Benign Breast Disease
Darlene M. Miltenburg, MD*, V.O. Speights, Jr, DO
Texas A&M Health Science Center College of Medicine, Scott & White Hospital, 2401 South 31st Street, Temple, TX 76508, USA
Benign breast disease includes all nonmalignant conditions of the breast. The spectrum of benign conditions that occur in the breast is limited andincludes benign tumors, trauma, pain and tenderness (mastalgia), and infection. The clinical presentation of breast diseases is also limited and includes one or more of the following signs and symptoms: palpable mass; swelling; skin dimpling, erythema, and thickening; pain; nipple discharge and inversion or retraction; or an abnormal screening mammogram with no clinical ﬁndings. Tools available toinvestigate breast problems include clinical breast examination (CBE), mammogram, and ultrasound. MRI of the breast is new and has speciﬁc indications. This article discusses the gynecologist’s role in maintaining breast health, clinical evaluation of breast problems, and management of benign breast disease. Maintenance of breast health Self breast examination Although monthly self breast examination(SBE) is recommended, it has not been shown to lower the mortality from breast cancer [1,2]. Advising women to be aware of their breasts and report any masses or skin changes immediately may be more realistic. Clinical breast examination It is diﬃcult for clinicians to become proﬁcient at physical examination of the breast. Unlike auscultation of the chest or assessment of cranial nerves, wherenormal ﬁndings do not vary among normal patients, normal breasts look and feel diﬀerent among normal women. Similarly, normal mammograms look diﬀerent from one woman to the next. It takes a long time before
* Corresponding author. E-mail address: email@example.com (D.M. Miltenburg). 0889-8545/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ogc.2008.03.008obgyn.theclinics.com
MILTENBURG & SPEIGHTS
a doctor is comfortable stating that a woman’s clinical breast examination (CBE) is normal, and even when they do, the fact remains that CBE is not a very sensitive tool for detecting early-stage cancer. One can approach CBE by trying to detect a ﬁnding in one breast such as a mass, that is not present in the other. Breasts should ﬁrst beinspected with patients sitting with their hands at their side, then on their hips, and above their head. Breast size and any asymmetry, visible masses, and skin changes, such as ulceration, erythema, dimpling, skin thickening, or edema, should be noted. Clinicians should look for nipple inversion, retraction, discoloration, or dryness. Patients then recline to supine and the entire breast issystematically palpated. A circular, vertical, or horizontal approach can be used as long as the entire breast is palpated, including the nipple areolar complex, the retroareolar area, axillary tail of Spence, and the axilla. Large breasts can be diﬃcult to examine and in these cases it may be helpful to position the patient on her side and palpate the breast when it has fallen away from the chest wall.There is no need to squeeze the nipple to look for discharge unless the patient is concerned about nipple discharge. Fluid can be expressed from most nipples if enough pressure is applied, and this is considered normal. Clinicians often use the term ﬁbrocystic to describe a breast that is tender, nodular, or dense on clinical examination. Fibrocystic disease or ﬁbrocystic changes is a pathologicterm and should not be used to describe clinical ﬁndings. Most breasts are not smooth, soft, or homogeneous in texture; they may be nodular, hard, or dense, and all of these ﬁndings are within the spectrum of normal. Because normal breasts vary greatly among patients, often what a clinician describes as ﬁbrocystic is a variation of normal breast tissue. Furthermore, most women report tenderness...