Breast & the

gynaecologist
Prof. Mohammed EL-Shafei
Prof. of Ob. & Gyn.
Faculty of medicine
Mansoura university
Egypt
Anatomy of female breast :
The breast lies between the 2nd and 6th ribs
on the vertical axis and between the sternal
edge and the midaxillary line on the horizontal
axis. Breast tissue also projects into the lower
axilla as the axillary tail. The breast is made up
of the secretory glandular tissue and
surrounding adipose tissue. The glandular
tissue comprises between 15 and 20 lobes
with varying numbers of ducts and lobules
surrounded by connective tissue. Each lobe
connects to a lactiferous duct, several of which
converge to form a lactiferous sinus or milk
chamber .
These sinuses empty into
the nipple where there are a
number of duct openings.
The nipple is surrounded by
a pigmented area, the
areola, which is lubricated
by secretions from the
sebaceous glands. Beneath
the tissues of the breast lie
the muscles of the chest
wall and between the two is
a layer of connective tissue
known as the fascia. Anatomy of the breast
Blood supply: the internal mammary artery, the
axillary artery and the intercostal arteries
Lymph drainage: is from superficial to deep
- The major drainage is then to the axilla and internal
mammary chain.
- To lesser extent, lymph also drains by intercostal
routes to nodes adjacent to vertebrae.
The axillary nodes found below the level of the
axillary vein are divided into 3 groups in relation to
pectoralis minor muscle.
Level I lymph nodes: lateral to the lateral border of
pectoralis minor .
Level II lymph nodes: behind pectoralis minor .
Level III lymph nodes: medial to the medial border of
pectoralis minor
Physiology of lactation: Lactation is
inhibited during pregnancy by the action of
estrogen on the hypoth. & pituitary.
Inhibition is removed immediately after
delivery  PRL  initiate lactation which
is then maintained by suckling (nerve reflex
via hypothalamus),  PRL, GH & ACTH
and  Gonadotropins. Delivery of milk
from the nipple is by contraction of
myoepithelial cells around acini by the
action of oxytocin secreted by
neurohypophysis.
Breast diseases:
I- Bening breast problems:
A) Congenital abnormalities and
development :
1- Supernumerary or accessory nipple
2- Supernumerary or accessory breast
3- Excessive breast enlargement 4- Hypoplasia or aplasia
5- Inversion of the nipples.
B) Breast pain (Mastalgia):
 Due to breast causes:
Cyclic: premenstrual and relieved with the onset of
menstruation. It may be unilateral or bilateral and radiate to
axilla.
Non cyclic: various causes as hormonal fluctuation, firm
adenomas, duct ectasia, macrocysts and soreness in the
pectoralis muscle from exertion or trauma
 Due to non – breast causes : e.g. angioma,
cholelithiasis, costochondritis, …..etc
Treatment:
1) Bromocriptine : Reduce PRL  relief
cyclic mastalgia, Dose: 2.5 mg twice daily
2) Danazol: Relief symptoms and reduce
nodularity, Dose : 200 mg
3) Tamoxifen : Reduce breast pain, Dose
20 mg
4) Gammalenolenic acid ( GLA ): Dose 6-
8 capsules / day
5) Non medical measures: A well fitting
brassier worn 24 hours / day,  caffeine
intake , regular exercise, phytoestrogen
C) Nipple discharge: Common, not all nipple
discharge is pathologic
Types:
i) Physiologic: not associated with underlying
breast disease, Bilateral, from multiple ducts and
serous in character.
Causes: exogenous estrogen and nipple stimulation
Require no treatment.
ii) Galactorrhea: see hyperprolactinemia
iii) Pathologic discharge: Localized to a
single duct and spontaneous. May be greenish ,
gray , serosangunous , serous or bloody
Causes :Benign breast disease
Investigation: mammography, biopsy from a mass
D) Duct ectasia: in women over 35
years.
Presentation:
- Nipple discharge (from several ducts –
cheesy in nature or with a palpable mass
which may be hard or doughy)
- Nipple retraction
- Duct dilate & shorten (inspissated material )
Treatment:
- formation
- Antibiotics to avoid abscess Total duct
excision with histological examination
E) Fibrocystic diseases: most common
benign breast complaint in 10% of
women < 21 years and more common
in the premenopausal period. It
produces bilateral pain and tenderness
7-10 days before menstruation
General lines of Treatment:
- Regular examination - OCS
- NSI - Diuretic therapy
- Avoid coffee, tea, chocolate and
caffeinated soda
Types:
 Fibroadenoma (breast mouse ): It is the most
common mass lesion < 25 years
Palpable breast mass in upper outer quadrant, well
circumscribed, firm, mobile discrete and may be
multiple or bilateral
Treatment: conservative or excision and biopsy.
Needs careful follow up
 Breast cyst: Common in perimenopausal age.
Small discrete lump (fluctuant)
Treatment: aspiration
Galactocele:
- During or after pregnancy or breast feeding
- Contain breast milk
Treatment: Aspiration (diagnostic and therapeutic)
II- Bening neoplastic lump:
1- Duct papilloma: rarely common.
Treatment: may need excision of
the duct
2- Lipoma:
Treatment: excise only if suspicion
of malignancy or if troublesome
III -Breast cancer:
Incidence: One in 12 women will develop breast cancer at
some time in life.
Risk factors:
1) Reproductive factors and endogenous hormones:
2) Family history of breast cancer
3) Other gynecological cancers: e.g. ovarian and endometrial
cancer
4) Oral contraceptive pills: slight risk.
5) Hormone replacement therapy: increased risk with long
term use
6) Other hormones: DES use in pregnancy and DMPA used by
very young the risk
7) Radiation exposure
8) Breast disease: as atpyical Hyperplasia, intraductal
carcinoma in situ
9) Obesity
10) Diet: Fat, alcohol
Breast cancer during or shortly
after pregnancy : more worse than
women with the same age and not pregnant
which may be due to delay of the diagnosis
and immunosuppressive effect of
pregnancy. So, breast examination should
be a part of prenatal examination, and
mammography can be done if suspicion
with the use of shield. Cancer breast
diagnosed during pregnancy should be
staged and treated in the same manner as
in non pregnant.
Abnormal signs and symptoms:
1. Change in breast size, puckering , dimpling
or retraction, thickening of skin or lump
2. Nipple discharge, retracted nipple, change
in nipple position, Scaling around nipples
3. Pain or tenderness and redness
4. Sore on breast that does not heal
Screening of breast cancer: all
women should be screened at the age 50 –
64 every 3 years with single oblique view
mammography. In women with family
history, mammography is routine before 50
years
Diagnosis:
1- Careful breast examination
2- Conventional mammography 3- U/S
4- Fine needle aspiration or biopsy
5- Excision biopsy: the only definitive diagnosis

Management:
Breast surgery: conservative lumpectomy with axillary
dissection in combination with radiotherapy is as effective
as mastectomy for local control in most cases.
 Tamoxifen: prolongs disease – free interval.
 Chemotherapy: has survival benefit in premenopausal
women.
 Endocrine therapy: aromatase inhibitors, LHRH analogues
and ovarian ablation. Steroid receptor is best predictive
Follow up: life long follow up is required
Subsequent contraception,
pregnancy and HRT:
Contraception: OCs is not recommended.
Other alternative should be considered
 Pregnancy: subsequent pregnancy have
no adverse effect. Patients are advised to
wait 2 years before becoming pregnant.
HRT: Tamoxifen is recommended if
menopausal symptoms are severe.