Most women experience breast changes at some time. Your age, hormone levels, and medicines you take may cause lumps, bumps, and discharges (fluids that are not breast milk).

If you have a breast lump, pain, discharge or skin irritation, see your health care provider. Minor and serious breast problems have similar symptoms. Although many women fear cancer, most breast problems are not cancer.

Some common breast changes are

• Fibrocystic breast changes - lumpiness, thickening and swelling, often just before a woman's period
• Cysts - fluid-filled lumps
• Fibroadenomas - solid, round, rubbery lumps that move easily when pushed, occurring most in younger women
• Intraductal papillomas - growths similar to warts near the nipple
• Blocked milk ducts
• Milk production when a woman is not breastfeeding

A mammogram is an x-ray picture of the breast. It can be used to check for breast cancer in women who have no signs or symptoms of the disease. It can also be used if you have a lump or other sign of breast cancer.

Screening mammography is the type of mammogram that checks you when you have no symptoms. It can help reduce the number of deaths from breast cancer among women ages 40 to 70. But it can also have drawbacks. Mammograms can sometimes find something that looks abnormal but isn't cancer. This leads to further testing and can cause you anxiety. Sometimes mammograms can miss cancer when it is there. It also exposes you to radiation. You should talk to your doctor about the benefits and drawbacks of mammograms. Together, you can decide when to start and how often to have a mammogram.

Mammograms are also recommended for younger women who have symptoms of breast cancer or who have a high risk of the disease.

When you have a mammogram, you stand in front of an x-ray machine. The person who takes the x-rays places your breast between two plastic plates. The plates press your breast and make it flat. This may be uncomfortable, but it helps get a clear picture. You should get a written report of your mammogram results within 30 days.

A mammogram is an x-ray picture of the breast.

Mammograms can be used to check for breast cancer in women who have no signs or symptoms of the disease. This type of mammogram is called a screening mammogram. Screening mammograms usually involve two or more x-ray pictures, or images, of each breast. The x-ray images often make it possible to detect tumors that cannot be felt. Screening mammograms can also find microcalcifications (tiny deposits of calcium) that sometimes indicate the presence of breast cancer.

Mammograms can also be used to check for breast cancer after a lump or other sign or symptom of the disease has been found. This type of mammogram is called a diagnostic mammogram. Besides a lump, signs of breast cancer can include breast pain, thickening of the skin of the breast, nipple discharge, or a change in breast size or shape; however, these signs may also be signs of benign conditions. A diagnostic mammogram can also be used to evaluate changes found during a screening mammogram or to view breast tissue when it is difficult to obtain a screening mammogram because of special circumstances, such as the presence of breast implants.

A mammogram is an X-ray picture of the breast. Doctors use a mammogram to look for early signs of breast cancer. Regular mammograms are the best tests doctors have to find breast cancer early, sometimes up to three years before it can be felt.

How is a mammogram done?

You will stand in front of a special X-ray machine. A technologist will place your breast on a plastic plate. Another plate will firmly press your breast from above. The plates will flatten the breast, holding it still while the X-ray is being taken. You will feel some pressure. The steps are repeated to make a side view of the breast. The other breast will be X-rayed in the same way. You will then wait while the technologist checks the four X-rays to make sure the pictures do not need to be re-done. Keep in mind that the technologist cannot tell you the results of your mammogram. Each woman’s mammogram may look a little different because all breasts are a little different.

What does having a mammogram feel like?

Having a mammogram is uncomfortable for most women. Some women find it painful. A mammogram takes only a few moments, though, and the discomfort is over soon. What you feel depends on the skill of the technologist, the size of your breasts, and how much they need to be pressed. Your breasts may be more sensitive if you are about to get or have your period. A doctor with special training, called a radiologist, will read the mammogram. He or she will look at the X-ray for early signs of breast cancer or other problems.

When will I get the results of my mammogram?

You will usually get the results within a few weeks, although it depends on the facility. A radiologist reads your mammogram and then reports the results to you and your doctor. If there is a concern, you will hear from the mammography facility earlier. Contact your health care provider or the mammography facility if you do not receive a report of your results within 30 days.

What happens if my mammogram is normal?

Continue to get mammograms according to recommended time intervals. Mammograms work best when they can be compared with previous ones. This allows the radiologist to compare them to look for changes in your breasts.

What happens if my mammogram is abnormal?

An abnormal mammogram does not always mean that there is cancer. But you will need to have additional mammograms, tests, or exams before the doctor can tell for sure. You may also be referred to a breast specialist or a surgeon. It does not necessarily mean you have cancer or need surgery. These doctors are experts in diagnosing breast problems. Doctors will do follow-up tests to diagnose breast cancer or to find that there is no cancer.

What is mammography?

Mammography is an x-ray imaging method used to examine the breast for the early detection of cancer and other breast diseases. It is used as both a diagnostic and screening tool.

How does it work?

During a mammogram, a patient’s breast is placed on a flat support plate and compressed with a parallel plate called a paddle. An x-ray machine produces a small burst of x-rays that pass through the breast to a detector located on the opposite side. The detector can be either a photographic film plate, which captures the x-ray image on film, or a solid-state detector, which transmits electronic signals to a computer to form a digital image. The images produced are called mammograms.

On a film mammogram, low density tissues, such as fat, appear translucent (i.e. darker shades of gray approaching the black background)., whereas areas of dense tissue, such as connective and glandular tissue or tumors, appear whiter on a gray background. In a standard mammogram, both a top and a side view are taken of each breast, although extra views may be taken if the physician is concerned about a suspicious area of the breast.

What will the results look like?

A radiologist will carefully examine a mammogram to search for high density regions or areas of unusual configuration that look different from normal tissue. These areas could represent many different types of abnormalities, including cancerous tumors, non-cancerous masses called benign tumors, fibroadenomas, or complex cysts. Radiologists look at the size, shape, and contrast of an abnormal region, as well as the appearance of the edges or margins of such an area, all of which can indicate the possibility of malignancy (i.e. cancer). They also look for tiny bits of calcium, called microcalcifications, which show up as very bright specks on a mammogram. While usually benign, sites of microcalcifications may occasionally signal the presence of a specific type of cancer. If a mammogram shows one or more suspicious regions that are not definitive for cancer, the radiologist may order additional mammogram views, with or without additional magnification or compression, or they may order a biopsy. Another alternative may be referral for another type of non-invasive imaging study.

Why does the breast need to be compressed?

Compression holds the breast in place to minimize blurring of the x-ray image that can be caused by patient motion. Also, compression evens out the shape of the breast so that the x-rays can travel through a shorter path to reach the detector. This reduces the radiation dose and improves the quality of the x-ray image. Finally, compression allows all the tissues to be visualized in a single plane so that small abnormalities are less likely to be obscured by overlying breast tissue.

What is digital mammography?

A digital mammogram uses the same x-ray technology as conventional mammograms, but instead of using film, solid-state detectors are used to record the x-ray pattern passing through the breast. These detectors convert the x-rays that pass through them into electronic signals that are sent to a computer. The computer then converts these electronic signals into images that can be displayed on a monitor and also stored for later use. Several advantages of using digital mammography over film mammography include: the ability to manipulate the image contrast for better clarity, the ability to use computer-aided detection of abnormalities, and the ability to easily transmit digital files to other experts for a second opinion. In addition, digital mammograms may decrease the need for the re-takes, which are common with film mammography due to incorrect exposure techniques or problems with film development. As a result, digital mammography can lead to lower x-ray exposures. To date, there is no evidence that digital mammographyis better that film mammography for reducing a woman’s risk of dying from breast cancer, however, digital screening may be more accurate for finding cancers in younger women or women with dense breasts.

What are the limits of mammography?

For certain types of breasts, mammograms can be difficult to interpret. This is because there is a wide variation in breast tissue density among women. Denser breasts are more difficult to image, and more difficult to assess for tumor diagnosis. For this and other reasons, the sensitivity of mammography in detecting cancer can vary over a wide range.

For many difficult cases, x-ray mammography alone may not be sufficiently sensitive or accurate in detecting cancer, so additional imaging technologies, such as ultrasound or magnetic resonance imaging (MRI) may also be used to increase the sensitivity of the exam. Recently, studies have shown that a type of nuclear medicine called molecular breast imaging (MBI) may be an effective and less expensive alternative to MRI for clarifying test results in patients with dense breasts. During MBI, patients are given an injection of radioactive molecules that are selectively taken up by cancer cells. Special cameras that detect radioactivity are then used to reveal these cancer cells in the breast tissue.

Are there risks?

Because mammography uses x-rays to produce images of the breast, patients are exposed to a small amount of ionizing radiation. For most women, the benefits of regular mammograms outweigh the risks posed by this amount of radiation. The risk associated with this dose appears to be greater among younger women (under age 40). However, in some cases, the benefits of using mammography to detect breast cancer under age 40 may outweigh the risks of radiation exposure. For example, a mammogram may reveal that a suspicious mass is benign and, therefore, doesn’t need to be treated. Additionally, if a tumor is malignant and is caught early by mammogram, a surgeon may be able to remove it before it spreads and requires more aggressive treatment such as chemotherapy.

When should I get a mammogram?

Several organizations and professional societies have developed guidelines for mammographyscreening. You can read more about these recommendations on their websites below. All recommend that women talk with their doctor about the benefits and potential harms of mammography, when to start screening, and how often to be screened.

What are examples of NIBIB-funded projects in breast cancer screening?

Dedicated Breast CT: Research funded by NIBIB has led to the development of a breast CT scanner (bCT) that allows radiologists to view the breast in three dimensions and has the potential to reveal small tumors obscured behind dense breast tissue. The scanner uses a radiation dose comparable to mammography by sending X-rays only through the breast and not the chest. At present, more than 600 women have been imaged using bCT in clinical trials. Results from these trials suggest that bCT is significantly better at detecting tumors than mammography, though mammography is better at detecting microcalcifications. Recently, positron emission tomography (PET) technology has been incorporated into the bCT platform. A PET scan highlights areas of increased metabolic activity, which could indicate the presence of a tumor. Additionally, injection of a contrast agent has been shown to improve bCT’s ability to detect microcalcifications and could help radiologists distinguish benign from malignant tumors. Research is currently focused on ways in which bCT could be used to provide real-time image guidance for biopsy needle placement and minimally invasive ablation of tumors.

Near-Infrared, Diffuse Light Imaging with Ultrasonic Guidance:Researchers funded by NIBIB have developed a novel, hand-held breast imaging system that uses visible light to distinguish benign lesions from early-stage cancer. The system creates maps of tissue density in a local area of the breast based on how the tissue scatters light; the denser the tissue, the more light is scattered, and the greater the likelihood that the tissue is cancerous. The method is currently being tested in a large number of patients undergoing surgery to remove a breast tumor. Early results indicate that the imaging system may be a promising adjunct to mammographyfor diagnosing breast cancer and determining disease prognosis. In addition, the system could allow surgeons to more rapidly determine tumor margins during surgery compared to methods used over the past twenty years. This could potentially reduce surgeries that need to be repeated because not all cancerous tissue was removed initially.

Although breast cancer is much more common in women, men can get it too. It happens most often to men between the ages of 60 and 70.

Breast lumps usually aren't cancer. However, most men with breast cancer have lumps. Other breast symptoms can include

• Dimpled or puckered skin
• A red, scaly nipple or skin
• Fluid discharge

Risk factors for male breast cancer include exposure to radiation, a family history of breast cancer, and having high estrogen levels, which can happen with diseases like cirrhosis or Klinefelter's syndrome.

Treatment for male breast cancer is usually a mastectomy, which is surgery to remove the breast. Other treatments include radiation, chemotherapy and/or hormone therapy.

General Information about Male Breast Cancer

KEY POINTS

• Male breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.
• A family history of breast cancer and other factors can increase a man's risk of breast cancer.
• Male breast cancer is sometimes caused by inherited gene mutations (changes).
• Men with breast cancer usually have lumps that can be felt.
• Tests that examine the breasts are used to diagnose breast cancer in men.
• If cancer is found, tests are done to study the cancer cells.
• Survival for men with breast cancer is similar to survival for women with breast cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

Male breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

Breast cancer may occur in men. Breast cancer may occur in men at any age, but it usually occurs in men between 60 and 70 years of age. Male breast cancer makes up less than 1% of all cases of breast cancer.

The following types of breast cancer are found in men:

• Infiltrating ductal carcinoma: Cancer that has spread beyond the cells lining ducts in the breast. This is the most common type of breast cancer in men.
• Ductal carcinoma in situ: Abnormal cells that are found in the lining of a duct; also called intraductal carcinoma.
• Inflammatory breast cancer: A type of cancer in which the breast looks red and swollen and feels warm.
• Paget disease of the nipple: A tumor that has grown from ducts beneath the nipple onto the surface of the nipple.

Lobular carcinoma in situ (abnormal cells found in one of the lobes or sections of the breast), which sometimes occurs in women, has not been seen in men.

Although it is rare, men can get breast cancer. Learn about symptoms of breast cancer in men and things that may increase your risk.

Breast cancer is most often found in women, but men can get breast cancer too. About 1 out of every 100 breast cancers diagnosed in the United States is found in a man.

The most common kinds of breast cancer in men are the same kinds in women—

• Invasive ductal carcinoma. The cancer cells begin in the ducts and then grow outside the ducts into other parts of the breast tissue. Invasive cancer cells can also spread, or metastasize, to other parts of the body.
• Invasive lobular carcinoma. Cancer cells begin in the lobules and then spread from the lobules to the breast tissues that are close by. These invasive cancer cells can also spread to other parts of the body.
• Ductal carcinoma in situ (DCIS) is a breast disease that may lead to invasive breast cancer. The cancer cells are only in the lining of the ducts, and have not spread to other tissues in the breast.

What Are the Symptoms?

The most common symptoms of breast cancer in men are—

• A lump or swelling in the breast.
• Redness or flaky skin in the breast.
• Irritation or dimpling of breast skin.
• Nipple discharge.
• Pulling in of the nipple or pain in the nipple area.

These symptoms can happen with other conditions that are not cancer. If you have any symptoms or changes, see your doctor right away.

What Are the Risk Factors?

Several factors can increase a man’s chance of getting breast cancer. Having risk factors does not mean you will get breast cancer.

• Getting older. The risk for breast cancer increases with age. Most breast cancers are found after age 50.
• Genetic mutations. Inherited changes (mutations) in certain genes, such as BRCA1 and BRCA2, increase breast cancer risk.
• Family history of breast cancer. A man’s risk for breast cancer is higher if a close family member has had breast cancer.
• Radiation therapy treatment. Men who had radiation therapy to the chest have a higher risk of getting breast cancer.
• Hormone therapy treatment. Drugs containing estrogen (a hormone that helps develop and maintain female sex characteristics), which were used to treat prostate cancer in the past, increase men’s breast cancer risk.
• Klinefelter syndrome.Klinefelter syndrome is a rare genetic condition in which a male has an extra X chromosome. This can lead to the body making higher levels of estrogen and lower levels of androgens (hormones that help develop and maintain male sex characteristics).
• Certain conditions that affect the testicles. Injury to, swelling in, or surgery to remove the testicles can increase breast cancer risk.
• Liver disease. Cirrhosis (scarring) of the liver can lower androgen levels and raise estrogen levels in men, increasing the risk of breast cancer.
• Overweight and obesity. Older men who are overweight or have obesity have a higher risk of getting breast cancer than men at a normal weight.

What Can I Do to Reduce My Risk?

If several members of your family have had breast or ovarian cancer, or one of your family members has a known BRCA1 or BRCA2 mutation, share this information with your doctor. Your doctor may refer you for genetic counseling. In men, mutations in the BRCA1 and BRCA2 genes can increase the risk of breast cancer, high-grade prostate cancer, and pancreatic cancer.

If genetic testing shows that you have a BRCA1 or BRCA2 gene mutation, your doctor will explain what you should do to find cancer early, if you get it.

All men can lower their risk by keeping a healthy weight and exercising regularly.

How Is Breast Cancer Treated?

As in women, treatment for breast cancer in men depends on how big the tumor is and how far it has spread. Treatment may include surgery, chemotherapy, radiation therapy, hormone therapy, and targeted therapy.

What is breast cancer?

Breast cancer is a cancer that starts in breast tissue. It happens when cells in the breast change and grow out of control. The cells usually form a tumor.

Sometimes the cancer does not spread any further. This is called "in situ." If the cancer spreads outside the breast, the cancer is called "invasive." It may just spread to nearby tissues and lymph nodes. Or the cancer may metastasize (spread to other parts of the body) through the lymph system or the blood.

Breast cancer is the second most common type of cancer in women in the United States. Rarely, it can also affect men.

What are the types of breast cancer?

There are different types of breast cancer. The types are based on which breast cells turn into cancer. The types include:

• Ductal carcinoma, which begins in the cells of the ducts. This is the most common type.
• Lobular carcinoma, which begins in the lobules. It is more often found in both breasts than other types of breast cancer.
• Inflammatory breast cancer, in which cancer cells block lymph vessels in the skin of the breast. The breast becomes warm, red, and swollen. This is a rare type.
• Paget's disease of the breast, which is a cancer involving the skin of the nipple. It usually also affects the darker skin around the nipple. It is also rare.

What causes breast cancer?

Breast cancer happens when there are changes in the genetic material (DNA). Often, the exact cause of these genetic changes is unknown.

But sometimes these genetic changes are inherited, meaning that you are born with them. Breast cancer that is caused by inherited genetic changes is called hereditary breast cancer.

There are also certain genetic changes that can raise your risk of breast cancer, including changes in the BRCA1 and BRCA2 genes. These two changes also raise your risk of ovarian and other cancers.

Besides genetics, your lifestyle and the environment can affect your risk of breast cancer.

Who is at risk for breast cancer?

The factors that raise your risk of breast cancer include:

• Older age
• History of breast cancer or benign (noncancer) breast disease
• Inherited risk of breast cancer, including having BRCA1 and BRCA2 gene changes
• Dense breast tissue
• A reproductive history that leads to more exposure to the estrogen hormone, including
  • Menstruating at an early age
  • Being at an older age when you first gave birth or never having given birth
  • Starting menopause at a later age
• Taking hormone therapy for symptoms of menopause
• Radiation therapy to the breast or chest
• Obesity
• Drinking alcohol

What are the signs and symptoms of breast cancer?

The signs and symptoms of breast cancer include:

• A new lump or thickening in or near the breast or in the armpit.
• A change in the size or shape of the breast.
• A dimple or puckering in the skin of the breast. It may look like the skin of an orange.
• A nipple turned inward into the breast.
• Nipple discharge other than breast milk. The discharge might happen suddenly, be bloody, or happen in only one breast.
• Scaly, red, or swollen skin in the nipple area or the breast
• Pain in any area of the breast.

How is breast cancer diagnosed?

Your health care provider may use many tools to diagnose breast cancer and figure out which type you have:

• A physical exam, including a clinical breast exam (CBE). This involves checking for any lumps or anything else that seems unusual with the breasts and armpits.
• A medical history.
• Imaging tests, such as a mammogram, an ultrasound, or an MRI.
• Breast biopsy.
• Blood chemistry tests, which measure different substances in the blood, including electrolytes, fats, proteins, glucose (sugar), and enzymes. Some of the specific blood chemistry tests include a basic metabolic panel (BMP), a comprehensive metabolic panel (CMP), and an electrolyte panel.

If these tests show that you have breast cancer, you will have tests that study the cancer cells. These tests help your provider decide which treatment would be best for you. The tests may include:

• Genetic tests for genetic changes such as in the BRCA and TP53 genes.
• HER2 test. HER2 is a protein involved with cell growth. It is on the outside of all breast cells. If your breast cancer cells have more HER2 than normal, they can grow more quickly and spread to other parts of the body.
• An estrogen and progesterone receptor test. This test measures the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. This type of breast cancer may grow more quickly.

Another step is staging the cancer. Staging involves doing tests to find out whether the cancer has spread within the breast or to other parts of the body. The tests may include other diagnostic imaging tests and a sentinel lymph node biopsy. This biopsy is done to see whether the cancer has spread to the lymph nodes.

What are the treatments for breast cancer?

Treatments for breast cancer include:

• Surgery such as
  • A mastectomy, which removes the whole breast
  • A lumpectomy to remove the cancer and some normal tissue around it, but not the breast itself
• Radiation therapy
• Chemotherapy
• Hormone therapy, which blocks cancer cells from getting the hormones they need to grow
• Targeted therapy, which uses drugs or other substances that attack specific cancer cells with less harm to normal cells
• Immunotherapy

Can breast cancer be prevented?

You may be able to help prevent breast cancer by making healthy lifestyle changes such as:

• Staying at a healthy weight
• Limiting alcohol use
• Getting enough exercisee
• Limiting your exposure to estrogen by
  • Breastfeeding your babies if you can
  • Limiting hormone therapy

If you are at high risk, your health care provider may suggest that you take certain medicines to lower the risk. Some women at very high risk may decide to get a mastectomy (of their healthy breasts) to prevent breast cancer.

It's also important to get regular mammograms. They may be able to identify breast cancer in the early stages, when it is easier to treat.

A common and benign breast disease characterized by varying degree of fibrocystic changes in the breast tissue. There are three major patterns of morphological changes, including FIBROSIS, formation of CYSTS, and proliferation of glandular tissue (adenosis). The fibrocystic breast has a dense irregular, lumpy, bumpy consistency.

A fluid-filled sac that forms in the breast that is sometimes filled with a mix of fluid and solid material. Breast cysts may occur in one or both breasts, and there may be more than one. Most cysts feel like a round or oval lump with a smooth, well-defined border that moves easily under the skin of the breast. But some cysts are too small to be felt. Symptoms may include pain or tenderness in the breast, especially around the time of a menstrual period, or a clear or cloudy fluid discharge from the nipple. Most breast cysts are not cancer and do not increase the risk of breast cancer. They can occur at any age but are most common in premenopausal women and in women taking hormone therapy for menopause.

Breast cysts are bubbles of fluid in the breast. They are like blisters. Breast cysts are benign (not cancer). They are common in females aged 35 to 50 years. They are also common in females taking hormone replacement therapy.

ductal carcinoma

The most common type of breast cancer. It begins in the lining of the milk ducts (thin tubes that carry milk from the lobules of the breast to the nipple). Ductal carcinoma may be either ductal carcinoma in situ (DCIS) or invasive ductal carcinoma. DCIS is a noninvasive condition in which abnormal cells are found in the lining of a breast duct and have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer. In invasive ductal carcinoma, cancer has spread outside the breast duct to surrounding normal tissue. It can also spread through the blood and lymph systems to other parts of the body.

Ductal Carcinoma in Situ (DCIS)

Ductal carcinoma in situ (DCIS) is a noninvasive breast condition in which abnormal cells are found inside the breast duct but have not spread outside it. DCIS is also called intraductal breast carcinoma or stage 0 breast carcinoma in situ. Although the cells are abnormal, they are not considered cancer because they do not have the ability to break through the duct wall or spread in the body, which is the definition of cancer. DCIS may sometimes become invasive breast cancer and spread to other tissues.

Doctors diagnose some cases of DCIS as being at lower risk of becoming invasive than others. However, since doctors don’t currently know for sure which cases of DCIS will become invasive cancer and which ones won’t, DCIS is almost always treated. Because research is ongoing and you have choices about treatment, it may be helpful to get a second opinion, discuss your treatment options with more than one doctor, and learn about clinical trials for DCIS.

Introduction

Gynecomastia relates to any condition in which the male breast volume is enlarged due to an increase in ductal tissue, stroma, or fat. Gynecomastia is derived from the Greek terms gyne and masto, gyne meaning feminine and masto meaning breasts. This condition most often occurs during times of hormonal change such as birth, adolescence and old age. There are many etiologies for this condition which include extreme obesity, steroid use, pharmacologic agents, medical conditions including hypogonadism, liver, and kidney failure. However, the majority of patients present with idiopathic gynecomastia. The treatment of this condition consists of treating the underlying condition, lab work, imaging, and surgical intervention, when necessary.

Etiology

The cause of most cases of gynecomastia is idiopathic. However, it has been proven to be associated with imbalances in the hormones estrogen and testosterone.

This condition can appear transient at birth; this is thought to be due to an increased level of circulating maternal estrogens. Adolescent boys may also suffer from this condition due to an imbalance of estradiol and testosterone. In men older than 65 years, hypertrophy is thought to be due to a decline in testosterone levels and a shift in the ratio of testosterone to estrogen. In addition, older men are more likely to be taking medications that cause gynecomastia.

Underlying medical conditions such as breast cancer, obesity, hypogonadism, adrenal disease, thyroid disease, cirrhosis, renal failure, and malnutrition may contribute to this condition. Tumors of the adrenal glands, pituitary, lungs, and testes can impact hormonal changes resulting in imbalances and ultimately gynecomastia. Medications that have been shown to contribute to this condition include digoxin, thiazides, estrogens, phenothiazines, and theophylline. Use of certain recreational drugs including marijuana has also been associated with this disease. Chemotherapeutic drugs known to cause gynecomastia include methotrexate, alkylating agent, imatinib and vinca alkaloids. The most common drugs, however, have estrogen-like activity and include cimetidine, spironolactone, ketoconazole, and finasteride.

Epidemiology

Gynecomastia appears more within certain age groups of the male population. Newborns can suffer from this condition until their hormonal imbalances normalize.

Adolescence hypertrophy occurs in boys beginning around age 13 and can last into early adulthood. The incidence of this condition again increases in men 65 years of age and older.

Pathophysiology

Gynecomastia is a result of enlargement of glandular breast tissue and adipose tissue. The hormone estrogen is responsible for the growth of glandular tissue, as well as the suppression of testosterone secretion. Estrogen suppresses luteinizing hormone, the hormone that is responsible for testicular secretion of testosterone. This process of hormonal imbalance leads to gynecomastia.

Pubertal gynecomastia is thought to be caused by a faster rise in estradiol than the rise of testosterone, causing an imbalance that normally regresses with time as testosterone increases.

Medical conditions such as tumors of the adrenal, pituitary, and testes can cause increases in estrogen and decrease testosterone. These imbalances lead to hormonal imbalances resulting in gynecomastia in some males.

Diseases of the liver, adrenal, thyroid, and testes can produce imbalances, along with the above-listed medications.

Three types of gynecomastia, florid, fibrous and intermediate, have been identified. The type seen is usually related to the length of the condition. Florid gynecomastia is usually seen in early stages of the condition, four months or less. This type is characterized by an increase in ductal tissue and vascularity. Fibrous gynecomastia is seen after a year duration and is noted to have more stromal fibrosis and few ducts. After one year, intermediate gynecomastia is present which is thought to be a progression from florid to fibrous.

Histopathology

Typical features include

• Proliferation of the stroma and ductules
• Loose stroma seen in acute cases and dense stroma with few ductules seen in chronic cases

History and Physical

Important factors in the history from the patient include onset and duration of gynecomastia, associated symptoms, problems with certain organ systems such as liver, renal, adrenal, prostate, pulmonary, testicular or thyroid.

In some cases, the patient is found to have gynecomastia after undergoing an MRI or CT scan of the chest.

A careful review of family history, genetic history, medications, and recreational drug use should also be taken into consideration. A complete and thorough physical exam should be done. The head and neck exam should evaluate for any abnormal masses or thyroid abnormalities. Assess breasts for the nature of the tissue, masses, skin changes, nipple discharge, asymmetries, and tenderness, along with an axillary examination. The testes should be examined to look for asymmetry, masses, enlargement, or atrophy. Those males with feminizing characteristics should have endocrine testing and genetic testing. Any other positive findings on physical examination should be treated in an appropriate manner.

A condition called pseudogynecomastia has to be differentiated from gynecomastia. In the former, there is only circumferential fat in the subareolar area. The condition is often bilateral and in most cases, the deposit of fat remain of the same size for many years. Observation is prudent in such cases.

Evaluation

The history and physical will guide the remainder of the workup. Healthy males with no associated symptoms or physical abnormalities other than long-standing gynecomastia (more than 12 months) need no further workup. However, if symptoms are present, or if there are positive physical exam findings, these should be investigated first.

• Testicular masses require the following: testicular ultrasound, serum testosterone, luteinizing hormone (LH), estradiol, and DHEAS. If a thyroid mass is present the following are required: thyroid function tests, thyroid ultrasound (US), and endocrine evaluation.
• If a breast mass is palpated, the patient needs the following: mammography or US, biopsy, and possible surgical consultation.
• If hypogonadism is present, order the following: serum LH/follicle-stimulating hormone (FSH), estradiol, testosterone, DHEAS + karyotype +/- adrenal scan with the endocrine consult.
• If abdominal masses or hepatomegaly are present order the following: liver function tests, serum LH/FSH, estradiol, testosterone, DHEAS +/- abdominal CT, and an endocrine consultation.
• Renal and liver function tests should be ordered
• If hyperthyroidism is suspected, thyroid studies are in order.

Treatment / Management

Gynecomastia is classified into three grades depending on the amount of breast enlargement, skin excess, and ptosis. The treatment for each Grade differs depending on the amount of skin excess and ptosis.

• Grade I: Small enlargement, no skin excess
• Grade II: Moderate enlargement, no skin excess
• Grade IIb: Moderate enlargement with extra skin
• Grade III: Marked enlargement with extra skin

Treatment of this condition consists first of treating any underlying condition if this is contributing to the condition. If the condition has been present less than one year, and the history and physical are within normal limits, observation can be done with close follow-up. If an underlying medication is noted within history, this should be discontinued. If anything abnormal is found on physical exam, treatment depends on this finding. If the underlying condition is treated, and the condition persists longer than a year, surgical treatment is suggested.

Medical therapy usually does not work in long-standing cases. Drugs like clomiphene, danazol and tamoxifen have been used in acute cases with varying success. However, these drugs also have adverse effects that are not well tolerated.

Patients with grade I or grade IIa can be treated with liposuction and surgical excision.

If the patient presents with grade IIb gynecomastia, open surgical excision with possible skin resection is indicated if a large amount of ptosis is present.

Differential Diagnosis

Breast cancer

Lymphoma

Dermoid cyst

Prognosis

Gynecomastia is not life-threatening but it can cause significant emotional distress. Most cases take months or years to resolve. Further, men with Klinefelter syndrome also have a risk of developing male breast cancer. Young people with gynecomastia become depressed, isolated, refuse to participate in any activity that involves removing the shirt and have low self-esteem.

Enhancing Healthcare Team Outcomes

Gynecomastia is not a life-threatening disorder but it can cause significant distress because of aesthetics. There is also a small risk of breast cancer. Gynecomastia is best managed by an interprofessional team that includes the pharmacist and nurse practitioner. The first thing is to rule out any medications that are causing the disorder; thus, the pharmacist should go over the patient's medications and recommend discontinuation of the problematic drug. In addition, patients need to be educated about the harms of marijuana and alcohol, both relatively common causes of gynecomastia.

Secondly, gynecomastia is not a surgical emergency and watchful observation is recommended because some cases may resolve spontaneously. The nurse should educate the patient that most acute cases subside on their own and no treatment is required. If the patient is to be treated with antihormonal drugs, then the pharmacist should educate the patient on the adverse effects and that the results are not immediate.

Those cases that persist should be referred to a plastic surgeon. Because of fibrosis in chronic cases, liposuction may not always work and an open procedure may be required. Finally, because gynecomastia can cause severe emotional distress, a mental health nurse should provide counseling. Only through an interprofessional approach with open communication, can the morbidity of gynecomastia be lowered.

The outcomes for males with gynecomastia are fair; the condition can lead to embarrassment and isolation.

Every breastfeeding experience is different. Some mothers have small challenges that become bigger with time. It is important to be aware of breast changes because sometimes they are signs of a breastfeeding challenge that is about to become a bigger issue.

Mastitis is inflammation or swelling of the breast tissue that may or may not include a bacterial infection. Mastitis can occur anytime during lactation, but usually happens in the first six weeks of breastfeeding.

Mastitis (mast-EYE-tiss) is soreness or a lump in the breast. It can cause symptoms such as:

• Fever and/or flu-like symptoms, such as feeling run down or very achy
• Nausea
• Vomiting
• Yellowish discharge from the nipple that looks like colostrum
• Breasts that feel warm or hot to the touch and appear pink or red

A breast infection can happen when other family members have a cold or the flu. It usually happens in only one breast. It is not always easy to tell the difference between a breast infection and a plugged duct, because both have similar symptoms and can get better within 24 to 48 hours. Some breast infections that do not get better on their own need to be treated with prescription medicine from a doctor.

What you can do

• Breastfeed on the infected side every two hours or more often. This will keep the milk moving freely and your breast from becoming too full.
• Massage the area, starting behind the sore spot. Move your fingers in a circular motion and massage toward the nipple.
• Apply heat to the sore area with a warm, wet cloth.
• Rely on others to help you get extra sleep, or relax with your feet up to help speed healing. Often a breast infection is a sign that you are doing too much and becoming overly tired.
• Wear a well-fitting, supportive bra that is not too tight, since a tight bra can constrict milk ducts.

Ask your doctor for help if you do not feel better within 24 hours of trying these tips, if you have a fever, or if your symptoms get worse. You might need medicine. See your doctor right away if:

• You have a breast infection in which both breasts look affected
• There is pus or blood in your breastmilk
• You have red streaks near the affected area of the breast
• Your symptoms came on severely and suddenly

Whereas the breasts are located far from the other female reproductive organs, they are considered accessory organs of the female reproductive system. The function of the breasts is to supply milk to an infant in a process called lactation. The external features of the breast include a nipple surrounded by a pigmented areola, whose coloration may deepen during pregnancy. The areola is typically circular and can vary in size from 25 to 100 mm in diameter. The areolar region is characterized by small, raised areolar glands that secrete lubricating fluid during lactation to protect the nipple from chafing. When a baby nurses, or draws milk from the breast, the entire areolar region is taken into the mouth.

Breast milk is produced by the mammary glands, which are modified sweat glands. The milk itself exits the breast through the nipple via 15 to 20 lactiferous ducts that open on the surface of the nipple. These lactiferous ducts each extend to a lactiferous sinus that connects to a glandular lobe within the breast itself that contains groups of milk-secreting cells in clusters called alveoli. The clusters can change in size depending on the amount of milk in the alveolar lumen. Once milk is made in the alveoli, stimulated myoepithelial cells that surround the alveoli contract to push the milk to the lactiferous sinuses. From here, the baby can draw milk through the lactiferous ducts by suckling. The lobes themselves are surrounded by fat tissue, which determines the size of the breast; breast size differs between individuals and does not affect the amount of milk produced. Supporting the breasts are multiple bands of connective tissue called suspensory ligaments that connect the breast tissue to the dermis of the overlying skin.

During the normal hormonal fluctuations in the menstrual cycle, breast tissue responds to changing levels of estrogen and progesterone, which can lead to swelling and breast tenderness in some individuals, especially during the secretory phase. If pregnancy occurs, the increase in hormones leads to further development of the mammary tissue and enlargement of the breasts.

What are dense breasts?

Breasts contain glandular tissue, fibrous connective tissue, and fatty breast tissue. Breast density is a term that describes the relative amount of these different types of breast tissue as seen on a mammogram. Dense breasts have relatively high amounts of glandular tissue and fibrous connective tissue and relatively low amounts of fatty breast tissue.

Are dense breasts common?

Yes, dense breasts are common. Nearly half of all women who are 40 and older who get mammograms are found to have dense breasts.

What factors influence breast density

Breast density is often inherited, but other factors can influence it.

• Factors associated with higher breast density include using menopausal hormone therapy and having a low body mass index.
• Factors associated with lower breast density include increasing age and having children.

How do I know if I have dense breasts?

Dense breast tissue cannot be felt by a woman, such as during a breast self-exam, or by her doctor during a clinical breast exam. Only a radiologist looking at a mammogram can tell if a woman has dense breasts. Dense breasts are sometimes called mammographically dense breasts.

How is breast density categorized in a mammogram report?

Doctors use the Breast Imaging Reporting and Data System (BI-RADS) to classify breast density. This system, developed by the American College of Radiology, helps doctors interpret and report back mammogram findings. Doctors who review mammograms are called radiologists. BI-RADS classifies breast density into four categories:

• Entirely fatty breast tissue: There is almost all fatty breast tissue. It is found in about 10% of women.
• Scattered fibroglandular breast tissue: There is mostly fatty tissue with some areas of dense glandular and fibrous connective tissue. It is found in about 40% of women.
• Heterogeneously dense breast tissue: There are many areas of dense glandular and fibrous connective tissue, with some areas of fatty tissue. It is found in about 40% of women
• Extremely dense breast tissue: There is almost all dense glandular and fibrous connective tissue. It is found in about 10% of women.

If your mammogram report letter says you have dense breasts, it means that you have either heterogeneously dense breast tissue or extremely dense breast tissue.

Does having dense breast tissue affect a mammogram?

Dense breasts can make a mammogram more difficult to interpret. That's because dense breast tissue and some abnormal breast changes, such as calcifications and tumors, both appear as white areas in the mammogram, whereas fatty tissue appears as dark areas.

As a result, mammography is less sensitive in women with dense breasts—that is, it is more likely to miss cancer. Women with dense breasts may be called back for follow-up testing more often than women with fatty breasts.

Are dense breasts a risk factor for breast cancer?

Dense breasts are not considered an abnormal breast condition or a disease. However, dense breasts are a risk factor for breast cancer. That is, women with dense breasts have a higher risk of breast cancer than women with fatty breasts. This risk is separate from the effect of dense breasts on the ability to read a mammogram.

In most states, mammography providers are required to inform women if they have dense breasts.

Should women with dense breasts have additional screening for breast cancer?

The value of additional, or supplemental, imaging tests such as ultrasound or MRI to screen for breast cancer in women with dense breasts is not yet clear, according to the Recommendation Statement on Breast Cancer Screening by the United States Preventive Services Task Force (USPSTF). Talk with your doctor or nurse to learn what is recommended for you, based on your personal medical history and family medical history.

Are breast cancer patients with dense breasts more likely to die from breast cancer?

No. Research has found that breast cancer patients who have dense breasts are no more likely to die from breast cancer than breast cancer patients who have fatty breasts, after accounting for other health factors and tumor characteristics.

Questions to consider asking your doctor or nurse

Ask these questions to get information that’s specific to you, based on your personal medical history:

• What are the dense breast-related findings in my recent mammogram?
• Do you recommend additional screening or diagnostic tests for me?
• What is my overall personal risk of breast cancer, given my risk and protective factors?

Are there clinical trials for women with dense breasts?

Yes, there are ongoing and completed clinical trials related to dense breasts that are studying better ways to detect breast cancer in women with dense breasts.

What are researchers studying about the relationship between breast density and breast cancer?

Here are some questions that researchers are working to answer:

• Can imaging tests such as 3-D mammography, MRI, ultrasound, or other imaging procedures help provide a clearer picture of breast density?
• Are there certain patterns or areas of dense breast tissue that are particularly “risky”?
• Why do some women with dense breasts develop breast cancer, whereas others do not?
• What biologic mechanisms explain the association between high breast density and increased breast cancer risk?
• Can biomarkers be identified that may help predict whether breast cancer will develop in a woman with dense breasts?
• Are changes in breast density over time associated with changes in breast cancer risk?
• Can women reduce their breast density, and potentially their risk of developing or dying from breast cancer, by taking medicines or by applying topical agents on their breasts?