Breast Health

 “If every day is an awakening, you will never grow old. You will just keep growing.” – Gail Sheehy


What is your perception of aging? Do you see aging as an awakening, as Gail Sheehy states? Can you acknowledge the occasional “wear and tear” on your body but reframe it in a positive way? I asked friends to describe what they liked about getting older; some people mentioned feeling more comfortable in their bodies as they aged. Some friends noted that as they have aged, they are more comfortable speaking up and stating an opinion. Others told me, after witnessing the death of loved ones, they clearly saw that life is short and precious and that small gestures of kindness and love often have had the biggest impact on their lives.

It isn’t difficult to read articles in the medical literature about aging that chronicle a gloomy erosion of health and wellness. But consider these aging facts:

  • Mammography is a more effective and sensitive screen in our aging breasts. As the connective tissue and milk ducts and glands are replaced by fatty tissue, the lower breast density improves the accuracy of the mammography screen. Also, less compression and less radiation is needed to adequately screen the less dense breasts. The next time you notice that “sag” in the mirror, smile and know it is a positive development!
  • The cyclic hormonal fluctuations of estrogen and progesterone throughout our reproductive lives are eventually replaced by a low level of hormones with less of a fluctuation; this results in fewer menstrual migraines and less premenstrual syndrome (PMS).
  • Better yet, we know that that lifestyle modifications in the area of nutrition, stress management and exercise work well in our bodies at any age! There are now several studies that show that regular walking or exercises with weights will increase bone density in postmenopausal women.

Dan Buettner, in his book The Blue Zones, looked at areas of the world where a higher percentage of the population live longer and healthier lives. Places like Okinawa, Sardinia, Loma Linda and Costa Rica all had “pockets of longevity” where people lived well into their 90’s without major illnesses. In studying these areas, Buettner noted several lifestyle similarities among these diverse ethnic groups including: eating more vegetables versus protein and processed foods, drinking red wine in moderation, a regular spiritual practice or religious participation, regular exercise or daily movement, having a healthy social network, regular vacations and making family a priority.

Maybe all of that is the definition of “making every day an awakening!”

I thoroughly enjoyed the opportunity to talk to the breast cancer support group at the Jewish Family Services Center here in Dallas this week. This was my second visit with them and again I was impressed by the intelligence, passion and generosity of the women who are drawn to this program. This time I was introducing the idea of an integrated approach to anxiety and depression. According to the National Institute of Mental Health, the prevalence of depression in the general population in 2008 (the latest year for which statistics are available) is 6.7% of the adult population and the prevalence in women is 8.1%. Adding the diagnosis of breast cancer understandably bumps the prevalence slightly higher.

I reviewed the current pharmaceutical and nutraceutical approaches to depression and anxiety and also led the group through some paced breathing and the quick coherence technique of HeartMath. One woman announced that the breathing exercise made her feel calmer than she’d been all day!

During the discussion, one women raised the question about Tamoxifen and anti-depressants. Her oncologist told her that only a few anti-depressants could be prescribed to women on Tamoxifen. Since this is relatively new information, I’ve been researching the claim for the group and decided to post my findings here in the blog.

The concern stems from a study done in Ontario that was published in the British Medical Journal (Kelly CM et al. BMJ 2010 Feb 8:340). This reference is available on PubMed. The researchers looked at women over 66 who were on Tamoxifen and found that the mortality rate was higher in women on Paxil (paroxetine) versus some of the other antidepressants. The reason appears to be that Tamoxifen is broken down in our livers by an enzyme called cytochrome P450 2D6 (the name of this enzyme is often shortened to cyp2D6). Some medications including Paxil are also broken down by cyp2D6. If someone has a genetic variation such that this enzyme is not as efficient, they are often called poor metabolizers. This genetic variation is called a “snip” for the abbreviation single nucleotide polymorphism. If they are poor metabolizers, they will be unable to break down the Tamoxifen effectively and its benefit will be “blocked” by medications that use this pathway. (sort of like musical chairs and everyone is competing for the same seat) Paxil is metabolized by this pathway, so is Thorazine, Prozac, miconazole (a yeast medicine), and quinidine – to name just a few. If a medication has no inhibition or a weaker inhibition of cyp2D6, the Tamoxifen will be broken down more efficiently – for that reason the authors suggest Celebrex or Lexapro because they don’t compete as strongly for cyp2D6.

I read a review article by Kathleen Pritchard which was published in Breast Cancer Research Vol 12 Supp 4 (also on PubMed) and she notes that there are studies that refute the claim – one from Denmark, for example, and states that the final answer isn’t really known as far as SSRI’s and Tamoxifen. Some people are suggesting that we should test the urine for endoxifen (a break down product of Tamoxifen) and make sure that the drug is being effectively metabolized. This isn’t the standard of care as yet, nor is checking women to see if they have genetic SNP’s in their detox genes.

I’ve done the gene testing on people if they note a lot of side effects from a long list of medicines or if we’re suspicious of a problem. The testing is fairly expensive ($500 to $1000 depending on which genes we test) and is NOT covered by insurance. Another wrinkle in the discussion, whenever genetic screening comes up, is how likely is a SNP? We know from population studies of the SNP’s for cyp2D6 that about 6% of Caucasians are “poor metabolizers” of this gene. Other ethnic groups show poor metabolizer rates of 3.3% (Black North Americans), 8.4% (French), 7.7% (Southern Germans) and practically 0% in Korean and Chinese populations.

So, the take home message is Tamoxifen and anti-depressants can mix – but choosing a medicine that is less likely to interrupt the enzyme cyp2D6 is probably a good idea. Or better yet, learn coherence training and get regular acupuncture treatments!

Until next time, be well!

The researchers with the Women’s Health Initiative (WHI) released more findings last week. The study began in 1999 as a joint venture between the National Institute of Health (NIH) and Wyeth pharmaceuticals and enrolled tens of thousands of women. The study was supposed to run for ten years but was stopped in the summer of 2002 because the risks of hormone therapy (in this case Prempro™ for women who had a uterus and Premarin™ for women who did not) outweighed the benefits. The risks included an increased risk of heart disease, blood clots and breast cancer in the women on the hormones. The benefits included a decreased risk of colon cancer and hip fracture.

My ob-gyn office phone rang and rang and rang when these initial findings came out. Prior to the WHI, the use of “hormone replacement therapy” was almost automatic for a peri-menopausal or menopausal woman. After the initial reports, many of my patients chose to discontinue their hormones. Some immediately restarted the hormones because of hot flashes and then gradually weaned off the hormones. Some stayed on the hormones because they felt the quality of their life was better on hormones than off of them.

As a nation, the incidence of hormone use decreased and the incidence of breast cancer has also decreased since the 2002 report came out. (See the graph at the beginning of the post) The latest report from the WHI suggests that breast cancer rates are LOWER on Premarin™ alone versus placebo in the women who had had a hysterectomy. I doubt this report will change hormone use a great deal.

As I said before in my book, the WHI left us with more questions than answers. What if different hormone preparations had been used? (Wyeth co-sponsored the WHI – the reason for the hormone choice) What if rather than a broad-based population we had targeted younger sympotamatic women (the average age of WHI participants was sixty – well after the onset of menopause). What if we screened the population and only treated nonsmokers?

I’m amazed that there were no extensive data gathered on nutrition (other than “low-fat”), life-pacing or stress management as part of the WHI. What’s more, as in most clinical trials that involve taking chemicals into our body, there was no discussion or measurement of our individual differences in metabolizing the same chemicals out of our body. Our genetic uniquenesses are likely to drive this discussion in ten to fifteen years; for now we are all lumped together as if we were identical metabolically. It’s unlikely that we’ll ever had this large a study population to explore these questions.

Here’s my short summary of recommendations regarding hormone: 1) Do you need them? If the perimenopausal years are wreaking havoc on your sleep patterns or your vaginal lubrication, start first with nutritional choices rich in fruits, veggies and whole grains. Ease off of the animal protein, sugar and caffeine. Learn some breath exercises and/or biofeedback techniques and practice them twice a day. Exercise three or four times a week. 2) If these lifestyle changes don’t lighten the severity of your symptoms, use low dose hormones topically (gels, creams, patches, intravaginal rings, etc) that are chemically identical to the hormones you make yourself. These “bio-identical” hormones are on your formulary and purchased through your insurance plans or compounded to a specific prescription by a specialty pharmacy. 3) If you stay on hormones longer than three months, measure your estrogen metabolites and make sure you are removing the hormones safely from your body. You’ll probably need to find functional medicine practitioners to do this.( 4) Reassess your hormone needs yearly and decide if you need to stay on them or if you can wean off of them. Wean slowly. Ask for assistance from your practitioner.

No doubt about it, some women need hormones for the perimenopausal transition. As a culture, however, we don’t always grasp that our nutrition and lifestyle choices affect our hormone levels. The WHI didn’t answer that question!

This blog is about that phone call and the follow-up testing. You know the phone call I mean. The one where the chipper woman calls and tells you there’s something wrong with the testing you did last week. It could be a doctor’s assistant calling about lab results or a hospital (in my case) staff member calling to let me know that there was “this new area” on my mammogram that needs further testing. And don’t get me wrong. I appreciate that she called on Monday morning and not Friday afternoon giving me the weekend to sit and stew!  But here’s the thing. She hadn’t really looked at the computer and/or wasn’t empowered to answer questions. For instance: why? what was seen or not seen on the original test? What was the concern? Was there a comparison to the testing done last year in Cincinnati? (Did they have the old information?)  Were there calcium deposits?  (Did the radiologist use the term “calcifications”?) You get the idea. No dice. Her job was to call and get me scheduled, not provide clinical information. Now forget for a moment that I’m a board certified ob-gyn physician. Even if I weren’t I’d still want some basic knowledge up front prior to the testing!

So then I make my appointment and check in. The receptionist doesn’t make eye contact or welcome me.  The intake clerk confirms my insurance information and collects my co-pay but never asks me how I would prefer to be addressed. I am Mrs. Harsh to everyone there. I correct the first three people who call me and ask to be called by my first name. (Yes I’m a doctor, but comfortable using my first name in just about every circumstance.) What’s your preference? Would it make you more comfortable if your preference is noted and used? Of course it would!

The waiting area is playing a brisk military march and there is a coffee pot and water dispenser. There are the usual magazines to read. And then there’s the mammogram tech. Pleasant, skilled and thorough. I ask to see the digital results from the previous test – there they are with the radiologist’s “circle” of concern. And then there’s the ultrasound tech. Pleasant, skilled and thorough. And then there’s the radiologist. Very nice and chipper because the spot compression films and the sonogram confirm the new area is a dilated duct and not pathological. Great news. No discussion about ways to reduce my risk of breast cancer. Just a “see you next year for your mammogram”.

So if I ran the hospital, I’d coach everyone in the front to introduce themselves and make eye contact and greet everyone who walked in. I’d capture the usual data for the purposes of the insurance billing and then double check if there were issues or concerns for this visit. I’d check on the clients preferences for how they were addressed. Then I’d listen to my staff and see if they had ideas for efficiency.

That’s how I’d run the (hospital) world. Focused on the patients. Allowing the professionals and their support staff to do the work they have trained their life to do. <sigh>

The New York Times reported on Wednesday that the latest data from the Women’s Health Initiative (WHI) showed that hormones “not only increase the risk of breast cancer but also that the disease will be more advanced and deadly.” They are quoting the JAMA article that came out 10/20/10 by Chlebowski RT et al. which was a compilation of longer follow-up on the original group of subjects in the WHI. Later in the Times article, the reporter notes the increased risk is low, but interviews the lead author of the JAMA article, an oncologist who treats breast cancer patients at Harbor-UCLA in Torrance, California who acknowledges that we (as doctors) don’t really know how much or how long women can safely take hormones. The North American Menopause Society responded with this summary: There are 1 to 2 extra deaths from breast cancer per 10,000 women per year. Specifically, for every 10,000 women in the study who were randomized to placebo, there were 1.3 deaths from breast cancer per year. For every 10,000 women randomized to combined hormone therapy, there were 2.6 deaths from breast cancer per year. The WHI found no increase in breast cancer risk with estrogen alone among women who had had a hysterectomy.
Hormone therapy in menopause became commonly prescribed after a book by Robert Wilson called “Feminine Forever” was published (1968, Pocket Books, New York). Dr. Wilson proposed that estrogen would keep women feeling and looking younger and more vital. It was during this time frame that hysterectomy rates peaked in our country and many women had their ovaries removed surgically – sometimes well before menopause. Supporting these women with patentable estrogen-like drugs was proven to help prevent osteoporosis (thinning of the bones) and atherosclerosis (hardening of the arteries). As a medical community, it became the standard of care to offer hormone “replacement” therapy to every perimenopausal and menopausal woman – even if they still had their uterus. Now fast-forward twenty to thirty years and recognize that hysterectomy rates are lower – partly because of improved technology for surveillance (ultrasounds, MRI scans of the pelvis, smaller sampling instruments to biopsy tissue from inside the uterus) and partly because of improved technology for therapies (endometrial ablations that remove or burn the lining of the uterus, and improved surgical techniques that allow smaller incisions for same-day procedures like laparoscopy or hysteroscopy).
When estrogen alone was shown to cause uterine cancer in a small percentage of women, a synthetic progestin was added and shown to “protect” the uterus. More women were on hormones than ever before. New pharmaceutical products were hitting the market one after another and pharmaceutical companies were watching us aging baby boomers with joyful anticipation.
The next chapter of the hormone story begins abruptly with the first publication of the results of the Women’s Health Initiative (WHI) in the summer of 2002. This study has produced lots of data and papers – this weeks study is one of the follow up papers. Over ten thousand women were randomized to receive either Prempro® (a combination of Premarin – a mix of hormones synthesized from the urine of pregnant horses – and medroxy progesterone actetate – a synthetic progestin) if they had a uterus or Premarin® alone if they didn’t. Although death rates were no different between the groups, there was a statistically decreased rate of colon cancer and osteoporosis and an increased rate of breast cancer, blood clots and strokes in the hormone-using group. The study was stopped early because the researchers believed that the risks of Prempro® use out-weighed the benefits. There is still an on-going analysis of the data as we try to understand the issue. It seems that rather than answering questions we’re left with more questions to answer! What if different hormone preparations had been used? What if we had chosen topical application rather than oral hormones? What if rather than a broad-based population we had targeted younger symptomatic women in their late 40’s or early 50’s? What if we screened the population and only treated non-smokers? I’m amazed that there was no extensive data gathered on nutrition, life-pacing or stress management as part of the WHI. What if we compared hormone use to acupuncture, a modality that has been shown to effectively treat hot flashes and sleep disruptions? It’s unlikely that we’ll ever have this large a study population to explore these questions.

I read my expert colleague’s opinions and am left with an empty feeling. I’m convinced a thorough discussion of stress management, psychosocial support and nutrition should precede any and all prescription pad actions. But that’s not the way medicine is prescribed today…

I’m not going to use the “C” (as in cancer) word in this blog post. The focus will be on breast health and optimal balance. Partly because it’s October and pink ribbons are everywhere and on everything. And partly because I’d rather focus on optimal breast health and save the discussion on diseases of the breast for another day.

Optimal breast health includes a healthy loving attitude towards our bodies. We cannot do careful self-breast exams unless we are touching and looking at our breasts carefully and thoroughly. We know that before and after pregnancies and breast-feeding, our breasts respond to our cyclic hormones by increasing in size and gland complexity.  We learn quickly that the hormonal fluctuations in our cycles can result in full, tender breasts if we are out of balance from a nutrition or stress standpoint. We also know that, anatomically, our breasts are fairly straightforward. There is a web of connective tissue with blood vessels surrounding a network of glands. Body fat “fills in the gaps” and provides the contour and texture. The fat also serves as a “storage silo” for hormones and their metabolites.

Breasts serve the amazing function of milk production for our newborn child after birth. There is an elaborate dance of hormones that interweave after labor and suckling. A relaxed, unstressed and nourished new mother produces milk easily and bountifully for her relaxed and unstressed child. Nature allows a smaller volume, higher protein colostrum to serve as nourishment and “immune system booster” until regular breast milk is created within a few days after birth.

But sometimes we forget this mystical dance. There’s a cultural expectation that we should undergo enlargement with implants if our breast size is too small and reduction with surgery if our breast size is too big.  And because our breasts are situated anatomically right over our heart, they are a magnifying focus for negative emotional energy from heartbreak and loss.

Listen, I’m all for pink ribbons and awareness and screening…don’t get me wrong. I’m just asking that we START with an attitude of awe and wonder and appreciation for our breasts and what they’re designed to do.