Breast health

Answers to our top five breast health concerns in menopause — what women want to know

by Dixie Mills, MD, FACS

In my years as a breast specialist, women have shared nearly every possible breast health concern with me. While each patient is an individual woman with a unique health history, it struck me recently how often I hear a set of core worries about our breasts that we all seem to share as we approach menopause. Women want to know:

1. whether there are increased risks of breast cancer in menopause;
2. more about breast pain, breast cysts, breast lumps and swelling;
3. whether breast exams and mammograms are necessary anymore;
4. the effects of hormone replacement therapy on breast health; and
5. how to feel good about the appearance and feel of our breasts.

It’s completely understandable that these questions arise at menopause — a time when many women begin to see the world differently. The way we perceive our breasts is part of this transition. So many women experience a wonderful breakthrough from fear when they begin to take time to listen to themselves, and also when they start hearing other women’s stories and concerns about breast health and realize they’re not alone. Through this kind of open discussion, we often readily embrace our “new” selves. So while all changes in our bodies can be cause to pay attention, let’s begin by addressing these “top five” questions I hear about breast changes during menopause.

1) Am I more susceptible to breast cancer now that I’m in menopause?

This is the question many women ask first, because in the past, we have seen a slight increase in risk after menopause that persists as we age. But let’s all stop to breathe for a moment. There is just no single “blanket” answer that applies to every woman the same way. And while the chance of getting breast cancer does appear to increase with age when everyone is pooled together, promising research indicates that this history may be about to change: researchers are now discovering that the past increases may actually have been due mostly to exogenous estrogen exposure in pills — and, since that is now decreasing, breast cancer rates may actually be going down for post-menopausal women. (See my article on breast cancer, progestins, and natural progesterone for more details.)

This is some of the very best news I’ve heard in a long time — but it’s unlikely that the direct cause for every woman with breast cancer is purely estrogen-related. It seems that way because women get breast cancer far more often than men, causing some to worry about the levels of the hormone in our bodies. (Don’t get me wrong: cultivating hormonal balance is a superb approach to breast health in menopause!) But when the body’s hormonal balance is off, it’s essential to approach every woman’s experience holistically. Usually there is no single hormone or aspect of the body to blame: we must consider our changing estrogen, progesterone, and testosterone levels, alongside many other factors, to paint a complete picture of healthy hormonal balance.

While some risk factors are beyond our control, we can all create better breast health in menopause by getting to know our breasts (and our bodies) as well as we can. Finding a breast lump doesn’t automatically signify cancer — far from it. And being on familiar terms with your breasts to detect anything unusual early on is one of the many ways you can positively influence your breast health.

Another point I’d like to share is that postmenopausal breast cancers are usually much less aggressive than those of younger women, and often highly treatable. While I used to find it very unfortunate when any woman was diagnosed with breast cancer, whether she was 80 or 30, older women usually have more options — and less invasive options at that. Recent reports also have suggested that some breast cancers may disappear on their own, raising the possibility that we may be over diagnosing and over treating some women. But until we can distinguish who needs treatment from who really doesn’t, I’m sure most women would rather be over diagnosed than the opposite, at least for now.

2) Why are my breasts painful or extra sensitive?

Most breast pain or sensitivity is completely normal and shouldn’t persist for more than a day or two — a week at most — but it can be a very real concern for women who experience it regularly. Although breast pain is highly unlikely to be a sign of cancer, if you have any concerns, visit with your healthcare practitioner to rule this out. At this point, we don’t know enough about why breast pain happens (most likely because men do not experience breast pain, so there has been little “reason” to research it), but regular cyclical mastalgia is likely due to the changing hormones we experience with our monthly cycles. And, similar to nipple tenderness in pregnancy, increasing breast tenderness may be an early sign of perimenopause.

Breast pain can reach new heights during the perimenopause years but usually diminishes significantly once one’s periods cease. During menopause, breast pain can appear for the first time, or it can happen less, or stop altogether. Some women correlate lots of fatty foods or coffee with how much breast pain or sensitivity they feel, and what we eat truly does influence our hormonal balance. The sheer weight of the breast can cause some women increased pain.

So should you worry about this breast pain and the swelling that often accompanies it? The answer is a bit paradoxical. We’ve been taught over the years to pay attention to pain, but many women just leap to a cancer diagnosis. So again, it helps to put things in perspective. Exercise caution, but you can also stay calm with the knowledge that your body may be sending a completely different message, such as a hormonal imbalance, an increase in inflammation, or some other avenue you have not yet considered.

If you’re experiencing breast pain unrelated to menstrual cycles, it makes sense to have it checked out. A new lump that appears suddenly and is painful is most likely a fluid-filled cyst, which is common during perimenopause and can be addressed with an ultrasound or aspiration. General swelling in the breasts after menopause can indicate a fluid problem, thyroid issue, or other metabolic concern and, again, should be looked into by your healthcare provider.

3) Are breast exams and mammograms necessary after menopause?

Studies show that women who perform regular breast self-exams find the vast majority of breast masses. If you feel reluctant to practice regular self-exam for any reason, however, you’re not alone. Women can avoid breast exams for lots of reasons — sometimes because of deep-seated emotions or beliefs. When we reach menopause, women may feel annoyed or inconvenienced, as though it’s an unnecessary or distasteful procedure, and avoid examining their breasts.

I counsel women to know their breasts as well as possible — though I don’t insist, because some feel less comfortable touching their breasts, and recent studies show that while breast self-exams may find more lumps, they don’t affect cancer incidence or mortality in women whose lumps are cancerous. That said, if you don’t do a breast exam, someone should, so a visit to your practitioner at least annually for an exam is a good idea.

If you do the exam yourself, each examination will teach you more about the natural design of your breasts, and you’ll probably notice any changes in texture. I encourage women to examine their breasts once a month, and if it helps you to stay in the habit, you can do it on the same day each month. Or do it a few days or a week after each period, when breasts are less sensitive and tender.

So watching over our breasts as best we can really does begin at home — but what about mammograms? Are they necessary after we enter perimenopause? Many women believe that mammograms themselves prevent cancer, which isn’t true — the screening process is designed to detect an irregularity, but it is far from perfect, and mammograms certainly don’t stop cancer from forming. That said, mammograms tend to be easier to read in most postmenopausal women (our breasts get fattier and less dense, and therefore easier to read), so it’s vital not to neglect to do this screening test — at least until we have something better! Many breast researchers are looking for better, safer, earlier cancer detection methods. At the Dr. Susan Love Research Foundation, we are working on a nipple fluid test to determine which women are at risk for breast cancer — so we can look forward to the day when mammography becomes a thing of the past.

4) How will hormone replacement therapy or bioidentical hormones affect my breast health?

This is one of the most complex and personal issues I discuss with my patients. For years, HRT was considered the “miracle for menopause,” and doctors simply put nearly every woman on the pills. But after the risks with combination HRT were found to outweigh its benefits by the Women’s Health Initiative, millions of women were taken off synthetic HRT or stopped on their own, to protect themselves from heart disease, stroke, and breast cancer, among other health risks. Now the research and results on safety and success of HRT are widely mixed — one of the only universal factors is that it seems at best a treatment that should be highly individualized, tailored specifically to certain women and their particular menopausal needs.

And ever since many synthetic HRT treatments were abruptly halted, the controversy heightened over whether there are risks for menopausal women using bioidentical hormone therapy. I wish there were more concrete news to share with you, but at this point, the estrogens and progesterone we produce naturally in the body just have not been analyzed widely enough, and the research we do have concerning the effects of bioidentical progesterone and estrogens on the breast is also mixed and imbalanced. Over the past decade or so, European studies analyzing different hormone regimes have shown greater safety with natural progesterone, but though reassuring, these findings still need to be replicated — and delivery method, timing, and duration of use also seem critical.

Bioidentical HRT has been used with good success since it became available, and we’ve observed differences between a natural approach and synthetics. I prefer bioidentical forms to the nonbioidentical versions because natural progesterone and natural estrogens behave differently in the body when compared to their synthetic counterparts, and many women experience fewer unwanted side effects.

As a breast specialist, I favor natural treatments for my patients because it stands to reason that the particular hormone molecules naturally produced in the human body would be more bioavailable and less problematic. But this isn’t always true, so frank conversation with your healthcare practitioner regarding treatment options for your unique needs is essential for every woman. It would seem most natural to go with the body’s normal plans, which would mean decreased reproductive hormones when we’re not reproducing. But when a woman’s quality of life is severely compromised by menopausal symptoms, it doesn’t make sense to deprive her of what modern science has created, either. So until we have more information, HRT remains a personal choice.

5) Why do my breasts look so much different than they used to?

It’s astonishing how many women make the same observation to me: “I hardly recognize myself anymore.” If there is a better caption for the transformation so many of us experience with menopause, I would like to hear it!

During the menopause transition, we can experience profound changes in how we perceive ourselves on every level. Whether on a day-to-day basis or even sexually, our view of our own bodies often changes. It’s been ingrained in us that breasts need to be “perky” to be beautiful — recall those cone-shaped bras that so many of us wore in the 1950’s. Much of this has to do with our youth-obsessed culture, and changes with the wind like all fashions — in the 1920’s, it was chic to be flat-chested!

But the ideal that dictates women’s breasts should be “perky” is deeply misinformed and frankly, I think it is also quite perverse. In many cultures around the world all breasts, regardless of age or appearance, are regarded with respect and even awe at every stage of a woman’s life. The natural shape and texture of the adult female breast is far more amazing, varied, gorgeous, complex, and interesting than merely “perky” (as if the breast is supposed to be a cheerleader).

This standard of beauty fails to reflect the reality that breasts fulfill so many roles in our lives — they nurture our children, they gift us with sensory pleasure, and they can also do not much of anything! But because the breasts do change with childbirth and menopause, I spend a good deal of time in my practice talking with women about how well they know their breasts, and the ways their breasts look and feel.

Changes can feel immediate, as though we suddenly awoke one morning with a completely different pair, or changes can be slow and gradual. Many women’s breasts shrink but don’t dry up after menopause with the decrease in hormonal stimulation — and breast augmentation is rare in postmenopausal women. Other women who may gain weight over menopause tend to also add weight (or fat) to their breasts. While most breast and nipple sensitivity doesn’t change, many women find the change of shape the most distressing alteration, particularly regarding the fairly inevitable sagging or swelling in one or both breasts.

The breasts actually have no muscle — the muscle lies behind the breast, and all those arm and chest exercises can add bulk there, but not to the breasts themselves. The ligaments of the breasts have been stretched out over time, and only a good support bra — and thank heavens we have tons of them — can provide the push-up look. In fact, to view your breasts differently, there is one wonderful strategy that can genuinely change the way you look and feel: you can be fitted for a new bra. And I mean really measured and fitted, instead of stuffing ourselves into whatever’s on sale, or having a bra that’s too big, what a friend once called the “uninflated balloon” look. You can even make an afternoon of it with a couple of girlfriends and finish up with tea and dessert.

Overall, if you are unhappy with your breast appearance, it may help to remember that while the breasts may be a strong part of a woman’s identity, the degree to which our breasts change during menopause depends on many things, including our genes, our diet, and our lifestyle. The breasts are at once part of our nurturing and sexy selves, yet they’re often completely unsexy or not nurturing at all. In other words, the breast is how we define it and depends entirely on our own perceptions.

How to support your best breast health in menopause

When women are in perimenopause and menopause, hot flashes, insomnia, and mood swings all seem to outweigh what’s happening with our breasts. But because the breast is a reproductive organ, it’s responsive to changing hormones too.

It’s wise to continue periodic exams and mammograms after menopause. Combining this practice with choices that foster hormonal balance through diet, lifestyle, and natural options creates the foundation of breast health in menopause, and addresses so many other concerns as well. But let’s also not ignore that an enormous part of how well we feel physically each day is connected to our self-image and feelings of worth.

I love this quote attributed to Siddhartha Gautama, the spiritual teacher who became the Buddha: “You yourself, as much as anybody in the entire universe, deserve your love and affection.” We need not be depressed, anxious, or fearful of our changing breasts. As we become aware of all the possibilities for change in menopause, we will begin to see our beautiful changing breasts — and our beautiful selves — in a whole new light.

Our Personal Program is a great place to start

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References & further reading on top breast concerns in menopause

 

Original Publication Date: 10/05/2009
Last Modified: 10/13/2009
Principal Author: Dixie Mills, MD