Seclusion and warmth are particularly important for examination of the breasts, to avoid discomfort and embarrassment to a patient; a good light is essential, to detect minor abnormalities.
There is wide variation in the size, shape and consistency of the female breast, not only between individuals, but also in each subject, during development, the menstrual cycle, pregnancy and in later life. If the breasts are asymmetrical establish if this is recent or longstanding.
The nipple usually points forward; unilateral or bilateral nipple retraction may be congenital, but recent changes and nipple deviation suggest underlying disease, as do a discharge or surrounding eczema (Paget’s disease). The initial pink coloured areolar becomes darker with age and brownish after pregnancy. The glands of Montgomery may stand out as tubercles, especially in pregnancy.
Start the examination with inspection (figure 4); this must always precede palpation. The subject is undressed to the waist and sits upright on the side of the couch. Observe from the front. Look for lumps in the breasts and axillae, flattening of the breast contour and skin dimpling.
Abnormal features are accentuated during arm movements and fixation. At first, ask the subject to rest her hands on the couch, on each side (figure 5a–c). This is followed by raising her arms above her head and leaning forward, and then by pressing the hands together, or on the hips. To assess tethering to the serratus anterior muscles, the subject leans forward with outstretched hands against resistance.
During these movements, observe the breasts for symmetry, compare the two sides and note the mobility of the breast on the chest wall. Elevation may produce unequal ascent in the presence of underlying abnormalities; it also allows examination of the skin under the breasts. Note any redness, edema, peau d’orange, ulceration, skin nodularity, or abnormal venous patterns that could indicate associated pathology.
Palpate the breast with the subject lying flat on the couch with the hand of the same side placed behind her head, and a pillow behind her shoulder (figure 6). This position serves to relax the pectoral muscles and allow the breast to spread evenly, ‘floating’ on the chest wall. If an abnormality has been reported on one side, begin with the other. On coming to the abnormal side, ask the patient to point out the area of abnormality, if it is not obvious.
Begin palpation with gentle pressure and rotation of the flat of the hand over the central part of the breast (figure 7).
Examine every part of the breast systematically. A possible technique is to start with the upper inner quadrant and progress anticlockwise (on the left: clockwise on the right) to the upper outer quadrant and the axillary tail (figure 8a–d). Palpate with the flat of the outstretched fingers with rotatory and to-and-fro movements, gently pressing the breast tissue onto the chest wall.
Be sure to gently palpate the nipple area and retroareolar tissues between the fingers and thumb, to detect any nodularity within this region (figure 9). In the case of nipple discharge, particularly in galactorrhea, gently express fluid from the breast by mediolateral and superoinferior expression, followed by expression from the nipple, and spread any discharge on a slide for microscopy.
Abnormal areas are further palpated between finger and thumb: pendulous breasts may have to be examined bimanually (figure 10). The axillary tail requires particular attention to define lumps.
Measure and record the size, shape, consistency and mobility of any abnormal areas. Tethering to the underlying fascia and muscles is defined by asking the subject to press her hands on her hips, and then moving the abnormal area to-and-fro in different directions. Superficial tethering is demonstrated by gently squeezing the overlying skin to assess whether it is free of the underlying abnormality. Normal breast tissue is commonly nodular and becomes engorged premenstrually. In doubtful cases, repeat the examination at a different time in the menstrual cycle.