ISSN: 1679-9941 (Print), 2177-5281 (Online)
Official website of the journal Adolescencia e Saude (Adolescence and Health Journal)

Vol. 4 No. 2 - Apr/Jun - 2007

Breast pathologies in adolescence

Thelarche is defined as the beginning of breast development in women. The normal age range for its onset is from 8 to 14 years of age, with an average of around 11 years. Usually, the first sign of puberty is followed within six months by pubarche and, in two to four years, by menarche(2). Asymmetrical development is not uncommon, with the other breast only beginning to develop after six months. The initial appearance of pubarche before thelarche is neither abnormal nor uncommon. The stages of breast development were described by Marshall and Tanner, who established an excellent system for assessing breast development(3).

Breast examination should be part of routine medical care, with inspection and palpation of the breasts, taking into account the Marshall and Tanner staging in relation to chronological age. The technique for the examination in adolescents is no different from that used in adult women. Many adolescents prefer the examination to be performed without the presence of their mother and/or guardian. The doctor, together with the patient, determines who should stay during the exam(1). This is an opportunity to explain normal breast development to both the adolescent and her companion, identify any abnormalities, and review some concepts that the patient may have.

In this age group, caution should be exercised when faced with a breast pathology(6). Observation and temporization for a reasonable period of time will be beneficial. Hormone treatments should only be administered in cases where this therapy is considered essential, which rarely occurs(5).

Indications for surgery should be carefully considered, since what may appear to be a tumor is often a breast bud in glandular development, which will disappear in due time. The patient and her family should be reassured(4).

CLINICAL PICTURE AND DIAGNOSIS

  • Thorough clinical examination with inspection and palpation of the breasts, armpits and embryonic mammary line;
  • fine needle puncture/aspiration: used to empty the cyst and investigate the material for culture and cytology;
  • ultrasound: excellent resource for evaluating cysts and solid nodules;
  • mammography in adolescents: not routinely indicated, since the developing breast parenchyma, still with little fatty tissue component, is normally composed of dense fibroglandular tissue, in addition to the low risk of malignant disease.

Table 1 presents the main breast pathologies found in this age group.

BREAST AGENESIA

Congenital breast agenesis, an extremely rare clinical condition, consists of the complete absence of the breast, unilaterally or bilaterally. It may be due to chromosomal alterations, gonadotropin deficiency or congenital adrenal hyperplasia. Treatment is performed through cosmetic surgery, with a myocutaneous flap, artificial prosthesis, creation of an artificial areola and nipples with the labia minora, in an appropriate and harmonious manner.

BREAST AMASTIA

Amastia is characterized by the presence of an areola and nipple and absence of breast tissue and pectoral muscle, and chromosomal alterations should be investigated. Treatment is performed through cosmetic surgery, with a myocutaneous flap, artificial prosthesis in an appropriate and harmonious manner.

BREAST ASYMMETRY

In these cases, the patient should be monitored until complete breast development, which will occur at 18 years of age, when she is in Tanner stage V. Due to the psychological problems that may occur, it is suggested that a prosthesis be used in the bra to achieve aesthetic balance. Mammoplasty with surgical prosthesis can be performed at the ideal time.

TUBEROUS DEFORMITY

These patients have small breast volume, with very large development and protuberance of the areola, unilaterally or bilaterally. In these patients, it is not possible to establish breast development through Tanner staging. In these cases, the criteria for determining the ideal time for cosmetic surgery should take into account pubertal stage, menarche, somatic growth and bone age.

BREAST ATROPHY

The size and shape of the breasts are controlled by several variables, including genetic factors, always with care to wait until the age of complete development. Because the breasts are composed mainly of fatty tissue, there is an association between breast size and weight. Significant weight loss can result in decreased breast volume. Breast atrophy can be due to other causes, including symptoms of hypoestrogenism and virilization. When systemic diseases lead to breast atrophy, it may be associated with weight loss, catabolism and/or hypoestrogenism.

JUVENILE OR VIRGIN HYPERTROPHY

This term refers to a pathological development of the breasts that can be unilateral or bilateral, and can also be familial. Deciding when the breasts are too large is subjective, but some patients develop them to such an extent that it can interfere with their physical and psychological state.

Rapid and massive breast development results in pain, shoulder injuries, hypovascularization, postural kyphosis, intertrigo and stretch marks. The patient will benefit both physically and psychologically from reduction mammoplasty.

MASTALGIA OR MASTODYNIA

Breast pain can be caused by estrogen therapy, trauma, hypertrophy, infection, and benign functional breast disease (BBF). Hormonal contraceptives, especially high-dose ones, have been associated with mastalgia, and in these cases, low-dose contraceptives or another non-hormonal contraceptive method should be tried. Nonspecific breast pain has been treated with vitamin E, but the real effectiveness of this therapy has not yet been demonstrated. Patients with mastalgia due to BBF have benefited from avoiding caffeine and dairy products. In treatment, the use of a higher-cup bra (which provides better support for the breasts), analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs) are currently the best options.

MASTITIS OR BREAST ABSCESS

Although mastitis is more common in patients who are breastfeeding, this bacterial infection can occur in non-lactating women, including adolescents. The most common causes are trauma, hair removal or scratching of the periareolar region. Signs of inflammation (pain, heat, redness) with hardened areas should be treated with analgesics, NSAIDs and broad-spectrum antibiotics. Surgical drainage is indicated in cases of abscess.

GALACTORRHEA OR PAPILLARY DISCHARGE

The differential diagnosis of galactorrhea should be made with pregnancy, lactation, hyperprolactinemia, hypothyroidism and benign galactorrhea. In cases of galactorrhea, rule out the intake of hyperprolactinemic medications and measure prolactin (basal and/or pool prolactin). If it is altered, investigate the sella turcica through cranial X-ray and/or brain computed tomography.

Causes of nipple discharge: infection, intraductal papilloma (usually produces a serosanguineous fluid), breast cyst and secretion of the areolar glands. Treatment will be determined by the etiology.

FIBROADENOMA

This is the most common breast alteration in this age group. Clinically, it is a benign, well-defined, hardened and mobile tumor. It may disappear spontaneously, however, if, after observation for a few months, it does not disappear and even increases, surgical excision is indicated.

BREAST CYST

The presence of a cyst can be detected by ultrasound. Treatment is performed through puncture with cytological study.

POLYTHELIA (ACCESSORY NIPPLES)

Polythelia is the most common breast anomaly, with the presence of a nipple and areola along the embryological mammary line, which runs from the armpit to the groin. A poorly developed nipple/areola complex commonly appears just below the breast, and may be unilateral or bilateral. The only treatment, when necessary, is surgical.

POLYMASTYA (ACCESSORY BREASTS)

Polymastia, that is, accessory breast tissue, is less common and may become a problem at puberty or during pregnancy and lactation. When this occurs, due to the growth of this extramammary tissue, surgical excision becomes necessary.

Bibliographic References
1. Emans SHJ, Goldstein DP. Pediatric & adolescent gynecology. Boston: Little, Brown and Company. 1990.

2. Garden AS. Pediatric & adolescent gynecology. London: Arnold Publishers. 1998.

3. Kreutner AKK, Hollingsworth DR. Adolescent obstetrics & gynecology. Chicago: Year Book Medical Publishers. 1978.

4. Sanfilippo JS, Murram D, Dewhurst J, Lee PA. Pediatric and adolescent gynecology. Philadelphia: WB Saunders. 1994.

5. Tourinho CR, Bastos AC, Moreira AJ. Gynecology of childhood and adolescence. 2nd ed. São Paulo: Byk-Procienx. 1980.

6. Zeiguer BK. Child and Adolescent Gynecology. Buenos Aires: Ed. Med. Panamericana. 1977.

1. Assistant Professor of Gynecology at the School of Medical Sciences of the University of Rio de Janeiro (FCM/UERJ); Master in Endocrinology from UERJ; Head of the Child and Adolescent Gynecology Sector of the Gynecology Department at FCM/UERJ.