OB-GYN 101

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Breast Examination

A breast examination consists of inspection and palpation of the breasts to identify abnormalities. Some breast examinations are focused on specific issues while others are more general. Although there are many good ways to examine the breasts, one of them will be presented here.

The breasts may be examined while the patient is sitting or reclining. Sometimes it may be desirable to do both.

With the patient in a sitting position, inspect the breasts visually. While generally symmetrical, most breasts are slightly asymmetrical in respect to size, shape, orientation, and position on the chest wall. Inspect for:

Visible masses (change in contour)
Skin dimpling
Nipple retraction
Redness

Have her raise her arms while you continue to watch the breasts.

An underlying malignancy can fix the skin in place.
Raising the arms will accentuate these changes.

Have her flex the pectoralis major muscles. A simple way to do this is have her place her hands on her hips and squeeze inward. Another way is have her place her palms together (praying position) and squeeze the palms together.

With flexion of the underlying muscle, areas of breast tissue that are fixed in place will move with the muscle, while the rest of the breast will not.
Suspicious areas will appear as a dimpling of the skin while she flexes these muscles.

Ask her to raise her arm over her head.

This has the effect of stretching and tightening the pectoralis major muscle that lies directly undeneath the breast.
Functionally, this places the breast on a fairly solid, fairly flat surface, making it easier to palpate abnormalities.

With the patient's arm raised over her head, palpate for lumps, masses or thickenings.

Breast tissue is normally somewhat nodular or "lumpy," particularly in the upper outer quadrant.
You are looking for a dominant mass.
Some have suggested that you are looking for "a marble in a bag of rice."

Hand

Palpate the breast using the proximal and middle phalanges of the fingers.

The palm of the hand is too insensitive to detect subtle changes in breast texture.
The fingertips are too sensitive and will focus on the normal granularity of the breast tissue rather than the more worrisome masses.

Use a Circular Motion

Move your hand in a circular motion while pressing into the breast substance.

Making these small circles will help you identify mass occupying lesions.
Cover the entire breast in a systematic fashion, including the tail of the breast that extends up into the axilla.

With smaller breasts, palpation with one hand will give good results.

When breasts are larger or pendulous, it may be useful to use two hands, compressing the breast tissue between them.

Some examiners have the woman raise both arms above the head during the examination. Others have her raise only one arm, leaving the other arm down.

Many patients feel exposed a vulnerable during this examination. It is not a comfortable feeling for them. They may feel more comfortable if only one arm is raised as they will feel less vulnerable.
Similarly, leaving one breast covered while you examine the other breast will often make the patient feel more comfortable during the exam. In cases where you are going back and forth, comparing findings from one side to the other, one-sided draping may not be practical.

Check the axilla for masses or palpable lymph nodes.

It is relatively common to find palpable lymph nodes in the axilla of normal patients.
These most often are the result of trauma to the arm, such as small cuts or scrapes
They usually disappear by themselves over a 1-2 month period of time.
Palpable axillary lymph nodes that are present because of an underlying malignancy will not gradually regress over time.

Check the supraclavicular area for palpable masses.

The supraclavicular area can be an area of spread of breast malignancy.
Palpable masses or lymph nodes in this area can be a sign of underlying malignancy.

Stripping the ducts toward the nipple will cause any secretions to be expressed.

This should be done firmly, but not so hard as to cause discomfort or pinching.
With effort, you will almost always be able to bring a drop or two of breast secretions to the surface. This is normal and the secretions will be clear, milky, or have a slight greenish tinge.
Bloody discharge is always considered a danger sign.
Large amounts (many drops) of secretions are not considered normal and usually require further investigation.

After completing the examination on one side, move to the other breast and repeat the examination.

Experienced examiners will frequently go back to the first breast to compare findings from one side to the other.
A thickening that is symmetrically present in both breasts is usually of no significance.
A thickening that is present in only one breast is more worrisome.

The breast examination can also be performed with the patient reclining.