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Adolescent Gynecology

Disorders of the Adolescent Breast

Jennifer E. Dietrich, MD, MSc; Mary L. Brandt, MD

Although breast concerns are common among adolescents, serious breast conditions are not—all the more reason for learning to recognize the rare exception.

The increased awareness of breast cancer has raised concerns about breast lesions of all types. In the adolescent—who is unlikely to have breast cancer—this often results in unnecessary diagnostic procedures and surgery. To avoid such mistakes, it is important to have a good understanding of normal developmental variations, common adolescent complaints, and the types of neoplasms that may occur in this population.

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DEVELOPMENTAL CONCERNS

Thelarche typically occurs between the ages of 8 and 13 years, with an average age of 10.3 years, when pubertal endogenous estrogen from the ovaries begins to stimulate lactiferous duct growth. Full breast maturation takes 2 to 4 years, and can be characterized by Tanner staging (Table 1).1 Estrogen and growth hormone promote ductal elongation, while progesterone controls alveolar development. This process involves not only the primary ducts, but also secondary ducts that form by branching centrally and laterally.

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TABLE 1. Tanner Stages of Breast Development1

Cause for concern may arise due to early, abnormal, or absent breast development. One of the most common conditions in young girls is precocious thelarche—ie, breast development before age 7 in black girls or age 8 in other ethnic groups.1 This is usually an isolated condition, with only 18% of affected girls experiencing precocious puberty.1 However, serial examinations are warranted to determine growth velocity and development of other secondary sexual characteristics. About 90% of patients with isolated premature thelarche will have resolution within 6 months to 6 years postdiagnosis, but some may have persistence of the breast tissue until puberty. Additional long-term follow-up has demonstrated that patients with a history of early breast development are not at increased risk for other disorders or tumors of the breast.2

Lack of breast development by age 13 is considered delayed. Because thelarche is the first indication of puberty, a general evaluation of pubertal status is indicated in these girls. Assessment of the hypothalamic-pituitary axis, ovarian hormone production, thyroid function, and androgen levels should be performed to rule out an endocrinologic cause.3 In the absence of an endocrinologic disorder, lack of breast development (amastia) or poor development (hypomastia) may be associated with conditions such as ectodermal dysplasia or Poland syndrome.2 In addition, chronic medical conditions such as malnutrition or Crohn colitis can result in improper development. A history of central line or chest tube placement, radiation exposure, or burn injuries may account for damage to the nipple complex (Figure 1).2

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FIGURE 1. Breast trauma secondary to central line placement as a premature infant. Image courtesy of Mary L. Brandt, MD.

Breast asymmetry is a normal variant for most adolescent girls, but can be a cause of distress; 25% of cases will persist into adulthood.1,3 Mild asymmetry with no other associated pathology is not worrisome. However, a significant discrepancy in breast size has been linked to connective tissue disorders and heredity.3 Unilateral hypoplasia has been associated with Becker nevus, a type of hamartoma with excess androgen receptors. Finally, a tuberous breast anomaly can result in unilateral or bilateral hypoplasia.2 This occurs when the base of the breast tissue is not wide enough, or with rapid pubertal progression when insufficient receptors respond to endogenous hormone in the lateral breast tissue. The result is a narrow, cylindrical breast with tissue developing only under the areolar complex. Plastic surgery may be indicated to correct the problem.1

The “milk line” develops from the axilla to the inguinal area, so that breast tissue can arise in any location along this line. Breast tissue development outside the mammary streak is rare.4 Supernumerary breast tissue (polymastia) and accessory nipples or polythelia occur in up to 2% of the population (Figure 2). Both conditions are usually asymptomatic, but the accessory tissue may be irritated by clothing, necessitating removal. Studies suggest an association between polythelia and congenital urinary or cardiac abnormalities, so the patient should be evaluated accordingly.4 Rarely, breast tissue may be present without a nipple or areolar tissue. Inverted nipples can predispose to infection, but surgical correction often results in permanent damage to the lactiferous ducts. Bifid nipples, intra-areolar polythelia, and dysplastic divided nipples have been described, but are considered normal anatomic variants that do not warrant surgical repair.

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FIGURE 2. Polythelia. Image courtesy of Mary L. Brandt, MD.

Excessively large breasts (macromastia or breast hyperplasia) are relatively common. Although the differential diagnosis should include tumor, pregnancy, and excessive exogenous hormone exposure, juvenile hypertrophy is the most common etiology.1,3 This spontaneous growth may be unilateral or bilateral, and may result from end-organ hypersensitivity to gonadal hormones.1,3 Early surgical intervention may be indicated in extreme cases involving skin necrosis or anatomic impairment (Figure 3).

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FIGURE 3. Unilateral juvenile hypertrophy. Image courtesy of Mary L. Brandt, MD.

Plastic surgery to achieve breast symmetry is indicated at the completion of puberty. Progestins or antiestrogens have been used to prevent continued growth, but are not uniformly successful.5 Patients should be advised that lactation can be affected by juvenile hypertrophy, particularly after reduction surgery, but the condition does not increase the risk of breast cancer.2

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MASTALGIA

Symptoms associated with breast pain may include swelling, nodularity, and tenderness. Mastalgia that is premenstrual and cyclic is usually hormonally mediated. A well-fitted bra can help, particularly during exercise.1 Smoking cessation should be encouraged, as nicotine has been shown to increase breast pain. Studies also suggest that dietary modifications (eg, eliminating or reducing caffeine intake) may be beneficial. Medical options include NSAIDs and combination hormonal contraception.1 Use of evening primrose oil and vitamin E has not been validated, but is popular among women who prefer alternative medicine.1

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INFECTIONS

Mastitis is the most common infection of the breast, occurring in both lactating and nonlactating women. It can result from simple skin irritation due to shaving or nipple stimulation, or even from piercing. Antibiotics and analgesics are warranted in all cases. As methicillin-resistant Staphylococcus aureus (MRSA) can be involved, antibiotics such as clindamycin, sulfamethoxazole, and vancomycin may be preferred. Abscesses may require surgical drainage. Use of a percutaneous drain is advisable to avoid damaging underlying breast tissue, particularly in the peripubertal patient.

For infections associated with breast or nipple piercings, recommendations include antibiotic treatment, removal of the foreign body, and screening for hepatitis B and C and human immunodeficiency. Piercing should be avoided in girls with metal allergies, diabetes mellitus, hemophilic or coagulopathic states, immune suppression, or heart valve defects.1 Many adolescents are uninformed about healing times for piercing, and delay seeking treatment in the presence of complications such as breast abscesses and endocarditis.1

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NIPPLE DISCHARGE

Nipple discharge in the adolescent girl is usually due to chronic irritation. However, pregnancy or use of antipsychotics, narcotics, or combined hormonal contraception can also be implicated. Discharge color and location are particularly important in determining the diagnosis (Table 2).2

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TABLE 2. Differential Diagnosis of Breast Discharge2

For patients presenting with red, brown, green, or yellow discharge, cultures should be obtained and appropriate antibiotics prescribed. Location is likewise important; for example, bloody or brown discharge from the ducts of Montgomery on the edge of the areola indicate a retroareolar mass, which is treated expectantly by limiting manipulation and warm soaks. Mammary duct ectasia with bloody discharge is a benign (possibly congenital) condition in which dilation of the subareolar ducts results in inflammation, fibrosis, and duct obstruction, predisposing to infection. It is treated by antistaphylococcal antibiotics and warm soaks, and may resolve spontaneously. Bloody discharge in adolescents can also be caused by papillomas, which should be surgically excised.2,3

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BREAST MASSES

Breast masses are common in adolescence, and are almost universally benign. Fibrocystic change is prevalent in this population, as are fibroadenomas.6 Fibrocystic changes require no surgical intervention, but persistent fibroadenomas—especially “giant” fibroadenomas greater than 5 cm—may require excision. Fibroadenomas can be safely watched over several menstrual cycles. They can generally be diagnosed without imaging, and are typically rubbery, ovoid, mobile, and nontender. Needle biopsy is not warranted in adolescents. Any growth of a lesion over time is an indication for ultrasonography and surgical referral.6

A less common and more worrisome breast mass in the adolescent is the phyllodes tumor, previously called cystosarcoma phyllodes. These are stromal tumors that are usually benign, but may be malignant in the adolescent population.7 These tumors tend to occur more frequently among black women. Diagnostic imaging may be unable to distinguish this tumor from a fibroadenoma. These tumors are larger than fibroadenomas, and often appear to be fixed to the surrounding tissue. The two cannot be differentiated by imaging, so a needle biopsy is indicated. About 20% of phyllodes tumors recur locally, and 14% to 15% of these metastasize.7

Other rare, benign breast masses occurring during adolescence include hamartomas, adenomas of the nipple, tubular adenomas, erosive adenomatosis, fat necrosis from trauma, and juvenile papillomatosis. Local excision is the treatment for many of these lesions.7-11 Hemangiomas or lymphangiomas are likewise possible; rapid growth or breast bud impingement may require surgical intervention after determining the extent of the lesion with magnetic resonance imaging.12

Girls who have undergone chest irradiation have a more than 80-fold higher risk of breast cancer, and should be screened carefully using adult algorithms. The risk is also higher among children aged 10 to 16 years at the time of radiation treatment, with approximately 40% of patients developing breast cancer within 20 years. Metastases of other primary tumors may occur and should be included in the history.

Most breast masses may be observed over time, but ultrasonography is preferred if imaging is needed, as mammography in the adolescent is unreliable. Lesions requiring biopsy or surgical excision should be managed by a specialist in pediatric breast lesions.

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CONCLUSION

As benign breast conditions are common among adolescents, girls should be educated regarding pubertal changes, normal anatomic variations, and potential risks (eg, piercing). Few breast lesions require surgical intervention, but patients requiring correction or excision should be referred to a specialist.

Neither author reports any actual or potential conflicts of interest in relation to this article.

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Jennifer E. Dietrich, MD, MSc, is Assistant Professor, Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology; and Mary L. Brandt, MD, is Professor, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery; both at Baylor College of Medicine, Houston, TX.

References

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11. Williams HJ, Hejmadi RK, England DW, Bradley SA. Imaging features of breast trauma: a pictorial review. Breast. 2002; 11(2):107–115.
12. Akyüz C, Yaris, N, Kutluk MT, Büyükpamukçu M. Management of cutaneous hemangiomas: a retrospective analysis of 1109 cases and comparison of conventional dose prednisolone with high-dose methylprednisolone therapy. Pediatr Hematol Oncol. 2001;18(1):47–55.

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