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The down & dirty on women's wellness


Breast

What Do I Do with These Boobs?

Sifting through the confusion around breast screening, from touching your tatas to mashing your melons

October 1, 2019

Any woman who has been to the doctor lately for her wellness exam has probably left with some degree of confusion about what it is that she is supposed to do with her breasts. Screening guidelines have changed dramatically over the course of the last 20 years, so much so that even healthcare providers are struggling to keep the recommendations straight. From one visit to the next, you might be told to perform a religious monthly self-breast exam or to not examine your breasts at all. You might be told you need yearly mammograms or you might be told that a clinical breast exam is not even warranted, despite your age or your expressed concerns. There was a time during which we all hung placards in our showers to remind us how to examine our breasts. Now, we have six different organizations making recommendations about our breast health and screening, and not one of them can agree on the best approach. In the end, the recommendations all seem to come together with only one unanimous, mostly unhelpful message: know thy breasts and decide for yourself. When even the experts seem confused, it’s no wonder myths and misconceptions around breast cancer and breast health abound. Here are 10 simple, straightforward tips to manage and understand your own breast health.


1. Lies about your lingerie: Underwire bras do not cause breast cancer. Period. Scientific studies have examined risks associated with bras. None have found any increased risk associated with wearing any kind of bra. Go ahead and support those puppies however you prefer! Push them up or let them hang. Your decision to wear or not wear a bra, however it is constructed, will not impact your likelihood of developing breast cancer of any kind.


2. Buddy up with your boobs: Breast self-awareness is absolutely key to early detection of both pre-cancerous and cancerous changes. While experts now recommend against rigorous, prescriptive self-breast exams (mostly because they seemed to be increasing anxiety without a corresponding or proportionate increase in the detection of disease), it is extremely important that you know what is normal for you. No two boobs and no two sets of boobs are the same. Your right breast might have more lumps than your left. Your left breast may have a nipple that sticks out further than the right. The most important thing is that your breasts feel and look fairly consistent FOR YOU over time. There will be fluctuations in the nature of your breast tissue throughout the month, as your hormonal levels naturally ebb and flow, causing the tissue to expand and contract, but there should not be new lumps, painful spots, or changes in your skin texture or appearance over the course of that month. If you become extremely familiar with what your own breasts feel and look like, over time and throughout each month, and you know which changes are normal for you as a result of differing hormonal levels, you will be able to tell when a change is not normal for you. The more you feel and look at your own boobs, the more you will understand them, and the more likely you are to notice when something concerning occurs. When you notice a change or have a concern, you should always tell your provider, who should ALWAYS do an exam in response to your concern.


3. Your lovely (lumpy) lady lumps: The problem with breast self-examination that arose was that women were examining their breasts and finding all kinds of lumps and bumps and nodules and “stuff”. Breasts are actually extremely lumpy things. If you perform a breast self-exam, chances are you’ll find a lump. And, if you find a lump, chances are you’ll worry it’s cancer. And, if you worry it’s cancer, chances are you’ll google your findings. And, if you google your findings, chances are the interweb will tell you that you definitely have cancer. And, if you do all this before you schedule your appointment with your provider, chances are you’ll be pretty worked up and nervous by the time you are actually seen by your provider. The reality is, though, that any concerning lump (that is, any lump that concerns you) a woman finds is not to be dismissed as “hysteria” or “anxiety.” If you find something that concerns you, you should be evaluated. Period. The end. The other reality, however, is that most of the things that you find (and you will find things) will NOT be cancer. Most breast lumps are benign (non-cancerous), but there are many changes that, while benign, DO increase your risk for developing breast cancer and do require increased monitoring to ensure stability. SO: if you follow #2 well & you know your boobs as well as you possibly can, you will know when something changes and you will be able to tell the difference between a lump that has always been there and a lump that is new or different.


4. Armpits are as important as tits: Your armpits and ribcages and shoulders and chest wall are actually parts of your boobs. They don’t sell cars very well, but they are part of the same organ, which means that getting to know your boobs also means getting to know these parts and pieces of your body as well. Lumps in armpits, down the sides of your ribcage, in your shoulders, or around your collar bones are NOT normal things and should always prompt you to call your provider for evaluation. As a side note, anti-perspirant itself does not cause breast cancer. Some myths exist that suggest that limiting your armpit sweat causes toxic build-up in the adjacent breast which can cause cancer. Your armpit sweat does not drain toxins from your breasts, and preventing your armpits from sweating will not increase the amount of toxins in your breast tissue. It will prevent you from smelling bad. There are, however, some concerns about some chemicals that are in some anti-perspirant (and many other personal care products) that may increase your risk for developing not just breast cancer but all kinds of cancer.


5. Toxins for the twins: We live in a world in which we now have all sorts of lovely and readily available products to help us live our lives beautifully, cleanly, and conveniently. From the plastic lining in the tin can that makes it easier for you to get the food out of it to the sunscreen you apply to PREVENT cancer, many products that women are exposed to on a regular, daily basis contain chemicals that are considered “endocrine-disruptors.” Endocrine disruptors are substances that mimic or block the activity of naturally occurring hormones in the body, which can jack up your own hormonal balance. Because hormonal disruption can make hormone-receptor-positive breast cancer grow and develop, it is prudent to try to limit exposure as much as possible to these problematic compounds, which are found in cosmetics, personal care products, pesticides, drinking water, lawn and garden chemicals, plastics of all variety, and some foods. This is enough to make anyone panicky or create complacency, since exposure seems practically unavoidable. Some of our exposure truly is out of our control, but much of our exposure can be modified by the choices that we regularly make. The Environmental Working Group is an American collective that creates databases of safe and concerning chemicals and products. They have a great website (ewg.org) that ranks brands from most concerning to least concerning to help you make decisions about limiting exposures. Alcohol is also a toxin. Sorry, ladies, but your evening nightcap also increases your risk of getting breast cancer. Compared to women who don’t drink at all, women who drink 3 alcoholic beverages a week have a 15% increase in their chance of getting breast cancer. For each additional drink per day, the risk increases another 10%. That said, you needn’t always forego wine or shun the occasional glass of champagne. Just know that moderation is crucial to limiting your overall risk. Other toxic exposures that are especially bad for the boobs include radiation and chemicals you may have been exposed to when you were a fetus. These are things that we can’t always modify, BUT, if you do have a known history of exposure, it is important to communicate it to your provider, who should individually tailor your screening plan.


6. Cigarettes actually are the devil: Just don’t smoke. If you do smoke, talk to your provider about getting help quitting. Vaping is NOT safer than smoking. Cigarettes are actually poison sticks. And e-cig/vaping juice is actually liquid poison. We know a lot about what cigarettes do to the bellows in our chests. We know cigarettes cause a whole host of lung-related diseases, including cancer. And we are learning more and more about the harms associated with vaping, including lung conditions that are potentially MORE problematic. We think very little about the impact of these activities on the crown jewels of our chests. We know, though, that smoking cigarettes is linked to a higher risk of breast cancer in younger, premenopausal women. Research also has shown that there may be link between second-hand smoke exposure and breast cancer risk in postmenopausal women. Moreover, if you do get breast cancer, smoking makes it harder to treat and harder for a woman’s body to heal. Just say no.


7. Jump Rope for Jugs: I am going to preach it until you can’t stand to hear it anymore. Exercise decreases a woman’s chance of dying from ALL CAUSES, including breast cancer. BUT, regular exercise also decreases the likelihood that a woman will develop breast cancer in the first place. Not only does exercise help prevent other conditions that would make treating and beating breast cancer harder, but exercise consumes and controls blood sugar and limits blood levels of insulin growth factor, which is a hormone that can affect how breast cells grow and behave. Additionally, women who regularly exercise tend to have lower body weights and less excess fat than women who don’t exercise. Fat cells create estrogen in the body and extra fat makes extra estrogen, which increases the risk of various female-specific cancers, including uterine, ovarian and breast cancers. Weight loss itself is a complicated creature, and many women need assistance with weight loss because their weight gain is the result of a medical condition, but, regardless of one’s ability to actually LOSE measurable pounds, time on the treadmill, laps in the pool, or a regular biceps curl will not only benefit your heart and potentially your waistline but will also protect your breasts.


8. The horror of hormones: Just being a woman increases your risk for breast cancer. Read that again. Women are 99% more likely than men to get breast cancer. Being biologically female causes breast cancer. The reason this is true is entirely because of hormonal differences in women and men, and they are the hormonal differences that make women need bras while (most) men don’t. Women’s breast cells are highly active and immature until they have their first full-term pregnancy. While they are immature, breast cells are extremely responsive to estrogen and other hormones as well as to all potential endocrine disruptors to which they are exposed. The earlier a girl begins to experience breast development, the longer her breast cells are susceptible to the effects of these hormones and hormonal disruptors. The later a woman stops having periods, the longer her breast cells are susceptible to the effects of her own hormones as well as hormonal disruptors. Taking combined hormone replacement therapy after or during menopause increases breast cancer risk significantly, but it seems not to be the estrogen (surprisingly) that is responsible for this increase. Rather, the progesterone component of the hormonal preparations seems to be the factor that increases risk significantly. For many women, combined hormonal replacement therapy is still safer than estrogen-therapy alone, but the exposure does increase overall risk of developing breast cancer, simply because of the effect those hormones have on the breast cells. Hormonal preparations of all kinds should be discussed from a risk/benefit perspective with your provider.


9. Mama’s milk factory: When a woman becomes pregnant, her breasts start to change dramatically. When breast cells are made during puberty, those cells remain immature and incredibly active until a woman’s first full-term pregnancy. The immature cells are extremely susceptible to the effects of the hormones in her body as well as to exposure to hormone-disrupting chemicals in products or the environment. Full-term pregnancy makes breast cells fully mature & renders them less vulnerable to the effects of hormones. Pregnancy, therefore, protects women against developing breast cancer. Being pregnant also reduces the exposure to overall menstrual hormonal fluctuations, which is also protective against breast cancer. Once a baby is born, breastfeeding dramatically decreases a woman’s breast cancer risk. This is because the hormonal environment required to produce breast milk is very different from the hormonal environment that exists when a woman isn’t making breast milk. Producing breast milk has a protective effect on the breast cells, causing them to be less susceptible to hormonal disruption, and breastfeeding a baby also causes women to avoid many of the toxins mentioned above, which provides additional protection against the development of cancer.


10. Lighten up: As a society, we spend more time inside, out of direct sunlight and we wear more sunscreen to prevent skin cancer. As a result, we have lower population levels of Vitamin D. Vitamin D we think of as a vitamin, but it is actually a hormone in our bodies. Research suggests that women with lower levels of vitamin D have a higher risk of breast cancer. Vitamin D may play a role in controlling normal breast cell growth and may be able to stop breast cancer cells from growing. The two most reliable ways to boost your levels of vitamin D are to get more exposure to direct sunlight and to take Vitamin D3 supplements. I am not suggesting you go tanning or expose yourself to sunlight for prolonged periods of time. Even short periods of direct peak sun exposure -- 15 minutes 3 times a week, for example -- can give you more than the recommended daily amount of vitamin D. It's also impossible to overdose on vitamin D from the sun. The flip side of light exposure for breast cancer risk is that women who are exposed to light during the night (for instance, women who work night shift, or women who sleep with the television on or have another source of artificial light invading their sleeping space at night) are more likely to develop breast cancer than women who sleep during the night and do so in a dark space. Researchers think that this increase in risk is linked to melatonin levels. Melatonin is a hormone that plays a role in regulating the body's sleep cycle. Melatonin production peaks at night and is lower during the day when your eyes register light exposure. When women work at night or if they're exposed to external light at night, their melatonin levels tend to stay low. There is not enough research that has been conducted yet on the use of melatonin supplements to suggest that this would mitigate the risk. Stay tuned, but in the meantime try to get a little natural sunshine exposure during the day and try to limit your exposure to light at night.


The issue of screening is complicated. As with any condition I treat, I like to have the existing evidence and use it as a guide, but I do not like to be beholden to recommendations that may or may not be applicable to any individual woman or any individual circumstance. I do strongly believe that well-trained clinicians who have had specific training in breast health and care (not the training that is offered in standard, general medical school and not the cursory training on breast health that is applicable to most practitioners providing women’s primary care) perform useful and indispensable examinations of the breasts, and I do strongly believe that these examinations are not a waste of time, as is suggested by some organizations’ screening guidelines. Because I am confident in my ability to detect abnormalities and discern a concerning lump from something that might be a normal physiologic variant, and because I have found breast cancer in women’s breasts, I will never stop performing clinical breast exams at least annually on my patients. Nor will I ever dismiss a concern that a woman brings to me about changes she has noticed in her own breasts. The issue of imaging is more complex and requires a discussion about individual risk profiles and modes of detection. Just as no two breasts are the same, no two women’s screening approach should look the same. Women with dense breast tissue need different screening approaches. How would you know if you have dense breast tissue? You wouldn’t. This is a relative term. A provider who is an expert in examining breasts would be able to determine the density of your breasts as compared to the average breast and direct you from there. The long and the short of screening is this: knowing your own breasts and regularly assessing them is crucial, seeing a skilled provider and having a regular assessment with her is key to detection and determining the best direction for further assessment and management, and crafting an imaging protocol that is specific to you and your personal risks is paramount.