Women's Bodies, Women's Wisdom (73 page)

Breast Cysts

Breasts are very sensitive to hormonal changes, and nonmalignant lumps or thickenings often go away over time. But it is a standard med ical recommendation that you tell your health care practitioner immediately about any lump you find. You want to know if the lump is a cyst. Breast cysts are very common in women in their forties when their hormone levels are changing. Breast cysts, which are fluid-filled, are di agnosed by placing a needle in them under local anesthetic and aspirating the contents. Sometimes a physician cannot tell a solid lump from a cyst on examination, so ultrasound is needed to make the distinction. If the lump is a cyst, its contents, usually yellow or greenish brown fluid, can be aspirated. Most experts feel that cyst fluid can be dis carded because it is rarely helpful to analyze it. The cyst will disappear following aspiration in most cases and no further treatment is required. If there’s any suspicion, however, the aspirated cells should be tested for cancer. If the ultrasound clearly shows a simple cyst and the woman does not want a needle stuck into her breast, the cyst can be watched. Many women track their cycles and stress levels by their cysts. When a cyst gets too painful or too large or sticks out, then she can go in and get it aspirated. Most cysts disappear with menopause.

If a lump is
not
clearly a cyst, the patient should be referred to a general surgeon with an interest in breast problems or to a comprehensive breast care center. I feel strongly that women should get the best med ical opinions possible about their situation before they embark on any treatment for a breast problem. In women younger than thirty-five (with some exceptions), a breast mass can be watched for several menstrual cycles to see if it goes away.

TREATMENT FOR BENIGN BREAST SYMPTOMS

The vast majority of women have breast pain from time to time. Breast pain (also known as mastalgia or mastodynia) is the number one reason why women visit clinics specializing in breast care and is present in 45 percent of the women who visit these clinics. But it’s so com mon that almost all general physicians see women with this problem. Unfortunately, like so many other women’s health issues, breast pain too often has been viewed by the medical profession as a neurotic all-in-her-head kind of disease, and so it hasn’t received the attention and care that it deserves. But every one of us knows that pain is a sign of imbalance somewhere in our lives. And breast pain is no exception.

The burning question that most women with breast pain want answered right away is this: “Is my pain a sign of cancer?” The an swer to this is almost always no. But there are a few cases in which the answer is yes. One study showed that breast pain alone is a symptom in only 7 percent of women who had early-stage breast cancer, and another 8 percent presented with both pain and a lump. Another retrospective study suggested an increased risk for breast cancer in women who have had a history of chronic cyclic breast pain compared with those who did not.
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Since breast cancer is multifactoral and we can identify only 20 to 30 percent of the known risk factors for this disease, it is clear that more and different kinds of studies are needed to fully address this issue. I’m going to assume that if you have significant breast pain, you have been to a health care practitioner, received a thorough breast exam, and have had a normal mammogram or sonogram if indicated. My own experience with seeing hundreds of women with breast pain over the years is that the link between breast pain and breast cancer is very low. In fact, in one study of women with breast pain in whom no breast cancer was found on routine screening exams, less than 1 percent (0.5 percent, to be exact) actually went on to develop subsequent breast cancer at some point in the future.
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What Causes Breast Pain?

To get relief from your breast pain, you first have to understand why it may be there. There is no doubt that the most common type of breast pain occurs premenstrually and is related to the hormonal changes in your body that are part of your menstrual cycle. In the luteal phase of your cycle (the two weeks before your period begins), all women have an increased tendency to retain fluid and to gain a pound or two. But in susceptible women, this slight fluid increase, as well as other hormonal changes associated with the menstrual cycle, can cause pressure or inflammation in the breast tissue, resulting in breast tender ness. The same inflammatory chemicals such as prostaglandins and cy tokines that cause menstrual cramps can also cause breast tenderness. Your breast tissue actually goes through cyclic changes each month that mirror those that are happening in your uterus. The difference is that the buildup of fluids and tissue in your uterus passes out of your body in the form of your menstrual flow. But the buildup of fluid and cellular tissue in your breasts simply gets reabsorbed back into your body. So it’s not difficult to see how pain might result in many women, particularly if their iodine intake is too low or if they are eating a diet that favors cellular inflammation (see my Program to Promote Healthy Breast Tissue, page 352). These cyclic hormonal changes also explain why women are so often offered a variety of hormonal therapies for their breast complaints—which I’ll address in a minute.

Some women experience breast pain that is not related to the men strual cycle at all. No one knows what causes this. Some sources think it is related to inflammation in the body, whereas others think it is related to neuroen-docrine changes resulting from subtle interactions between our environment, our perceptions, and our hormonal and immune systems (breast pain has been linked to alterations in steroid and protein hormones, including estrogen, progesterone, LHRF [luteinizing hormone releasing factor, made by the hypothalamus], and prolactin). The key to pain relief is following an inflammation-reducing diet and supplementation program, including iodine, and at the same time acknowledging and then releasing the various emotional states, including trauma, depression, anxiety, and learned helplessness, that have been shown to alter the body’s immune and hormonal systems.
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Discovering the Messages Behind the Symptoms

Sometimes a woman’s breast pain persists until she addresses a deeper cultural wounding. One of my patients got over her breast pain only after she remembered that at the age of five she had been playing in a barn and some boys forced her to pose nude for them. She remembered that her chest was a major focus of this activity. After her breasts grew at puberty, her emotional and psychological discomfort at this kind of attention became chronic and eventually manifested as physical pain.

A forty-seven-year-old woman told me that when her daughter turned thirteen and became quite independent from her, she became acutely conscious of her breasts for a while. She said that they ached at times, as though they were longing to nourish or cradle a baby. She hadn’t given birth to her daughter but had adopted her. She said, “Heading into menopause, I remembered that I never beheld her infant face, nor did she drink from my breast. I experienced an intense desire to hold a baby for as long as I needed to. Several months later, a thick ening in my left breast was found during my routine annual exam. It was near my heart. I knew what it was about. I needed to deal with renewed feelings about my infertility and its losses. I felt intense sadness over not giving birth to this wonderful child of mine. Now for the first time, my body was letting me know that it, too, was sorry.” Two months after she had this realization, her breast thickening was gone at her follow-up exam. Sometimes the body heals simply when you give your self permission to listen to its messages.

Breast Biopsy

Any persistent mass requires further testing for definitive diagnosis, most often (but not always) in the form of a biopsy of some kind. High-resolution ultrasound has decreased the number of biopsies required. Most breast biopsies are done on an outpatient basis under local anes thesia by a general surgeon with a special interest in breast care. A needle biopsy can be done in an office setting under ultrasound or mammographic guidance, thus saving the patient from disfiguring lumpectomy for benign lumps and giving her a diagnosis quickly. In fact, in some breast care centers, diagnosis can be made vir tually the same day as the needle biopsy. Sometimes, however, the diagnosis must wait for several days until the pathologist can perform further diagnostic tests on the breast tissue. Many women worry that the needle will spread the cancer. Yet years of experience haven’t borne this out. Dr. Mills has seen only two cases of this in twenty years, and those were of a rare variant of breast cancer.

One of the most unpleasant experiences a woman can have is living with the uncertainty about whether a breast lump is cancerous. Happily, there are better options than waiting and worrying, and I’ll cover them later in this chapter.

MAMMOGRAPHY

Mammograms: The Limitations of a Gold Standard

A mammogram is an X-ray study of the breasts used to diagnose breast cancer in its earliest stages, before it can be felt on clinical exam. It has long been considered the gold standard for early detection of breast cancer (and the perception of a greater chance of cure). Fear of breast cancer is many women’s number one fear. A 1995 Gallup poll found that 40 percent of women believe they will die of breast cancer, even though the actual risk of death from the disease is less than 4 percent. So women and doctors historically have clung to mammograms and early detection as though they were lifelines.

But in November 2009, the United States Preventive Services Task Force (an influential government-appointed group giving guidance to doctors, insurance companies, and policy makers) made headlines when it reversed its long-standing advice and released new guidelines recommending that most women start regular breast cancer screening at age fifty (instead of forty, as previously suggested).
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The guidelines also recommended that women between the ages of fifty and seventy-four have mammograms only every two years. The guidelines did not recommend routine screening for women older than seventy-four at this time because the risks and benefits remain unknown. (These new guidelines did not apply to women at high risk for breast cancer because of a gene mutation that makes breast cancer more likely or because of previous extensive exposure to radiation.)

The task force concluded that the risks associated with mammograms for women in their forties (including a 60 percent greater chance of getting a false-positive result thanks to denser breast tissue, even though they are less likely to have breast cancer) outweigh the benefits (a 15 percent reduction in breast cancer mortality).
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These risks have long been reported in the literature. For example, as far back as 2000 and 2001, Danish researchers Ole Olsen and Peter Gotzsche published two stud ies in the
Lancet
of their reviews of seven randomized controlled stud ies on the benefits of mammography in reducing mortality from breast cancer. They found that five of the seven studies were so flawed they couldn’t even be reviewed. In the remaining two, they also found major design flaws and limitations. They concluded that mammograms had no effect on deaths attributed to breast cancer. The studies also showed that mammograms often led to needless treatments and were linked to a 20 percent increase in mastectomies, many of which were unnecessary.
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Almost all cancer screening modalities (except functional ones such as thermography) identify the slow-growing lesions that women would die “with,” not “from.” In other words, they would never become life-threatening if left alone. An intriguing and important study published in the November 2008 edition of
Archives of Internal Medicine
suggests that some breast cancers will indeed go into remission without any treatment.
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This study followed more than 200,000 Norwegian women between the ages of fifty and sixty-four over two consecutive six-year periods. Half of the women received regular, periodic breast exams or regular mammograms; the rest had no regular breast cancer screenings. Researchers found that the women who received regular screenings had 22 percent more incidents of breast cancer. The researchers concluded that the women who didn’t have regular breast cancer screenings probably had the same number of occurrences of breast cancer, but that their bodies had somehow naturally resolved those abnormalities without intervention. Other doctors unrelated to the study analyzed the data and concurred that this conclusion makes sense.

People believe that it takes a miracle for cancers to disappear, but this happens more often than you might think. In fact, the American Cancer Society, long a vocal advocate for early diagnosis through screening, has now shifted its position and is quietly working to make its message more realistic, admitting that the value of early detection, especially for breast (and prostate) screening, has been overstated. For example, it is estimated that for every one hundred women who are told they have breast cancer, as many as thirty have cancers that are so slow-growing that they are unlikely to be life-threatening.
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Addressing this issue, Barnett S. Kramer, M.D., associate director for disease prevention at the National Institutes of Health, said this: “The health professions have played a role in oversimplifying and creating the stage for confusion. It’s important to be clear to the public about what we know and be honest about what we don’t know.”
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Still, for the moment, major medical organizations such as the American Cancer Society and the American College of Obstetricians and Gynecologists continue to support the regular use of mammography for women starting in their forties. The American College of Radiology was so opposed to the change that it even went so far as to ask the task force to reverse its recommendation. Some medical groups, however, including the National Cancer Institute, announced they would reevaluate their guidelines. This dichotomy isn’t difficult to understand. Both inside and outside medicine, we as a culture have come to rely on screening to save us. And even though the evidence doesn’t support it, individual women and their doctors often feel safer if they perceive that they’ve “covered all the bases.”