Summary
Consultation regarding mammary pathology is frequent in teenagers; therefore gynaecologists and paediatricians must train to treat it appropriately, since it is different from the one observed in adult women. The main pathologies at this stage are mastalgias, development anomalies and benign tumours originating in fibro-connective tissue.
Conjunctival tumours
Very often, mammary pathology is a reason for consultation with a service or practice for teenage girls. Therefore, at least one member of the professional team should be very knowledgeable about this topic, including related surgical aspects, to avoid referrals. It is frequent for physicians to wrongly diagnose teenage girls by poorly interpreting mammary disorders related to growth. Terms such as cyst or dysplasia are inappropriately used to poorly describe a painful, irregularly surfaced, tight gland, which is quite common during perimenarche due to the usual oestrogen–progesterone imbalance occurring at this age.
Many breast disorders in adolescent girls and teenagers have important psychological effects on them. Mammae are the most obvious secondary sex characters of sexual development experienced by adolescent girls. This character identifies teenage girls with their feminine role, socially positions them as women and makes them desirable to the opposite sex. Unlike inferior mammals, only women’s breasts remain erect during non-breastfeeding periods as a symbol of sexual attraction. Not surprisingly, teenage girls focus a great deal of attention on breast development and alterations and frequently make consultations about slight deviations from what they consider normal and, therefore, gynaecologists should provide them with correct answers.
Embryologic concepts
Phylogenetically, the mammary gland is considered as a highly specialised sweat gland. It is a cutaneous field that becomes transformed to fulfil new functions, becoming adapted to such task. Despite the fact that the final and functional anatomical development occurs a long time after birth, there are already signs of its origin in the 6-week embryo, with the appearance of mammary ridges, consisting of epidermal thickenings on both sides of the trunk ( Fig. 1 ). These thickenings will subsequently penetrate deeper as cords (4th month) ( Fig. 2 ).
These cords will form the walls of the main ducts and the cellular accumulation on their ends will branch to create minor ducts and the secretory acini of the gland ( Fig. 3 ). This growth occurs very slowly and, because it mostly develops alone, formed ducts show no differences between both genders. This is the first growth.
The second growth occurs during puberty, due to the effect of oestrogens, progesterone and the growth hormone. Oestrogens stimulate the development of ducts and connective tissue. They enlarge the vascular system, increase its permeability and prepare the action of progesterone, on which alveolar growth is dependent.
Finally, prolactin, cortisol and insulin cause secretory differentiation of the epithelium.
The adipose tissue located between the mammary rudiment and the muscle grows independently from the gland, but it is necessary for ducts to branch in it.
It appears that the involution of mammary buds, excluding the fourth ones, depends on the appearance of androgen receptors in the cells of the underlying mesenchyme, which is compensated until dehydrotestosterone causes them to vanish.
The mammary button may begin to form at the age of 9 years and is expected to normally appear up to the age of 13 years. It becomes clinically evident due to the nipple rising on a usually unilateral, slightly painful, hard glandular plate. It may be mistaken for a mammary nodule due to ignorance.
As from that moment, the growth rate is highly variable from one teenage girl to another: some of them complete all stages in 2–3 years and others only complete them at the age of 19. It is usual that stage 4 is skipped, jumping directly from stage 3 to the adult mamma.
The body weight is relevant throughout this growth period because one-third of the mamma is made up of adipose tissue. If a teenage girl is overweight during premenarche, the skin may not withstand the pressure of mammary growth and the unattractive dermal striae caused by broken collagen fibres, which are difficult to repair, may appear. This weight/mammary size ratio is important for assessment during consultations for hypo- and hypermastia (see consultation during childhood) and advice as regards the use of a proper bra.
Embryologic concepts
Phylogenetically, the mammary gland is considered as a highly specialised sweat gland. It is a cutaneous field that becomes transformed to fulfil new functions, becoming adapted to such task. Despite the fact that the final and functional anatomical development occurs a long time after birth, there are already signs of its origin in the 6-week embryo, with the appearance of mammary ridges, consisting of epidermal thickenings on both sides of the trunk ( Fig. 1 ). These thickenings will subsequently penetrate deeper as cords (4th month) ( Fig. 2 ).
These cords will form the walls of the main ducts and the cellular accumulation on their ends will branch to create minor ducts and the secretory acini of the gland ( Fig. 3 ). This growth occurs very slowly and, because it mostly develops alone, formed ducts show no differences between both genders. This is the first growth.
The second growth occurs during puberty, due to the effect of oestrogens, progesterone and the growth hormone. Oestrogens stimulate the development of ducts and connective tissue. They enlarge the vascular system, increase its permeability and prepare the action of progesterone, on which alveolar growth is dependent.
Finally, prolactin, cortisol and insulin cause secretory differentiation of the epithelium.
The adipose tissue located between the mammary rudiment and the muscle grows independently from the gland, but it is necessary for ducts to branch in it.
It appears that the involution of mammary buds, excluding the fourth ones, depends on the appearance of androgen receptors in the cells of the underlying mesenchyme, which is compensated until dehydrotestosterone causes them to vanish.
The mammary button may begin to form at the age of 9 years and is expected to normally appear up to the age of 13 years. It becomes clinically evident due to the nipple rising on a usually unilateral, slightly painful, hard glandular plate. It may be mistaken for a mammary nodule due to ignorance.
As from that moment, the growth rate is highly variable from one teenage girl to another: some of them complete all stages in 2–3 years and others only complete them at the age of 19. It is usual that stage 4 is skipped, jumping directly from stage 3 to the adult mamma.
The body weight is relevant throughout this growth period because one-third of the mamma is made up of adipose tissue. If a teenage girl is overweight during premenarche, the skin may not withstand the pressure of mammary growth and the unattractive dermal striae caused by broken collagen fibres, which are difficult to repair, may appear. This weight/mammary size ratio is important for assessment during consultations for hypo- and hypermastia (see consultation during childhood) and advice as regards the use of a proper bra.
Reasons for consultation
In our experience and since we created the Comprehensive Adolescent Care Program (Programa de Atención Integral al Adolescente, 1987), mammary pathology consultations have accounted for 4.8% of total consultations.
Most frequent reasons are as follows:
- ▪
Mastalgia
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Skin affections in the area, areola and nipple
- ▪
Mammary cysts
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Acute galactophoritis
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Nipple discharges
- ▪
Development anomalies
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Tumours
Below is a description of each:
Mastalgia
This is a frequent reason for consultation, which should be given proper meaning. The first question that should be answered is whether pain specifically belongs to the mamma or is referred from elsewhere. Due to shyness or embarrassment caused by breast growth, teenage girls usually become round-shouldered to hide their breasts, and this position causes dorsalgia.
Postural disorders, kyphosis, scoliosis and sternocostal chondritis may cause pain at the breast area level, thus causing confusion. This pain is usually unilateral, non-cyclic and mammae are soft and painless when pressed. In these cases, the back should be examined for spine deviations and paravertebral painful points, which generally extend to costal arches, going through the depth of the armpit, up to the sternum. A timely consultation with an orthopaedist, doing appropriate exercises and postural corrections solve the problem ( Fig. 4 ).
On the other hand, if premenstrual pain is bilateral and is accompanied by turgid and sensitive mammae, hard and irregular to the touch, pain is clearly originated in the breast. Mammary pathology texts call this type of pain mastodynia, but it is actually a frequent phenomenon in these types of patients, even in the presence of oestrogen/progesterone imbalance and irregular growth among stroma, ducts and lobules. In addition, the relation among stress, prolactin and mammary disorders is currently known. Increased prolactin interferes with the production of gonadotropin-releasing hormone (GnRH), changing the oestrogen/progesterone ratio and also increasing the formation of oestrogen receptors in the mamma.
This functional hyperprolactinaemia cannot be detected by determining prolactin in an isolated manner, but in a detailed 24-h profile showing changes in the pulsatile pattern (Noel, 1980). This explains pain and mammary induration events in the presence of severe emotional distress, both in adolescent girls and adult women. The sociological profile of these young women with intense mammary pain generally matches hyperemotional, perfectionist and very slim women.
The presence of breast cancer in any close relative that may trigger a hypochondriac attitude in the patient should also be dismissed.
Based on the above, the therapeutic approach of our service is as follows:
- 1)
Dismiss referred spine pain and carcinophobia.
- 2)
Explain the physiopathology of mastalgia.
- 3)
Detect distress.
- 4)
If necessary, objectify through ultrasound.
- 5)
Permanent and appropriate use of bra, specifically during premenstruum.
- 6)
Medication (placebo?)
- a)
Local progesterone gel, 10 days prior to menstruation.
- b)
One vitamin complex (A + E + B6) tablet per day, due to its anti-oestrogenic properties, which improve epitheliums and the premenstrual syndrome.
- a)
Development anomalies
First, we should differentiate what adolescent girls interpret as growth alternations from actual development anomalies. Therefore, a correct diagnosis should begin with an appropriate general assessment of growth and development stages, weight/height ratio, bone age and hormonal parameters. The plastic surgeon is an important team member, as described in the chapter Genital malformations . Plastic surgeons should be suitable and familiar with the treatment of young people and should also integrate into the professional team.
Development anomalies we have treated are as follows:
Asymmetries
Anomalies
Areola and nipple anomalies
Hypertrophies
Supernumerary mammae
Unilateral agenesis
Amastia
Cases where patients wrongly interpreted malformations that were actually temporary alterations due to normal growth were excluded from the list. Below is a brief description of these pathologies:
Hypomastia
This is a frequent reason for consultation but, in most cases, there is no pathological significance and concern is generally caused by a distorted body image due to poor self-esteem and a sense of inferiority ( Fig. 5 ). Patients are explained that the maximum volume occurs at the end of the growth cycle, after gaining weight and particularly during the breastfeeding period. Meanwhile, indications include corrective bras, a good diet and gymnastics to tone up pectoral muscles. Local treatment with oestrogens is ineffective, unless hypomastia is caused by ovarian insufficiency. The only result is that the areola and the nipple become pigmented ( Fig. 6 ).
