There’s little that scares women more than finding a breast lump — especially if you know you’re at risk for breast cancer because of family history or for other reasons. But if it happens to you, the first thing to do is take a deep breath (and then another, and then another if you need to) and try to stay calm, because that lump doesn’t necessarily mean what you think it does.

So what does that lump mean? There are lots of possibilities.

Know your breasts

The first thing to know is that almost every woman has some lumpiness in her breasts, most of which is normal fatty or fibrocystic breast tissue. That’s one of the reasons breast cancer advocacy groups have encouraged women to practice breast self examinations on a regular basis — so you know the “landscape” of your breasts and can better identify a lump that develops unexpectedly.

If you haven’t yet gone through menopause, the “regular” part of that recommendation is even more important, because your breasts (and their lumpiness) are likely to change just before you menstruate. Knowing what “PMS breasts” feel like versus how they feel just after your period is important, too. (Not to mention — when checking your breasts, be sure to check all the way into your armpits, as your breast tissue can extend there.)

So if you’ve never spent much time doing breast self exams before, and you try it and find a lump or multiple lumps, don’t panic. Take some time to get to know where the lumps are. Explore them and think about these questions:

• Do they feel hard, rubbery, or squishy?
• Is there just one, or are there multiple lumps?
• Are they painful
• Do they come and go or change over time?
• Do they change based on where you are in your menstrual cycle, if you’re pre- or perimenopausal?
• Does the skin of your breast look normal?

Most of the time, the lumps are benign fibrous tissue or cysts and nothing to worry about, but keep up your breast exams so you have a sense of what is normal to you.

If you already have that familiarity, though, and you find something that feels different or unfamiliar when you’re examining your breasts — or even if your gut just tells you “this is not right” — it’s important not to ignore it.

What to do about a suspicious breast lump

If you find a lump that has you worried, make an appointment with your healthcare provider as soon as possible to obtain an ultrasound and/or a mammogram. Most healthcare providers will try to accommodate you quickly, particularly if you have familial risk factors or, in the case of women over 40, if you have not yet had your first mammogram screening. An ultrasound will show whether the lump is filled with fluid (a cyst), is solid (possible tumor but not necessarily cancerous) or just fibrous breast tissue. Mammograms also may be helpful but aren’t as useful in women under 40, whose denser breast tissue makes spotting abnormalities difficult.

If you do not have a regular healthcare provider or lack insurance, you can still get breast screening via the National Breast and Cervical Cancer Early Detection Program, which provides low-cost or free screenings for women without health insurance.

Your next steps depend on what the imaging shows. If you have an ultrasound and the lump is identified as a cyst, there’s not much to worry about — but make note of the cyst’s location so you can be aware that it’s there for future breast exams. An ultrasound showing a solid or “questionable” mass means you should see a provider specializing in breast health, who can (if necessary) take a biopsy sample via a fine needle aspiration (or core needle aspiration). Examining the tissue cells under a microscope allows the pathologist to identify or rule out whether cancer is present, usually within 24-48 hours of the biopsy.

A breast lump that is found to be benign doesn’t have to be removed — unless you want it to be. It is up to you whether a needle biopsy or an excisional biopsy (surgical removal and examination of the entire lump) is the way to go. This is something that you and your healthcare provider should discuss.

What if the findings are abnormal?

If the pathologist looks at your biopsy sample and finds abnormal cells, your healthcare provider will be told what was found and will meet with you to pass on that information. Understand that “abnormal” doesn’t always mean “cancer,” but there are certain abnormal cells that may mean you need further investigation — that is, the tissue mass may need to be surgically removed (if it wasn’t already) so the pathologist can get a better look.

If the pathologist’s report shows that cancer cells were found, it will also tell your healthcare provider specific details of what kind of cancer was found and whether it responds to certain hormones or has certain genetic characteristics. This information will help your practitioner to identify treatment strategies that will work best to treat the cancer. Some common cancers are easily treated with surgery, chemotherapy, immunotherapy or radiation therapy and have a high cure rate. Other, more aggressive cancers can be more complicated, but may have targeted therapies that will help fight them.

Your healthcare provider will explain the options to you. Don’t be afraid to ask questions about anything you don’t understand, or to ask for a second opinion if you’re unsure about your diagnosis.

Take care of yourself

Finding a lump can be frightening. Your first priority is to take care of yourself — which means more than just “go see a doctor.” If you have women friends or relatives who have been through this, talk to them! Even if the lump proves to be benign, having supportive people around you can make a difficult time easier and less stressful. There are many, many resources that can help you if your lump turns out to be cancerous, so don’t feel you have to go it alone.

Resources:

• American Cancer Society: Breast cancer early detection and diagnosis.
• BreastCancer.org: Where to get a mammogram.
• Mayo Clinic: Breast Biopsy: What you can expect.

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When a woman who isn’t nursing a baby notes fluid seeping from her nipple it can be very distressing. But nipple discharge is actually quite common — it just isn’t talked about much. Many women become anxious and worried about fluid coming from their nipples. Some are curious about it, others are completely freaked out about it, and some are just plain disgusted! Fortunately, nipple secretion is benign the vast majority of the time. Even so, it’s important to distinguish the rare situation in which further evaluation may be needed, since so many different things can cause nipple discharge and problems stemming from it can usually be treated most effectively when detected early. Let’s take a closer look at the breast to learn more about what causes nipple discharge and when you should seek evaluation.

Anatomy of a nipple

The word nipple is a derivative of an obsolete German word meaning meaning “small protuberance” and, like breasts, nipples come in all shapes and sizes. Nipples develop in mammalian embryos in a line extending from the armpit to the groin. In human fetuses most of these nipples disappear by the end of nine months’ gestation. But people who are born with third nipples — typically located beneath the breast on the ribcage — are not altogether uncommon. In fact, that Napoleon was said to have one.

Although the function of our nipples is to provide milk for our babies, men also have nipples because all embryos start out as proto-female by default until about six weeks’ gestation when, because males have a Y chromosome, testosterone kicks in and creates the male brain and genitalia but leaves a pair of nipples. And truth be told, women do not have a monopoly on breast issues: men can get breast pain and swelling (called gynecomastia); breast cancer, though rarely; and more rarely still, males have been reported to lactate under certain circumstances!

The nipple itself is a fascinating anatomical device created to deliver the milk made in our breasts to nourish our offspring. It is designed to be easily latched onto by the day-old mouth, to suckle and, almost like a watering can, provide essential nutrients. Nipple tissue is quite sensitive with a robust supply of nerves, which is why they can be an erotic zone for many women. Many women say they know they are pregnant when their nipples become more sensitive.

The darker circle of skin surrounding the nipple is called the areola. They, too, come in all colors and sizes, but I think it serves as the perfect target for a newborn baby’s eyes. The areola darkens with pregnancy — all the better for baby to see the bullseye! Newborns will sometimes have discharge from their nipples, as well, due to high levels of hormones crossing the placenta before birth. This neonatal milk has been called “witch’s milk,” and will most often resolve itself within a couple of weeks.

The nipple itself has about 20 microscopic openings called pores. Recent work by Susan Love, MD and colleagues has investigated where these openings go. They found that only about five to eight of them lead to true ductal systems — the pipelines and branches to the lobules in the breast that convert blood and other fluids into milk. The others seem to be short blind tubes that may secrete sweat-like substances or have some other as-yet undefined function. Each of the ducts within the breast has a small sphincter right under the opening which prevents substances from freely entering or leaving the breast.

A human female’s breasts are unique among mammals, having multiple ducts in one breast — other mammals such as rodents or cats and dogs have only one duct per teat. Even other primates have smaller breasts which do not develop as much after puberty or childbirth. The significance of this is unclear.

Immediately after delivering a baby, a woman’s estrogen and progesterone levels fall, signaling the hormones prolactin and oxytocin to begin producing milk. The entire miracle of milk production is a remarkable, carefully orchestrated interaction of multiple hormones. Women who choose to nurse and those who have tried know that the process can be quite amazing – and at times frustrating.

What causes nipple discharge?

There are many different causes of nipple discharge. Discharge from both nipples when a woman is not nursing is usually a physiological or a normal system response to something not quite right or different going on in the body. It is known as galactorrhea when it looks like milk but is not associated with childbirth or the nursing of an infant. (The term galaxy was actually derived from the Greek word for milk — galaktos — think Milky Way!).

Nipple discharge can be relatively common during perimenopause, when a woman’s hormones are in a state of transition. No one knows exactly what, why, and where the fluid comes from. Some people think of it as just a stagnant pool which, for unclear reasons sometimes decides to erupt spontaneously from the nipple. Obviously there is something more to it than that.

We do know more about the breast as it prepares milk for breastfeeding our offspring. We know that many food compounds, caffeine, nicotine, and now even pesticides can be found in breast milk. Any mother who has breastfed will have some story to tell about something she ate that affected her baby. But we don’t know if substances can be transferred from the blood into the ducts when a woman isn’t lactating. Hopefully these questions and others regarding nipple discharge will be studied soon.

We also know that repetitive squeezing can cause perpetuation of the discharge. Some methods of breast self-examination have women squeeze their nipples, but this action is now discouraged by most breast specialists. Studies have found that over half of women — by some estimates up to 85% — can elicit some fluid from their nipples and that it is not abnormal. This nonspontaneous discharge is also nearly always benign.

Benign breast discharge can also be caused by many drugs, such as birth control pills, hormone replacement therapy (HRT), and certain anti-anxiety medications (see table). There is also an undefined neuropsychological component which is probably related to the release of hormones such as cortisol and oxytocin. From time to time in “empty-nest” mothers and women who have newly become grandmothers will see this — especially if for some reason they have little opportunity to spend time with their new grandchildren.

What should you do about breast discharge?

Nipple discharge should always be brought to the attention of your health care practitioner so he or she can determine whether further evaluation and treatment are needed. If you and your provider can see that the discharge is coming from both nipples and out of more than one opening you shouldn’t worry. If you stop squeezing it should go away on its own in a few months.

If the fluid looks like milk and comes out pretty freely you should probably have your prolactin level checked. This can help rule out problems such as a pituitary tumor called a prolactinoma. If the test is positive, the next step is an MRI of the brain to confirm this small, benign tumor which secretes too much prolactin and causes the discharge. These tumors can be watched or you can take a medication — rarely are they removed. You should also see an endocrinologist and a neurosurgeon for treatment of these rare tumors.

There are other causes of galactorrhea, and we’ve compiled a table of some of the more and less common sources of breast discharge. Another simple blood test that should be checked is a thyroid level — thyroid imbalances can also affect the breast either with breast pain or breast discharge.

Nipple discharge and breast cancer

Women and their doctors are naturally quite fearful of breast cancer. Everyone knows someone who has had breast cancer, and everyone wants to diagnose this disease as early as possible whenever it’s present. Unfortunately, breast cancer has few early symptoms. When anything out of the ordinary occurs in the breast such as pain, itching, or discharge, women naturally worry that it may be a sign of cancer. Fortunately or not, discharge is rarely a sign of breast cancer — probably less than 2% of all nipple discharges are related to cancer. There are a few exceptions, however and women should be aware of them. The following list includes the types of discharge that should definitely be looked into, although the majority of these cases will turn out to be benign:

• When discharge is spontaneous (occurs without manipulation)
• When the discharge is from only one opening in one nipple
• When the discharge has a sticky, clear consistency
• When the discharge occurs in a woman over age 60 who is not on hormones
• When the discharge is bloody
• When there is a lump or other abnormal finding on a mammogram

Under any of the above conditions, women should be referred to a breast specialist who can evaluate the condition in more detail by taking a detailed history, including a family history; reviewing medications; performing an extended breast exam; and ordering additional tests if needed.

Testing nipple discharge

Every breast specialist has a slightly different algorithm for working up abnormal or pathological breast discharge. Some may start with a smear of the discharge. This is an easy test to do, and it is comforting to the woman to know that something is being done right then and there. If the result shows some atypical cells, something further should be done — usually a surgical biopsy — sooner rather than later. If the smear is read by a cytologist as benign (hopefully at a center which does a lot of them), other less invasive tests can be done.

An ultrasound (again, at a center which does a lot of them) can identify a dilated duct and even a small growth within the duct.

A ductogram (again, hopefully performed by an experienced radiologist) can identify a filling defect or blockage in the duct, such as a papilloma (a small, benign wart-like growth). During a ductogram, a very small catheter is inserted into the opening that is emitting the discharge, a small amount of dye is injected, and then a mammogram is taken to outline the ductal system. If done correctly ductograms are actually not painful.

Some centers are now exploring the use of MRI to evaluate the ducts as well, but this is quite expensive and still experimental. And of course, if a woman hasn’t had a mammogram in more than six months, one should be ordered.

Ductal lavage is a relatively new evaluation technique in which a catheter is inserted into a ductal opening as in a ductogram. A small amount of the anesthetic lidocaine may be used, and then fluid is injected instead of dye to rinse out the duct. The fluid is then aspirated back out through the catheter and sent for cytology. The cytologist studies the aspirate for cells that have sloughed off from the ductal lining (somewhat like a Pap smear); hormone levels may also be analyzed; and some centers are now trying to identify biomarkers for very early precancerous changes.

If there is any question after any of these tests or if the discharge persists, most doctors and patients want the duct removed surgically so the discharge stops. This can be done in a very non-deforming way if the surgeon is able to identify the correct duct and simply excise it and a small amount of tissue around it.  Most breast surgeons can identify the duct with some sort of a probe or dye. The filling defect in the duct may have to be found preoperatively with an ultrasound or mammogram. An incision is made around the areola and should not create a significant scar.  The old-fashioned way, where surgeons did major ductal excisions and took all the ducts and created deformed breasts, is thankfully obsolete.

Inverted nipples and nipple cancer

Some women with inverted nipples can have a small amount of exudate that is usually just sweat and not actually discharge from the ducts. If a woman’s nipple starts to invert where it never had before, this should be brought to a healthcare provider’s attention. Sometimes a lump underneath the nipple can cause the nipple to retract and can be a warning sign of cancer. However, many women are simply born with inverted nipples. These women can still nurse their babies, though the nipple may require a bit of stimulation to evert and will usually then retract. This normal variant is very different from a pathological nipple inversion.

Another sign of cancer can be a red and itchy rash over the areola. This type of condition does not respond to lotions or antibiotics and can be a rare form of breast cancer called Paget’s disease. If you are worried about something like this (it is usually only present on one nipple), you should be seen by a breast specialist who will then do a small skin punch biopsy in the office. We know now that cancers found in the nipple and only located in the nipple can be effectively treated conservatively with lumpectomies and radiation. The nipple can then be reconstructed by a plastic surgeon or, alternatively, many women do without and are just thankful they still have their breast form and cleavage.

Nipple infections

Women can get infections around their nipples, which can become quite sensitive and painful. Most breast specialists will attempt to treat them with antibiotics first but they can be quite difficult to cure, requiring lengthy periods on drugs. This type of infection (chronic subareolar abscess) is usually found in smokers or people who are exposed to second-hand smoke.

We really don’t understand the etiology of these infections, and usually women go on to have some sort of surgery to drain the abscess or remove the duct. But even with surgery the infections often recur. Again this is something for which a woman would want to see a specialist, one who sees this condition often. It is obviously a nuisance but not life-threatening, and sometimes time and patience are the best medicine.

Don’t ignore what your nipples are telling you

Women should always feel that they are being listened to and not thought to be complaining or whining when they are genuinely anxious about breast or nipple change. Neither should they ever be made to feel so worried, or that they might have done something wrong. Knowledge is power, and a woman should always feel comfortable asking questions — and more questions — if necessary.

If you are confused or worried about something that is occurring in your breasts or nipples, call your healthcare practitioner for an appointment. If you can’t talk freely with him or her, ask friends and relatives for a referral. Women have a complicated relationship with this part of their anatomy. The breasts and nipples are where human life begins to be nurtured: make awareness of breast health a part of your own process of self-nurturance.

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One of the most controversial subjects in women’s health is the use of mammograms in detecting breast cancer. In 2005, a study published in the Journal of the National Cancer Institute came out with the news that yearly screening mammograms did not decrease deaths from breast cancer. This was a surprise to a lot of women who had been dutifully if reluctantly getting their yearly mammograms. The reality is that mammography is one tool in detecting breast cancer — but certainly not the definitive answer. Nor are they a form of prevention.

Sadly, the technology is just not there yet in terms of detection. Radiologists differ significantly in how they interpret mammography, and false-negative rates for mammograms can be quite high. Often the lesions missed are the more aggressive cancers and women walk away thinking they’re fine while the cancer has time to spread.

Thermography is a new form of imaging that uses infrared cameras to detect metabolic and vascular abnormalities taking place within your body. The current technology still cannot detect cancer definitively, but the theory is that the changes that are typical of most developing breast tumors are accompanied by variations in temperature on the surface of the breast. Thermograms can be used to generate images that reflect these precancerous changes in the breast over time, so that you can detect cancer before it starts. But the key is how well the results are interpreted. So if you’re considering thermograpy, be sure to find someone who is certified in reading the results.

We don’t yet have a great option for later breast cancer detection, so it always helps to assess your risks early on. If you’re concerned about breast cancer, you might consider genetic profiling, or testing that assays your estrogen metabolite levels. Estrogen is transformed in the liver into three main types, 2–OH, 4–OH, and 16–OH estrogen, and some metabolites are more problematic if they stick around too long. Though we don’t have definitive answers, analyzing the ratio between the three provides clues as to the risk of breast and other estrogen-related cancers. If you and your practitioner see numbers that cause concern, you can start implementing preventative measures, like supplementing with DIM (diindolylmethane). DIM, the digestive product of a phytonutrient found in cruciferous vegetables (broccoli, cabbage, cauliflower, and others), supports the detoxification pathways in the liver that metabolize estrogen. You might also implement regular exercise, and include more soy and flaxseed in your diet. (Even if you do not digest these foods well, you can take digestive enzyme to help overcome this issue.) Since the estrogen molecule is cleared along the same pathways that dispose of drugs and other environmental toxins, avoiding toxins of all kinds can support your breast health.

Rather than relying on mammography alone, we need to avail ourselves of multiple tools to identify breast cancer early on. These tools include self-breast exams, annual physical exams, mammograms, ultrasounds, and MRI’s, thermography, and genetic testing, and estrogen metobolite testing where warranted. And clearly prevention is important, with high quality nutrition, regular exercise, decreasing our toxic burden, and gaining a solid understanding of our own bodies.

For information on mammograms and more, see our articles on breast health.

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A mammogram is a 2-dimensional imaging tool that uses x-rays to detect breast cancer in women without symptoms. Most women get what’s known as screening mammograms. These imaging tests allow a radiologist the opportunity to detect something new or see changes in your breast tissue.

Mammogram screening guidelines do change and these updates can sometimes be difficult to sort out. There were long-standing recommendations that women get mammograms once a year starting at 40 and check their breasts monthly. But now the US Preventive Services Task Force, or USPSTF, recommends that most women put off their first mammograms until age 50, and then get them every other year instead of annually.

Early detection is the goal of mammograms

There is no one simple message when it comes to when and whether to have a mammogram. Having annual mammograms will not prevent you from getting breast cancer. Mammography will detect some pre-existing lumps, but the technology and the experience are far from perfect. And mammograms do come with some real risks.

Though early detection through mammography is still the most widely available tool we have to fight breast cancer, especially for women at elevated risk, mammography is just one piece of the story. In terms of preventing breast cancer, a lot of research points to the benefits of daily exercise, maintaining a healthy weight, eating soy, and supplementing with fish oil, iodine, and indole-3-carbinol, a compound found in cruciferous vegetables like broccoli.

Current guidelines for mammograms

The USPSTF now recommends that unless women have specific risk factors, they should start mammography screening at age 50 and obtain a mammogram every two years, rather than yearly. Over the past 30 years, mammograms have been shown to decrease breast cancer deaths in women over 50 years of age by 30% but a benefit for women in their 40s was never clearly demonstrated.

The Task Force also recommends women discontinue screening mammograms at age 74. Researchers found that not only did the great majority of women gain no benefit from yearly screening mammograms, some are harmed. Other studies have pointed to over-diagnosis and the emotional toll of false-positives as drawbacks to yearly mammograms.

The American Cancer Society (ACS) now advises women with “average risk” to have their first mammograms at age 45, instead of 40. But other groups, including the American College of Radiology and the Society of Breast Imaging continue to recommend annual mammograms starting at 40. The ACS also suggests that women with average risk who are 55 and older should have mammograms every other year.

The USPSTF recommendations are based on:

• New statistical data from computerized models and a number of well-designed, carefully conducted studies, each with over 10 years of follow-up, that showed mammogram screening exams would prevent only 1 death in nearly 2000 women aged 40-49, with potentially 99 false-positive results per 1000 screening exams.
• The hazards from radiation exposure from extra images that cause added harm to this age group.
• The studies and statistical analyses that showed no difference in survival among women 50-69 years of age who were screened every 1 to 2 years.

These recommendations bring the US in line with the protocols followed by most European countries for the last 10 years. Most of Europe does not have higher rates of death from breast cancer than the US.

In another study reported in 2005 in the Journal of the National Cancer Institute, researchers looked back at almost 4000 women in the US between the ages of 40 and 69. It was a surprise when the study found that women who underwent regular screening died at the same rate as those who declined mammograms.

The results suggested there may be a benefit to regular screening for women who are at increased risk for breast cancer due to family history or prior atypical breast biopsy. (See the NCI’s free, interactive Breast Cancer Risk Assessment Tool and be sure to discuss the results with your healthcare provider.)

Is there a “safe” choice when it comes to mammograms?

We all have known someone who has been diagnosed with the disease, or who has died from breast cancer at a young age. Most women are willing to undergo whatever testing is available if they think it will help them beat this frightening disease.

Even so we’re hearing more and more women ask, “Do I really need that mammogram?”

And there are some downsides to the test:

• Mammograms are uncomfortable and sometimes outright painful.
• Mammograms come with high levels of false positives for younger women. An estimated 10% of mammograms are read as false positives, depending on the age of the woman, the center, the radiologist, the equipment, and the protocol used to read the images. This leads to increased anxiety and fear in many women.
• Mammograms can lead to unnecessary procedures. Mammograms lead to the diagnosis of more cancers, but particularly in situ (confined to the original site) cancers, which are generally noninvasive and not associated with an increase in mortality. Are they actually saving lives? Perhaps not as many as you may hope. And many women have unnecessary additional radiation and invasive surgical procedures.
• Mammograms expose you to radiation. There’s a risk-to-benefit ratio to consider, and the younger we are when exposed to radiation, the more sensitive our tissues are to it. Epidemiologists have calculated that cumulative radiation exposure from yearly screening mammograms starting at 40 could cause a net overall increase in cancer deaths.
• Up to 30% of cancers are missed. Many women may have had a false sense of security after being told that their mammogram was normal only to be shocked to find a lump a couple months later that turns out to be malignant.

Originally healthcare practitioners thought mammograms would help with early detection of all breast cancer, but we now know that there are more than five types of breast cancer. Some grow fast and act aggressively in the body, while others are slow growing. Some types act in ways that make finding them early very helpful, while others do not. And now we know that some forms of cancer might be better off left undetected and untreated.

All of this information makes it important for women to discuss mammograms with a trusted healthcare provider to balance risks and benefits with their own health history and beliefs.

Mammography’s imaging limitations

It’s hard to get a quality image of the breast, otherwise known as what author Malcolm Gladwell calls the “picture problem.” In the 2-D world of screening mammography, two black-and-white pictures of each breast are taken. These contrasting views provide some dimension, but not much.

Compression imaging was introduced in the early 1980s, which simplified the mammography process and provided a better view — opening the door to mass screenings. While the radiation doses have decreased significantly since the 1960s, not much else has changed in terms of depth and detail in an average mammogram image.

What can a mammogram see?

Mammograms are clearest when imaging “fatty” breasts, which are naturally more prevalent in older women — usually post-menopausal women not on HRT. Higher hormone levels naturally cause breasts to be more fibrous and harder to image on a mammogram — or “dense.” (Perhaps this is the reason mammograms are more beneficial for older women). How your breasts feel to you does not always correlate with how they look on mammograms.

A textbook cancer — one that a medical student could see — would show up on a mammogram as an irregular white shape, often called a mass or a nodule. “Nodule” refers to lymph nodes, the little shapes generally seen higher up in the armpit. The white shape shows up best on a background that is gray or black on a mammogram.

Dense breasts contain a lot of perfectly normal fibroglandular tissue that shows up as white areas on a mammogram. Part of the image problem with mammograms of dense breasts is that the white areas created by those fibrous tissues can conceal a small cancer — like trying to find a polar bear in a snowstorm.

It’s best when women with family histories or other high-risk factors are screened at a breast center where they’re informed of their results quickly and, if necessary, additional imaging carried out right away. If not women should be scheduled right away for follow-up, so the period of waiting without knowing is minimized. If you’re in such a position, you can certainly advocate for having that experience.

There’s a lot of variation in how mammograms are read and human and technological errors aren’t uncommon. That’s why it’s a good idea to get a second opinion whenever there’s a questionable result.

Are there alternatives to mammography?

There are other forms of breast imaging in use and in development today that provide an alternative picture of breast tissue. Some of these imaging techniques are still experimental, some have limited availability, and some are considered more appropriate for diagnostic rather than screening purposes. But you may be able to request an alternative, if your breasts are dense, or you’re otherwise at higher risk, or you do not believe in or want to have mammography.

Sometimes ultrasound screening or magnetic resonance imaging (MRI) of the breasts is recommended as a follow-up to screening mammography. Because these techniques are generally more costly, not all centers provide them and not all insurance policies cover them. Ask your healthcare provider to discuss all your options — and verify your insurance coverage beforehand so you know what to expect.

Many institutions have converted to digital rather than film mammography, where the images are digitized. They can be reviewed on a high-resolution monitor and the contrast and some other image qualities can be manipulated. Computer programs have been developed to help analyze tissue changes that take place over time.

Digital mammography offers significant benefits over film for premenopausal women and women with dense breasts, according to a study published in NEJM. A radiologist can view your files from a remote location which is helpful for second opinions. False positives and false negatives are still possible, and digital mammography is still not widely available in some areas.

Thermography, or heat detection, is an old method that newer technology is bringing back. At this point, very few large studies have looked at thermography. We encourage women interested in the test to find an experienced institution that will correlate their findings with other testing. It’s possible to see false positive and false negative results with different practitioners using different types of cameras.

What is the bottom line on mammograms?

Mammography is definitely not as good as anyone wanted it to be — yet, anyway — or as beneficial as we’d like it to be. Mostly, we think we are better off with it than we would be without it. It may be prudent to follow the new guidelines and get a mammogram every other year between the ages of 50 and 74, but it should always be your choice. If you have good reasons not to get regular mammograms, your likelihood of dying from breast cancer is still very small.

What you should take into account is your own individual health picture: your risk factors, age, breast density, and your threshold for anxiety and risk. Some women may be comfortable getting a mammogram only a couple times in their 40s and 50s; others may want more regularly imaging.

Researchers are now studying markers of cancer (or risk of getting it) in nipple aspirate fluid, blood, saliva and urine. Women will benefit if the focus shifts to finding the cause or causes of breast cancer so we can learn how to prevent it altogether. Check out the Army of Women for more information.

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Women with the most common form of breast cancer may find that their treatment plans include tamoxifen. Tamoxifen is one of the most frequently-used chemotherapy drugs though it is somewhat controversial.

When it comes to any kind of breast cancer chemotherapy, there’s a lot to think about. If you have a high-risk profile for breast cancer, or if you’ve been diagnosed with the disease, you may be asking, “Do I need to take tamoxifen?”

What is tamoxifen?

Tamoxifen has been in use for a long time — over 30 years. It is classified as a selective estrogen receptor modulator or SERM. Tamoxifen and raloxifene, a similar drug, are the only medications to be FDA-approved for prevention of breast cancer in women who are at higher risk because of familial risk factors. Only tamoxifen can be used for prevention in all women, and raloxifene can only be used in postmenopausal women. Tamoxifen has also been used as a primary treatment for some early stage forms of cancer and as a secondary, or adjuvant (supportive), treatment in more advanced cancers.

SERMs like tamoxifen are endocrine therapies, meaning they affect how hormones work. SERMs work by blocking the effects of estrogen in the body’s tissues. Other endocrine therapies suppress the body’s production of estrogen in various ways. Since 70% to 80% of breast cancers are estrogen receptor-positive — they grow in response to the presence of estrogen — tamoxifen and other endocrine therapies are used to treat the majority of breast cancers that develop in women.

What is tamoxifen used for?

Tamoxifen is often used for breast cancer prevention in high-risk women. This includes both women with family-related risk factors who’ve never had cancer, as well as women who’ve already had a lumpectomy or mastectomy for a previous estrogen-receptor positive cancer. In this group, tamoxifen is used to prevent cancer from spreading or recurring. Tamoxifen is also used regularly to treat early-stage cancers, such as ductal carcinoma in situ (DCIS), particularly in younger women who seem to tolerate it better.

When it comes to advanced, later-stage cancers, tamoxifen isn’t usually the first option because it is less effective and has more unpleasant side effects than some newer drugs. However, if newer drugs aren’t enough, tamoxifen can sometimes be added, or used alongside radiation therapy and surgery to treat advanced breast cancer.

In addition, women who have completed cancer treatment may be offered tamoxifen as “maintenance chemotherapy” to prevent recurrence, over the course of about 5 years. However, new genetic tests target the tumors themselves to help determine who needs this maintenance chemo and who doesn’t. About 15% of tumors are unlikely to come back even without tamoxifen treatment and that’s good news for women!

The pros and cons of using tamoxifen

Tamoxifen is a well-known drug that has been used in cancer treatment for decades. One of its positives is that there aren’t many unanswered questions about how it works and what women can expect if they take it. When it comes to preventive uses, tamoxifen has a good track record of substantially reducing new or recurrent cancer in women with high levels of cancer risk.

Another positive is its cost. As an older drug, tamoxifen is available in generic form, so it is likely to be less expensive than some newer medications. That may be important if your insurance doesn’t pay for the full cost of treatment.

But there are key drawbacks to tamoxifen: its side effects. Like other endocrine therapies, tamoxifen can cause women who haven’t yet gone through menopause to experience menopausal symptoms, like hot flashes, vaginal dryness or discharge, weight gain, fatigue or insomnia, mood changes, and bone loss, among others.

And there are a few serious possible side effects to tamoxifen that other endocrine therapies, such as aromatase inhibitors like anastrozole (Arimidex), do not share. Side effects include increased risk of blood clots in the lungs and legs, stroke, and endometrial and uterine cancers. These risks can be particularly concerning for a woman who already has a personal or family history of any of these disorders. She and her healthcare provider might want to consider other options.

Another potential problem is liver-related. The liver enzyme, cytochrome P450 2D6 or CYP2D6 for short, that breaks tamoxifen down into its active forms is suppressed by common medications that many woman may be taking. These include serotonin selective reuptake inhibitors (SSRIs) used for depression, like paroxetine (Paxil) and sertraline (Zoloft), and the antihistamine diphenhydramine (Benadryl), which is found in many over-the-counter sleep aids and allergy medicines.

If you’re prescribed tamoxifen, it’s important to discuss any medications you use, even if you only use them occasionally, to make sure they won’t interfere with its activity.

Are there other reasons to avoid tamoxifen?

There are some women who shouldn’t use tamoxifen at all, because the harms outweigh the risks. If you’re weighing this choice, consider these issues:

• If your cancer is not estrogen-receptor positive, tamoxifen probably will not be effective against it. Approximately 20 to 30% of breast cancers fall into this category.
• About 6–10% of the population has a genetic variation of CYP2D6 that doesn’t work quite right. If you’re one of them, tamoxifen likely won’t work well (or at all) for you. Other medications may prove more beneficial.
• If you have a clotting disorder treated with anticoagulant medications, or have had a previous episode of pulmonary embolism or deep venous thrombosis, tamoxifen is contraindicated.
• If you have a personal or family history of uterine or endometrial cancer, your risk of developing one of those cancers would be even greater if you use tamoxifen while other medications do not have similar effects.
• In premenopausal women who are pregnant or breastfeeding, tamoxifen should not be used.

These and other health issues should be discussed thoroughly with your healthcare provider before making a decision whether to use the drug.

Support your body through its cancer journey

Coping with cancer is stressful, even without the added questions of treatment side effects. Whether you opt for treatment with tamoxifen or decide on something else, support your body with good nutrition, plenty of pure water, and ample rest. Take time to care for yourself — body, mind and spirit — as you follow a path back to wellness.

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There are many causes of breast pain but the first fear for many women is that it’s a sign of breast cancer. Breast pain (mastalgia) is rarely a symptom of breast cancer though your first step is still to see your health provider for a breast exam and ultrasound, and most likely, peace of mind.

When you feel pain or something seems out of the ordinary, it’s a signal from your body and it’s always a good idea to pay attention to those messages. You’ll feel better once anything serious is ruled out. Women with breast pain can benefit from tracking it — when and where it occurs, etc. — to help reveal any patterns that might be related to the menstrual cycle or for women in their 40s other symptoms of perimenopause.

Figuring out that breast pain is cyclical can be enormously reassuring, even if you’re still uncomfortable. When you have any kind of pain, it helps to know what’s causing it, and why. Often that information leads you to good solutions and a better understanding of your body and how it works.

Breast pain and your menstrual cycle

The most common cause of breast pain is one or more changes to your sex hormones — estrogen, progesterone and testosterone — during your menstrual cycle. When breasts are stimulated by estrogen and progesterone during the second half of your cycle, they swell and can become lumpy and tender. Then with the arrival of your period, the uterus sloughs off its lining, and your breasts reabsorb the extra fluid instead of discharging it.

At different times your hormones can become a bit off balance and your breasts can be more tender and sensitive. Many women can often identify when they ovulate by the sensations in their breasts or nipples. For some women this sensitivity may mean having too little or too much estrogen, but for others it’s due to not having enough progesterone.

This type of cyclic breast pain can occur in both breasts, though it’s sometimes more one-sided than another. It is often felt more in the lateral aspect where there is more breast tissue. Breast pain may differ from month to month but it typically gets worse before a period and then lets up with menstruation.

Breast pain and perimenopause

Even if you haven’t experienced breast pain, sensitivity or swelling with your menstrual cycle, you may develop it as you begin perimenopause. This is due to stronger or more frequent hormonal fluctuations during the menopause transition.

Persistent breast pain for three out of four weeks of the month can indicate hormonal imbalance. For women in their 40s, breast pain is sometimes one of the first signs of perimenopause. For most women, breast pain will go away after menopause, but a small number of women may experience sensitive breasts into their 70s.

Additional causes of breast pain

Along with hormonal changes related to the menstrual cycle or perimenopause, other factors can contribute to breast pain or make it even worse:

• Hormone medications. The most common medications that cause breast pain are pills with hormones in them — either birth control pills or hormone replacement therapy (HRT). The amounts of either estrogen or progesterone (or both) may not be right for a particular woman, or she may react to the additives in the pill or the synthetic compounds.
• Other drugs. Some psychiatric medications or antidepressants may increase breast pain. Even some cholesterol-lowering and heart medications can cause breast changes.
• Stress. Being tense and stressed out can exacerbate breast pain, although we are still learning why. Scientists are only beginning to understand the links between the immune system, emotions and hormones. Everyone has different stress levels and stressors, but it’s true for us all that too much stress is not good for our health.
• Certain bras. If you wear a bra, it is important to wear one that fits well and is comfortable. If a bra is too tight it can pinch or rub against the skin which irritates the skin and breast tissue and leads to pain. Worst of all are underwire bras which may interfere with lymph flow and cause other issues. You can remove the wires from your bra fairly easily or just don’t buy them in the first place, especially if you have breast pain issues.
• Simple breast cysts. These fluid-filled sacs in the breast are common in women before menopause but they can happen at any age. Simple breast cysts come in many sizes and textures. They can swell and recede and sometimes cause pain. They often go away on their own, but if they persist, you can see your healthcare practitioner to evaluate your options, which can include draining the fluid from the breast cyst.
• Diseases. If breast pain persists for several months and does not appear to be cyclic, then a few standard medical tests, a chest x-ray, thyroid tests and a dental exam should be done to rule out other issues. Breast thermography is another option — it’s non-invasive and reveals a lot about the breast tissue and structure.

Natural treatments for breast pain that really work

The natural approach for dealing with breast pain is to help your body balance its hormones. We suggest you start by making dietary changes, adding targeted dietary supplements including omega-3s, Vitamin E, B vitamins and gentle endocrine support. Creating space in your life for exercise along with a structure for reducing stress are key lifestyle changes to consider, too. You get all these basic components in our Hormonal Health Program.

Another factor to think about is taking steps to reduce the estrogen in your body, including estrogen disruptors like xenoestrogens (natural or synthetic compounds that mimic estrogen) that are absorbed from the environment. These can have estrogenic effects once they get inside your body.

While this approach is very effective, many women need additional pain relief. Consider trying the following:

• Topical iodine. This can be bought over the counter in the grocery or drugstore and should be used on the skin only. Apply it in a quarter-sized area once a night on the painful breast until the brown spot persists overnight, or for one month. The iodine seems to have the effect of adjusting hormones just enough to keep the swelling down, or may be treating some subclinical virus or bacteria.
• Bioidentical progesterone support may also be helpful. Consult your healthcare practitioner for guidance.
• Lymphatic massage. A therapist trained in lymphatic massage can treat some types of breast pain by helping improve the lymph flow in your body even if you don’t have lymphedema or arm swelling. There are also some good self-massage techniques that can reduce pain and improve breast tissue quality. We like this one as demonstrated on YouTube. You can try breast massage techniques on yourself first, if you want.
• NSAID (nonsteroidal anti-inflammatory drugs such as Motrin or Advil) creams. At least two randomized, blinded, placebo–controlled studies found NSAIDs cream to be effective and safe for breast pain. Unfortunately these creams are difficult to find over the counter in the US and are available only by prescription or from a compounding pharmacy.
• Castor oil packs. These are simple, natural remedies that help loosen up the breast tissue. A side benefit is they also require a woman to take at least 20 minutes to rest while they’re being applied to the painful breast. You can buy a kit online or use our guide to make your own.
• Diet changes. Cyclic breast pain can be made worse by what we eat or drink. Consider limiting caffeine because it contains a chemical called methylxanthine that causes blood vessels to dilate. (Note: caffeine is in lots of things besides coffee, including certain foods and medications.) Diets high in salt increase swelling by causing fluid retention that puts a strain on the breast tissue. There is also some evidence that fatty foods — mostly animal fats — contribute to breast pain.
• Emotional factors. How you feel emotionally can lead to or create pain. It’s important to try and identify the source or cause of your pain and deal with it specifically so you can let go of fear and worry at the same time. Sometimes reassurance that it isn’t something bad is enough to help release stress.

While some breast pain is still mysterious, women don’t have to stay locked in a state of anxiety about what’s causing it. First off, get it checked out to ease your mind and validate your concerns. Find someone who will listen to you and offer reassuring solutions because, after all, your breast pain isn’t all in your head.

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It’s a revelation to many to learn how common breast discharge is in women, not to mention the many different forms it can take — clear, milky-white, greenish, yellowish, brown, sticky, or bloody! And though we’re far from fully understanding the body chemistry that leads to one form of nipple discharge or another, we are aware of a wide spectrum of lifestyle, dietary, environmental and drug factors at play.

Here is a table of causes of breast discharge, some more common, others less common. This is just a partial list of potential influences and not meant to be comprehensive but to give you an idea of how broad the possibilities are.

So as you can see, there is a multiplicity of causes of breast discharge, which may help explain why the incidence is so high — up to 85% by some estimates. Likewise, some of these factors may have an interactive effect, particularly medications. And though a full explanation for these various forms of breast discharge still eludes us, we can pretty safely conclude that the underlying cause is imbalance in the system.

We also understand that each woman is unique and what may be causing nipple discharge in one woman will not have the same effect on another, and something you tolerated well at one age could affect you quite differently at another stage in your life.

Remember, fluid discharge from the breast is only rarely an indication of something serious, but if you have some type of nipple discharge, we encourage you to seek evaluation with your healthcare provider to be on the safe side.

For an in-depth discussion of nipple discharge and what to do about it, please refer back to our full article.

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