By lying down, the breast tissue being palpated should be evenly distributed over the chest wall, providing a firm surface for examination. There are a number of positions to use to accomplish this. Most women will probably need to be in two positions:
- Supine position with your right hand (when examining right breast) under the pillow (if pillow is available) and upper arm at a right angle to the torso. This position is used when examining from the chest center/sternum to the nipple.
- The position that can be used to examine from the nipple to the armpit is the Cahan position (side-lying position). For this position, you need to lie on your side opposite the breast being examined. Then open the arm and shoulder on the side being examined towards the exam table, bring your arm up, with the back of your hand resting on your forehead. The doctor may position a pillow, or folded towels, under your arm and shoulder to assist in comfort and help distribute the breast tissue. The benefit of having the hand on the forehead is that the pectoral muscles are more relaxed than if hand is over the head.
The pattern that is most effective is the vertical strips pattern (also called lawnmower technique). Research has shown this pattern to give more thorough coverage over the concentric circles and radial spokes patterns. This involves examining in long, straight, vertical strips, going up and down between the clavicle and the bra line. To examine all breast tissue, rows should be overlapping with the doctor palpating towards themselves. One generally has better control over hand movement when working towards self.
The doctor palpates from the sternum to the nipple with you in the supine position (the nipple is a clear marker as a place to stop and begin again - this should also be palpated).
You are asked to turn on your side in the Cahan position (as previously described). The doctor palpates from the nipple to the axilla, continuing in the vertical strips pattern. The order would also be reversed when doing your self breast exam, so that you should palpate toward the center of your body. (1) Turn on side into Cahan position (or use pillows if this is too uncomfortable), (2) palpate in the vertical strips pattern from axilla to nipple, (3) lie in the supine position and (4) palpate from nipple to sternum.
This part of the exams continues using the same methods as with all palpation of breast tissue: pads of 2-3 fingers, dime-size circular motions, 3 degrees of pressure, fingers should maintain contact with surface, and proper spacing.
If you have complained of nipple discharge, or if it is noted in the examination, the doctor may attempt to locate the source of the discharge in this position by first palpating the aureola, applying pressure against the nipple with their finger, then stripping the quadrants (4 sections of the breast upper right & left, lower right & left), moving in towards the nipple.
That concludes the breast exam. At this point, the doctor should discuss with you the date of your next self breast exam and your next clinical breast exam.