sexually transmitted infection (caused by Candida species) gives a thick, white, curdy discharge often associated with marked vulval itching. Bacterial vaginosis is a common, non-sexually acquired infection, usually caused by Gardnerella vaginalis , producing a watery, fishy-smelling discharge. The pH of normal vaginal secretions is usually < 4.5 but in bacterial vaginosis it is > 5. Sexually transmitted infections (STIs) can cause discharge, vulval ulceration or pain, dysuria, lower abdominal pain and general malaise. They may also be asymptomatic.
Urinary incontinence
Inappropriate and involuntary voiding of urine severely affects 10% of women and its prevalence increases with age.
Stress incontinence occurs on exertion, coughing, laughing or sneezing and is associated with pelvic floor weakness.
Urge incontinence is an overwhelming desire to urinate when the bladder is not full, due to detrusor muscle dysfunction.
Prolapse
In 30% of women the pelvic contents bulge into the vagina ( Fig. 11.20 ). Women feel something ‘coming down’, particularly when standing or straining. Uterine prolapse is associated with previous childbirth and is classified as:
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Grade 1: halfway to the hymen.
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Grade 2: at the hymen.
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Grade 3: beyond the hymen.
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Grade 4 (procidentia) : external to the vagina ( Fig. 11.21 ).
Fig. 11.21
External prolapse of the uterus.
The top of the vagina (vault) can also prolapse after a previous hysterectomy. More commonly the bulge relates to the vaginal wall. A cystocoele is a bulge on the anterior wall containing the bladder (see Fig. 11.20 ) and a rectocoele is a bulge on the posterior wall containing the rectum. An enterocoele is a bulge of the distal wall posteriorly containing small bowel and peritoneum.
Drug history
Tamoxifen has oestrogenic effects in postmenopausal women, antibiotics can cause vaginal candidiasis, antipsychotic drugs can cause hyperprolactinaemia, and antiepileptic or antituberculous drugs may reduce the effectiveness of oral contraceptives.
Family and social history
Family and social history, including smoking status and lifestyle, may also have an impact on gynaecological conditions. For example, obesity is associated with an increased risk of gynaecological malignancy.
Sexual history
Sometimes a sexual history is required but people often find it difficult talking about sexual matters. It is important for you to be at ease and ask questions in a straightforward manner. Explain why you need to enquire, use clear, unambiguous questions ( Box 11.4 ) and be non-judgemental. The sexual partners of women with STIs should be informed and treated to prevent further transmission and reinfection of the treated person. Confidentiality is paramount, so do not give information to a third party. Do not perform a pelvic examination in someone who has not been sexually active.
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Are you currently in a sexual relationship?
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How long have you been with your partner?
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Have you had any (other) sexual partners in the last 12 months?
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How many were male? How many female?
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When did you last have sex with:
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Your partner?
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Anyone else?
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- •
Do you use barrier contraception – sometimes, always or never?
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Have you ever had a sexually transmitted infection?
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Are you concerned about any sexual issues?
The physical examination
A vaginal examination is required to perform a routine cervical smear. Otherwise the focus of gynaecological examination is to detect abnormalities that could explain the symptoms or alter treatment options (for example, body mass index (BMI) and blood pressure assessment affect the use of the contraceptive pill). Signs of gynaecological disease are not limited to the pelvis and a general as well as a pelvic examination is required ( Box 11.5 ). You should offer a female chaperone and record this in the records. The examination area should be private, with the equipment and an adjustable light source available. The woman should have an empty bladder and remove her clothing from the waist down, along with any sanitary protection. Give her privacy to do this.
| Clinical feature | General examination | Pelvic examination |
|---|---|---|
| Abnormal bleeding | Anaemia Underweight (hypogonadotrophic hypogonadism) Galactorrhoea, visual field defects (hyperprolactinaemia) Hirsutism, obesity, acanthosis nigricans (PCOS) | Enlarged uterus (fibroids, pregnancy) Abnormal cervix Open cervical os (miscarriage) Vaginal atrophy (most common cause of PMB) |
| Pain | Abdominal tenderness | Uterine excitation (acute infection or peritonism) Fixed uterus (adhesions or endometriosis) Adnexal mass (ovarian cyst) |
| Vaginal discharge | Rash (associated with some STIs) | Clear from cervix (chlamydia) Purulent from cervix (gonorrhoea) Frothy with strawberry cervix (trichomoniasis) |
| Urinary incontinence | Obesity, chronic respiratory signs (stress incontinence) Neurological signs (urge incontinence) | Demonstrable stress incontinence Uterine or vaginal wall prolapse |
| Abdominal distension or bloating | Ascites, weight loss, lymphadenopathy, hepatomegaly (malignancy) Pleural effusion (some malignant or benign ovarian cysts) | Pelvic mass (uterine, ovarian or indiscriminate) Fixed uterus and adnexae Abnormal vulva (skin disease or malignancy) |
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