Breast examination

The Importance of Breast Self-Examination

Regularly examining her own breasts allows a woman to become familiar with how her breasts normally look and feel and can help her more readily detect any changes that may occur. Many women naturally have some lumpiness and asymmetry (differences between the right and left breast). The key to the breast self-exam is to learn how to find changes in the breasts that persist over time.

While most women are aware of monthly breast self-examination, many still do not know how to perform it properly. Performing BSE incorrectly can be almost as bad as not doing the exam at all since it can give women a false sense of security. After reading these sections on BSE, women should discuss any questions they might have about BSE techniques with their physicians and ask him or her to demonstrate how to perform BSE during the clinical breast exam portion of the physical exam.

The Best Time to Perform Breast Self-Examination

Menstruating women: Hormonal changes due to the menstrual cycle may make the breasts more lumpy or swollen. Women who are menstruating should perform breast self-exam from a few days to about a week after menstruation (period) has ended, when breasts are usually less tender or swollen.

Women who are no longer menstruating: should do their BSE on the same day every month. Try to pick a day that is easy to remember, such as the first or fifteenth of every month, and make that the day each month for breast self-exam.

Women using oral contraceptives: are encouraged to do their BSE each month on the day they begin a new package of pills.

Breast Changes and Warning Signs To Watch for During Breast Self-Exam:

  • Any new lump or hard knot found in the breast or armpit
  • Any lump or thickening that does not shrink or lessen after your next period
  • Any change in the size, shape or symmetry of your breast
  • A thickening or swelling of the breast
  • Any dimpling, puckering or indention in the breast
  • Dimpling, skin irritation or other change in the breast skin or nipple
  • Redness or scaliness of the nipple or breast skin
  • Nipple discharge (fluid coming from your nipples other than breast milk), particularly if the discharge is bloody, clear and sticky, dark or occurs without squeezing your nipple
  • Nipple tenderness or pain
  • Nipple retraction: turning or drawing inward or pointing in a new direction
  • Any breast change that may be cause for concern

If any of these changes are noted, women should see their physicians as soon as possible for clinical evaluation. However, in the majority of cases (80%), breast lumps and changes are not cancer. Women should not allow their fear of breast cancer keep them from telling their physician or healthcare provider about a lump or change they have found.

Women with Normally Lumpy Breasts Should Also Perform BSE

Even if a woman has normally lumpy breasts (typically called fibrocystic breasts), she can still learn the usual pattern of lumps and then point out new or unusual lumps to her physician. While lumpy breasts or breasts with benign (non-cancerous) masses or cysts can be more difficult to examine, monthly breast self-exams are still critical. In fact, without knowledgeable direction from the patient, it may be more difficult for a physician to differentiate between a new mass and a stable lump. If a woman’s breasts are normally lumpy, she should note how many separate lumps she feels and their corresponding locations when performing self-exams. Then, during subsequent exams, she should check for any changes, particularly an increase in the size of lumps that persist after her period. Any changes should be reported to a physician or healthcare provider.

Breast Examination During and After Pregnancy Is Critical

Women should continue monthly breast self-examination during pregnancy. Clinical breast examination by a healthcare professional should also be made on a monthly basis during pregnancy. It is especially important that clinical breast exam be performed during the first doctor visit of the pregnancy, before the breasts go through significant physiologic changes. Some changes or lumps are more difficult to evaluate once the breasts have enlarged and become more nodular. The main problem with breast cancer during pregnancy is a delay in diagnosis that results in women being diagnosed with breast cancer at a later, more advanced stage. Vigilant, monthly breast self-examination during pregnancy and afterwards during breast-feeding can help prevent delayed diagnosis of breast cancer and enables optimal treatment. 

Normal Breast Anatomy and Non-Cancerous Lumps

The breast is made up of various anatomic structures including skin, fat, milk glands or lobules, milk ducts, and connective tissue. Breast milk is produced by the glands during lactation (breast-feeding) and carried through the ducts to the nipple. Underneath the breast are the pectoral muscles in the chest and the ribs. A web of lymph canals also feeds the breast. Together with lymph nodes, the lymph system helps filter infection and disease from the body. In addition to this normal breast anatomy, there may be masses present such as cysts (packets of fluid) and are not cause for concern:

  • Normal, non-cancerous lumps such as cysts are usually soft, smooth and moveable
  • Suspicious lumps are usually firm, irregular in shape and fixed in place

If something that seems unusual is felt in one breast, women should feel for it in the other breast. If the area is found in both breasts, it is probably normal breast anatomy

Monthly breast self-examination includes both looking and feeling over the entire breast and chest area. The steps can be performed in any order, but each step is important. Women should use the pads, not the tips, of the three middle fingers when performing BSE. The time required to perform the exam varies with the size and features of a woman's breasts but usually only takes about 15 to 20 minutes each month. Women should be sure to examine the breasts in the same manner each month, check the entire breast and armpit area, and remember how the breasts feel from month to month. Some women prefer to keep a small diary of their monthly breast self-exams.

Women should use three different patterns when examining the breasts each month: 

  1. Vertical or "up and down" pattern (or "squares") covering the entire breast.
  2. Spiral or ring pattern, making concentric rings that tighten in a spiral, starting on the outer edges of the breast and ending around the nipple.
  3. Wedge patterns in and out (or "quadrants").

Women should use three levels of pressure (light, medium, and firm) and small "massaging" circles when palpating the breast using the patterns described above. Women should not lift the fingers while feeling the breasts to ensure that no area is missed.

Women should perform BSE when they can be in a private place that is free from disturbances, so they may concentrate fully on the examination. BSE should be performed in a warm room or during a warm shower so that the breast tissue is relaxed and easier to examine. Cold air or cold water causes the breasts and nipples to contract and may make examining the breasts more difficult.

Some women prefer to use a small amount of baby powder or talcum powder on the skin of their breasts to help reduce friction and allow the fingers to move more easily over the skin. In addition to performing BSE in front of a mirror, some women also like to do the standing portion of breast self-exam while taking a warm shower. Soapy fingers reduce friction and allow some breast changes to be more easily recognized.

Areas to Examine with Particular Care

It is important to thoroughly examine the entire area of the breast every month:

Outside: armpit to collar bone, and below the breast
Middle: the breast itself
Inside: the nipple area

However, cancerous tumours are more likely to be found in some parts of the breast than in others. Approximately half of all breast cancers occur in the upper, outer region of the breast toward the armpit. Some physicians refer to this upper outer region as the "tail" of the breast and encourage women to examine it with great care.

Approximate percentage of breast cancers found in each area:

41% in the upper, outer quadrant
14% in the upper, inner quadrant
5% in the lower, inner quadrant
6% in the lower, outer quadrant
34% in the area behind the nipple

BSE Method While Standing in Front of a Mirror

Because the upright position can make it easier to check the upper and outer portions of the breasts and armpit, breast self-examination should be performed standing up in addition to lying down. Looking (inspection) should take place in front of a mirror in a well-lit area. A tall dressing mirror is often best. While standing in front of a mirror, undress down to the waist.

Place the arms at the sides. Check the breasts for any changes in size, shape or position, dimpling or puckering of the skin, pushed-in or misshapen nipples, other changes in the nipple, redness, swelling or other irregularities. Then, repeat this process with the hands on the hips, pressing firmly to flex the chest (pectoral muscles). Bend forward with the hands on the hips and note any irregularities.
Raise the arms overhead or put the hands behind the head. Turn to each side to check the breasts in profile. Note any changes in symmetry between the right and left breast. Remember, it is often normal for women to have one breast that is larger or a different shape than the other.
Examine each breast separately and feel for any new lumps, changes, or irregularities. Use the pads of the fingers, not the tips, and practice the patterns of examination described in the above section (up and down line, spiral, wedge pattern). The nipple should also be examined during this time. First, squeeze the nipple and check for any discharge Then push the nipple deep into the hollow beneath it. Note any unusual resistance, hardness or lump beneath the nipple. 

During the standing portion of the exam, the lymph nodes in each armpit and surrounding areas under the arm should be carefully examined. Lymph nodes are normally about the size of kidney beans. Sometimes the lymph nodes may be enlarged by a non-cancerous infection. Occasionally, lymph node enlargement may be caused by a cancerous process. As with any breast or nipple changes, women should report any lymph node changes or enlargement to their physicians.

BSE Method While Lying Down

In addition to standing, breast self-examination should also be performed while lying down. Women should use the pattern of examination described in the above section and should ask their physicians if they have questions about performing BSE.  

Lie down with a pillow or folded towel under the right shoulder and place the right arm behind the head. Check the entire breast and armpit area using the pads of the first three middle fingers on the left hand to feel for lumps, changes, or irregularities in the right breast. Press firmly enough to know how the breast feels. A firm ridge in the lower curve of each breast is normal. The exam should then be repeated on the left breast, using the finger pads of the right hand (the pillow or folded towel should also be moved under the left shoulder at this time).

 While performing BSE lying down, the nipple should also be checked for any changes. After making an initial examination, gently squeeze the nipple to check for any discharge of fluid. Note any changes in appearance, discharge (including the colour and whether the discharge occurs spontaneously or by squeezing), or cracking.

  Nipple fluid that is green or yellow is usually normal. Nipple fluid that is bloody, dark or clear and sticky is considered abnormal (although most suspicious nipple discharges are found to be caused by non-cancerous conditions such as papillomas). In approximately 10% of all cases, nipple discharge is due to a cancerous lesion. In women less than 30 years of age, less than 10% of nipple discharge is due to cancer. Nevertheless, any persistent nipple discharge should be reported to a physician for clinical evaluation.

BSE Method While in the Shower

Many women find that performing breast self-examination in the shower in addition to standing in front of a mirror and lying down is helpful because the skin can be lubricated by soap. Some breast changes can be felt more easily when the skin is wet and soapy.  

Raise the right arm above the head and place the right hand behind the head. Using the left hand, examine the right breast using the methods described in the above sections. Feel the breast with the pads of the index and middle fingers, moving in increasingly smaller circles from the outside inward. Compress gently, feeling for lumps. When circling the nipple, look for changes or discharge. Repeat the exam with the left breast using the right hand. Make sure to examine the area adjacent to the breast and below the armpit (this area contains breast tissue and lymph nodes).

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