Microscopy, Morphology, and the Menstrual Cycle
Histologic changes in the normal breast have been identified in relation to the endocrine variations of the menstrual cycle.48 Normal menstrual cycle–dependent histologic changes in both stroma and epithelium have been observed.

Cyclic changes in the sex steroid hormone levels during the menstrual cycle profoundly influence breast morphology. Under the influence of follicle-stimulating hormone and luteinizing hormone during the follicular phase of the menstrual cycle, increasing levels of estrogen secreted by the ovarian graafian follicles stimulate breast epithelial proliferation. During this proliferative phase, the epithelium exhibits sprouting, with increased cellular mitoses, RNA synthesis, increased nuclear density, enlargement of the nucleolus, and changes in other intercellular organelles. In particular, the Golgi apparatus, ribosomes, and mitochondria increase in size or number. During the follicular phase, at the time of maximal estrogen synthesis and secretion in midcycle, ovulation occurs. A second peak occurs in the midluteal phase, when luteal progesterone synthesis is maximal. Similarly, progestogens induce changes in the mammary epithelium during the luteal phase of the ovulatory cycles. Mammary ducts dilate, and the alveolar epithelial cells differentiate into secretory cells, with a partly monolayer arrangement. The combination of these sex steroid hormones and other hormones results in the formation of lipid droplets in the alveolar cells and some intraluminal secretion.

The changes in breast epithelium in response to hormones are mediated through either intracellular steroid receptors or membrane-bound peptide receptors. The presence of steroid receptors for estrogen and progestogens in the cytosol of normal mammary epithelium has been demonstrated. Through the binding of these hormones to specific receptors, the molecular changes, with their observed morphologic effects, are induced as physiologic changes. Similarly, membrane receptors are present to mediate the actions of prolactin. Increases in endogenous estrogen can also exert a histamine-like effect on the mammary microcirculation, resulting in an increased, maximal blood flow 3 to 4 days before menstruation, with an average increase in breast volume of 15 to 30 cm3. Premenstrual breast fullness is attributable to increasing interlobular edema and enhanced ductular-acinar proliferation under the influence of estrogens and progestogens. With the onset of menstruation, after a rapid decline in the circulating levels of sex steroid hormones, secretory activity of the epithelium egresses.

Postmenstrually, tissue edema is reduced, and regression of the epithelium ceases as a new cycle begins, with concomitant rises in estrogen levels. Minimum breast volume is observed 5 to 7 days after menstruation. The cyclic changes in breast cellular growth rates are related to hormonal variations in the follicular and luteal phases of the menstrual cycle. Measurement of these changes can be made by observation and measurement of a variety of cellular and nuclear parameters:

• Histologic pattern
• Cellular morphology
• Nuclear morphology
• Mitoses
• Tritiated thymidine uptake
• Image cytometry:
  nuclear area
  circumference
  boundary fluctuation
  chromatin granularity
  stain intensity
• Proliferation markers
  Ki-67
  PCNA
  MIB-1
  

Most observations have been made from surgical specimens, which are usually from women with breast abnormalities, or from autopsy specimens, which may have resulted in inconsistent and contradictory results.

Most studies have shown that breast epithelial cell proliferation increases in the second half (luteal phase) of the menstrual cycle.

A study of nuclear tritiated thymidine uptake in surgically excised breast tissue showed that peak uptake was during the luteal phase on days 22–24, coinciding with an increase in circulatory progesterone levels and a second peak of estrogen. The role of estrogen was considered unimportant, because the preovulatory peak of estrogen was not associated with an increase in tritiated thymidine uptake. The possibility of a synergistic action between estrogen and progesterone would therefore be unlikely.

The role of estrogen and progesterone was subsequently studied in explants of human breast tissue implanted subcutaneously in nude mice. An increase in epithelial cell growth was observed seven days after exposure to estrogen; progesterone had no effect, and a combination of estrogen and progesterone neither enhanced nor diminished the proliferative effect of estrogen. These observations may explain why proliferation increases during the luteal phase subsequent to the preovulatory estrogen peak.

M. P. Osborne: Department of Surgery, Joan and Sanford I. Weill Medical College, Cornell University
New York Presbyterian Hospital, New York, New York

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