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Breast A-Z Knowledge


Anatomy of Breast

The breast is a glandular, containing fatty and fibrous tissue located over the pectoralis muscles of the chest wall and attached to these muscles by fibrous strands. The breast itself actually has none of muscle tissue that is why exercises cannot help build up breasts. A layer of fat surrounds the breast glands and spreads throughout the breasts. This fatty tissue provides the breast soft consistency and gentle, flowing contour. The actual breast contains fat, glands with the capacity for milk production when stimulated by special hormones, blood vessels as well as milk ducts to transfer the milk from the glands to the nipples and sensory nerves that give feeling to the breast. These nerves extend from the muscle layer to the breast and are greatly sensitive, especially in the areas of the nipple and areola that accounts for the sexual responsiveness of some women’s breasts.

As the breast is made of tissues with different textures, it might not have a smooth surface and is often feel lumpy. This abnormality is normally noticeable when a woman is thin and has small breast fat to soften the contours; it turns to be less obvious after menopause at the time that the cyclic changes and endocrine incentive of the breast have ceased and the glandular tissue softens. Estrogen supplements after the menopause can produce continued lumpiness. The breast glands drain into collecting system of ducts that go to the base of nipples. The ducts then extend through the nipples and open on its external surface to serve as a channel for milk. These ducts are often sources of breast problems.

The ducts terminate in the nipple, and are a conduit for the milk evolved by glands and suckled by a baby during the breast-feeding time. There is essential variation in women’s nipples. In some, the nipple constantly erects; in others, it only becomes erect when impacted by cold, physical contact or sexual activity. Other women have inverted nipples. The surrounding of nipple is slightly raised circle of pigmented skin which is called the areola. The nipple and areola contain muscle fibers that make nipple erect and give the areola its firm texture. The areola contains Montgomery’s glands that may appear as tiny, raised lumps on the areola. These glands lubricate the areola. They are not symptoms of unusual condition. Under the breast is a large muscle, the pectoralis major, that supports arm movement and the breast rests on this muscle. On the chest wall, the pectoralis major extends from under the breast to the upper arm. It also helps shape the axillary fold, created where arm and chest wall meet. The axilla is the depression behind this fold. Each woman’s breasts are different. Individual breast appearance is influenced by the volume of a woman’s breast tissue and fat as well as her age, a history of previous pregnancies and lactation. Her heredity, the quality and elasticity of her breast skin and the influence of hormones are also the important factors.

Breast Compositions

Cooper’s Ligament: Strong ligamentous band spreading upward and backward from the Gimbernat’s ligament along the iliopectineal line to which it is attached (called also ligament of Cooper).

Pectoralis major: A bigger chest muscle that arises from the clavicle, the sternum, the cartilages of most of the ribs, and the aponeurosis of the external oblique muscle. It is inserted by a strong flat tendon into the posterior bicipital ridge of the humerus.

Pectoralis minor: A smaller muscle beneath the larger, arises from the third, fourth, and fifth ribs, and is inserted by flat tendon into the coracoid process of scapula.

Connective tissue: A tissue of mesodermal origin which is rich in intercellular substance or interlacing processes with little tendency for the cells to meet in sheets or masses, especially the connective tissue of stellate or spindle-shaped cells with interlacing processes that pervades, supports, and binds together other tissues and forms ligaments and tendons.

Blood vessels: Any of vessels through blood circulates in the body.

Ribs: The paired curved bony or partly cartilaginous rods that strengthen the lateral walls of the body and protect the viscera which occur in mammals or almost exclusively in the thoracic region, and that in humans normally include 12 pairs of which all are articulated with the spinal column at the dorsal end and the first 10 are connected also at the ventral end with the sternum.

Subcutaneous fat: fat cells living, used, or made under skin.

Infra-mammary crease: The fold or crease under the breast where breast lobe meets torso.

Breast fat:  Fatty tissue above the glandular of breast.

Ducts: A bodily tube or vessel for carrying the secretion of a gland, especially breast milk.

Glandular tissue: Of involving glands, gland cells, or their products such as breast milk production

Nipples: The protuberance of a mammary gland. In female, the lactiferous ducts open while the milk is drawn.

Lobules: The glandular of the breast where milk is formed.

Breast envelope: The skin surrounds the structure of breasts.

Asymmetrical Breasts

There is a third situation that often occurs in puberty: the breasts grow unevenly. In some cases this is simply a question of the rate of the breasts’ growth, and in a year or two the breasts are fairly symmetrical for example, one breasts will be an A cup size, while the other is a B cup size. (Keep in mind that most people’s breasts are slightly uneven, as are their feet and hands.) But sometimes the breasts remain extremely asymmetrical. Again, asymmetrical breasts are perfectly “normal” form a medical viewpoint: they can both produce milk. But they can create extreme psychological distress, causing the adolescent girl and the grown women to feel like sexual freak. Some girls refuse to date in their teens because they fear their condition will be discovered and ridiculed. A falsie or a pile of several falsies can be worn on one side, of course, but that can still leave a feeling of something ugly and somehow shameful that must be hidden from the world.

For a woman who is bothered by extreme asymmetry, cosmetic surgery can help achieve a reasonable match. Either the larger breast can be reduce or smaller one augmented or combination of both can be done. It’s important for the surgeon to discuss these options often we assume a women will want her small breast made larger and neglect to suggest the possibility of reducing the larger breast. What a woman decides will depend on the size of both breasts, the degree of asymmetry, and, above all, her own aesthetic judgment.

It’s fortunate that plastic surgery techniques exist for women who want them. But don’t assume that because you have atypical-looking breast you have to get them altered. Many women are quite pleased with how their breasts look. Some women with large breasts feel that their breasts are “feminine and sexy.” Small breasts, too, have their advantages. Some women like their small breasts because “they’re unobtrusive, and they work well during nursing. Occasionally some male person will intimate that they’re less than optimal. That’s his problem, not mine.” Another likes her tiny breasts because they don’t get her way when she engages in spots. A woman with very asymmetrical breasts says she used to feel self-conscious about them, but has “come to terms with them” since she nursed her child.

There is a woman telling a wonderful story about a friend of hers who had inverted nipples’ “When I was 12 and my cousin was 14, we stood before the bathroom mirror and compared breasts. I notice how different her nipples were; they didn’t protrude, the way mine did. We had this big discussion about whose were ‘normal.’ I was convinced mine were, but she insisted hers were and since she was older and I thought, more knowledgeable, I decide she must be right. After she graduated From College and was studying in Paris, she became ill and had to be hospitalized. The doctor who was examining her asked if her nipples ‘had always been like that.’ That’s how she learned that she had inverted nipples and that mine were the normal ones!”

Obviously, the women inverted the nipples hadn’t caused her any distress. If you don’t object to the way your breasts look, don’t think about plastic surgery. You’re fine as you are.

Awareness on the Breast Cancer Signs

What are the symptoms that should alert you to the possibility of breast cancer? The most common is a painless lump, although some painful lumps can be cancerous as well. A thickening of the breast or a change in density also should be checked out. As we’ve mentioned in previous chapters, occasionally breast cancer shows up as a lump under the arm, a redness of the skin over the breast, eczema of the nipple, or dimpling of the skin. Finally, the most common finding these days is an abnormality seen on mammogram with no physical findings at all.

Once you’ve discovered a symptom or a lump that alerts you to the possibility of breast cancer, you should see a doctor. Start with your own primary care physician or gynecologist. If you’re over 35 your doctor should send you for a mammogram. Even if the mammogram shows no abnormalities, if the symptom or lump persists ask to be referred to a surgeon or a breast specialist. In some areas of the country there are surgeons who specialize in breast disease; in other areas you may be referred to a general surgeon. Don’t be scared by the word “surgeon”—the fact that you’re going to see a surgeon doesn’t automatically mean an operation. Surgeons are the doctors best trained to diagnose breast problems. If you’re unsatisfied with the answers you’re getting from one surgeon, find another.

Breast Compositions

The breast is glandular, fatty, and fibrous tissues over the pectoral muscles of the chest wall and connected by fibrous strands called Cooper’s ligaments. A layer of fatty tissue encloses breast glands as well as spreads over the breast. The fatty tissue offers the breast soft consistency.

The glandular tissues of the breast are like a house for lobules and ducts (milk passages). At the nipple, each duct extends to form a sac. While performing the lactation, the bulbs on the ends of lobules create milk. When milk is produced, it will be transferred through the ducts and the nipple later on.

The breast compounds of:

  • Milk glands (lobules) that produce milk.
  • Ducts that transport milk from the milk glands (lobules) to the nipple.
  • Nipple
  • Connective tissue that surrounds lobules and ducts.
  • Fat

Breast Sensitivity

Breasts are usually very sensitive as you’ll notice if you get hit in the breasts. It’s very painful, but if you’ve been told being injured in the breast leads to cancer, ignore it. All a bruised breast causes is temporary pain. Similarly, scar tissue that results from an injury to the breast won’t cause cancer. The supposed fragility of women’s breasts has been used as an excuse to keep girls from playing contract sports. Interestingly, however, the extreme sensitivity of testicles is rarely used to keep men form such sports. You own pain threshold, plus your enthusiasm for the particular game, should determine whether or not you want to avoid risking pain by playing. A bruised breast will hurt, but so will a bruised shin.

The sensitivity of the breast changes within the menstrual cycle. During the first two weeks of the cycle it’s less sensitive; it’s very sensitive around ovulation and after, and it’s less sensitive again during menstruation. There are also changes during the larger development process. There’s little sensitivity before puberty, much sensitive after pube11rty, and extreme sensitivity during pregnancy and perimenopause. After menopause, the sensitivity decreases slightly, but never fully vanishes. As in most aspects of the normal breast, sensitivity varies greatly among women. There’s no “right” or “healthy” degree of responsiveness.

Breasts are also very greatly in their sensitivity to sexual stimuli. Physiologic changes in the breasts are an integral part of female sexual response. In the excitement phase the nipples harden and become more erect, the breasts plump up, and the areola swells. In the plateau just before orgasm breasts, nipples, and areola get larger still, peaking with the orgasm and then gradually subsiding. For most women’ Breast stimulation contributes to sexual pleasure. Many enjoy having their breast stroked or sucked by their lovers, but have been told that this can lead to cancer. It can’t. Breasts, after all, are made to be suckled and your body won’t punish you because it’s a lover rather than a baby doing it. Some women’s breasts are so erogenous that breast stimulation alone can bring them to orgasm; others find breast stimulation alone can bring them to orgasm; others find breasts stimulation uninteresting or even unpleasant. Neither extreme is more “normal”: as we know, different people have different sexual needs and respond to different sexual stimuli. Couples may wonder whether their lack of sexual excitement around their breasts means something is wrong with them or not. It’s doesn’t. There is an unfortunate tradition in our culture to label as “frigid” women whose sexual needs don’t correspond to those of their (usually) male partners. Ironically, the converse of this still persist in our supposedly liberated era: a women who is easily sexually stimulated is seen as a “tramp.” All such stereotypes are unfortunate and destructive. If your breasts contribute to your sexual pleasure, enjoy it. If not, enjoy what you do like, and don’t worry about it.

Breast Lift

Sagging breasts (known medically as “ptosis”) can be made firmer through an operation called a mastopexy, which Dr. Goldwyn describes as “a face-lift of the breasts.” A mastopexy can give your breasts uplift, but Dr. Goldwyn warns that it Will not make your breasts look like a 20-year-old’s. And it will leave scars—sometimes bad ones, depending on how your body usually scars. Like a face-lift, it won’t last forever: remember, you’ve got gravity and time working against you.

Your first step is to set up a meeting with your plastic surgeon, who will take a very thorough medical history. You should get a mammogram before proceeding further, if you haven’t had one recently. Be sure to get a full description of both the best and the worst possible results of a mastopexy.

This operation usually involves removing excess skin and fat and e1evating the nipple. If you’re very large-breasted, you may want reduction surgery as well, especially since a mastopexy is less effective on very large breasts: gravity pulls them down. If you’re very small-breasted, you may want an augmentation.

If your operation doesn’t involve reduction or augmentation, it’s a simpler procedure, and can be done either in the hospital under general anesthetic or in the doctor’s office with local anesthesia. Since insurance won’t pay for it, most women prefer the latter. The operation lasts about two and a half hours; the stitches are removed in two weeks. By three weeks, you’ll be able to participate in sports. You should wear a bra constantly for many weeks after surgery. Follow-up is minimal—three or four visits during the year after surgery.

You may experience some very slight loss of sensation in the nipples or areola. Other than that, there are no particular side effects to mastopexy.

Cup Size and Appearance Changes

Women breast size and shape varies considerably. Some women have large amount of breast tissues, so they have large breasts. Other women who have smaller amount of the tissues gain smaller breast size.

Factors of woman’s breast size:

  • Amount of breast tissue
  • Family history
  • Age
  • Weight
  • Pregnancies and lactation
  • Thickness and elasticity of breasts
  • Hormonal influences on breasts
  • Menopausal conditions

Normally, breasts are rarely balanced or symmetrical. One breast might be larger or smaller, higher or lower, or shaped differently than the other. The size of the nipples is also different in each woman. Some women’s nipples are constantly erect, while others’ only become erect when stimulated by cold or touch. Also, some women might also have inverted nipples. This is not a a serious condition unless it is a new change. Hair follicles around nipples are actually common as long as it is not occur on the breast.

Nipples can be flat, round, or cylindrical in shape. Its color is determined by the thinness and pigmentation of the skin. Nipple and areola contain particular muscle fibers that stimulate the nipple to erect. The areola also contains Montgomery’s gland that may occur as tiny, raised bumps. The Montgomery’s gland provides lubricate for the areola. Whenever nipples are stimulated, the fibers will contract areola so the nipples become hard.

Breast appearance undergoes various changes as a woman gets older. For young women, breast skin expands as the breasts grow, which promotes a rounded breast appearance. However, they tend to have denser breasts more than older women.

At menstrual period, breast tissues swell from changes due to levels of estrogen and progesterone. The milk glands and ducts enhance and the breasts retain water. During this time, women might feel swollen, painful, tender, or lumpy on their breasts.

Cancer of both breasts

Once in a great while a woman will be diagnosed as having a cancer in each breast at the same time. Typically, this will be discovered when finding a lump in one breast, she gets a mammogram to find out what’s going on there, and learns there’s also a lump in the other breast. A biopsy shows them both to be cancer.

They’re probably both primary cancers; one isn’t a metastasis of the other. So they’re both treated the same way: we do a lumpectomy, or mastectomy and lymph node dissection on one and then the other side. Usually the surgeon will first dissect the lymph nodes on the side that appears worst, so that, if the nodes are positive and will require chemotherapy, the other nodes won’t necessarily have to be dissected if the second cancer has a low likelihood of spreading to the nodes. Unfortunately, the surgeon’s guess isn’t always right. There was a woman who had three cancers: she had a lump in the top of her right breast, and the mammogram showed to densities in the bottom of the left breast. They’d all been biopsied with needles. She really wanted to keep her breasts, so a surgeon did a wide excision of the right breast and sampled the lymph nodes, and they were fine. Then he did a wide excision of two cancers in the left breast, and on the left side she had positive lymph nodes. You can have radiation treatment on both breasts at the same time but the radiation therapist has to be very careful that the treatment doesn’t overlap and cause a burn in the middle area.

It’s isn’t necessary to do the same treatment on both breasts. You might decide on a mastectomy on one side and wide excision plus radiation o the other, for example. It is important to note that your prognosis is only as bad as the worst of the two tumors, not doubly as bad as either one.

Chemotherapy for Breast Cancer

After you decide about local treatment, you will need to decide about systemic therapy: chemotherapy, hormonal therapy, or both. Chemotherapy was initially used to treat leukemia, a cancer which, by definition, is present throughout the bloodstream. Later it was used to treat any metastatic cancer. The idea was that drugs circulating through the bloodstream could get to all the places a cancer cell was likely to hide. Unfortunately, it didn’t always work. On further study, the researchers came to understand that the failure stemmed from two problems: there were too many cancer cells for the drugs to handle, and some cancer cells became resistant to the drugs. They then began to consider giving chemotherapy earlier and earlier, and the concept of adjuvant chemotherapy was born. Perhaps the time to give chemotherapy was right after the primary local treatment—either surgery alone or surgery and radiation—when any spread would still be microscopic. And indeed this approach seemed to work. The first studies by Gianni Bonadonna and by the N SABP showed that premenopausal women with positive nodes had a significant decrease in breast cancer mortality when given adjuvant chemotherapy. This set the stage for the now common practice of using systemic treatments at the time of initial diagnosis. We now give adjuvant chemotherapy to all premenopausal women with positive nodes, many with negative nodes, and many postmenopausal women.

Development of the Breast

Human breast tissues start to develop at sixth week of fetal life. Breast tissues initially improve along the lines of the armpits and stretches to the groin. At the ninth week, it returns back to chest area, leaving two breast buds on upper half of chest. For women, a large amount of cells grow inward from each breast bud. They become separated sweat glands with ducts leading to nipples. Both male and female infants actually have small breasts and face some nipple discharge during the first few days.

Women breasts do not develop until the puberty which is the period in life when body undergoes a various changes to prepare for reproduction. Puberty usually starts when women age around 10 or 11. As the pubic hairs grow, breasts begin to respond the hormonal changes. The production of two hormones including estrogen and progesterone signals improvement of glandular breast tissues. At this period, fat and fibrous breast tissue becomes more elastic. Breast ducts start to grow and will grow until menstruation begins. Menstruation supports breasts and ovaries for potential pregnancy.

Before puberty Early puberty Late puberty
The breast is flat except for nipples that stick out from the chest Areolas become prominent buds; breasts begin to fill out Glandular tissues and fats increase in breasts, and areolas become flat
Women Breast Developmental Stages
Stage 1 The tip of the nipple is raised.
Stage 2 Buds appear, breasts and nipples raise, and areolas enlarge.
Stage 3 Breasts are slightly bigger with glandular breast tissue present.
Stage 4 Areolas and nipples raise as well as the rest of breasts
Stage 5 Mature breasts; breasts become rounded and only nipples are raised.

Five Stages of Breast Development

  Breasts during childhood. Breasts are flat and show no signs of development.
  Breast bud stage. Milk ducts and fat tissue form a tiny mound.
  Breast continues to grow. Breast becomes rounder and fuller.
  Nipple and areola form separated small mounds. But not every girl goes through this stage. Some girls skip stage 4 and go directly to stage 5.
  Breast growth reaches finial stage.
Adult breasts are completely full and round shaped.


The nipple is an especially sensitive area and subject to a number of problems, such as the subareolar abscess discussed earlier. The most common nipple problem or rather concern, since it’s not always a problem is discharge. Most women do have some amount of discharge or fluid when their breasts are squeezed, and it’s perfectly normal. In a study at Boston’s Lying-in hospital breast clinic women had little suction cups, like breast pumps, put on their nipples and gentle suction applied. Eighty three percent of these women (young, mothers, non-mothers previously pregnant, never pregnant) had some amount of fluid. This fluid can be analyzed for precancerous cells.

The ducts of the nipple are pipelines; they’re made to carry milk to the nipple, so a little fluid in the pipes shouldn’t be surprising. (It can come in a number of colors like gray, green, and brown, as well as white.)

Sometimes people confuse nipple discharge with other problems like weepy sores, infections and abscesses. Inverted nipples can sometimes get dirt and dried-up sweat trapped in them, and this can be confused with discharge.

Some women are more prone to lots of discharge than others: women on birth control pills, antihypertensive such as Aldomet, or major tranquilizer such as thorazine tend to notice more discharge, because these medications increase prolactin levels. It may seem aesthetically displeasing, but beyond that there’s nothing to worry about.

There are also different lift periods when you’re more likely to get discharge than others: there’s more discharge at puberty and at menopause than in the years between. And there’s the “witch’s milk” that newborn babies get. This makes sense, since the discharge is a result of hormonal processes.

When should you worry?
The time to worry about nipple discharge is when it’s spontaneous, persistent, and unilateral (only on one side). It comes out by itself without squeezing; it keeps on happening; and it’s only from one nipple and usually one duct. It’s either clear and sticky, like an egg white, or bloody. You should go to the doctor right away. There are several possible causes:

  1. Intraductal papilloma: This is a little wart-like growth on the lining of the duct. It gets eroded and bleeds, creating a bloody discharge. It’d benign; the surgeon removes it to make sure that’s what it is.
  2. Intraductal papillomatosis: Instead of one wart, you’ve got a lot of little warts.
  3. Intraductal carcinoma in situ: This is a precancer that clogs up the duct like rust.
  4. Cancer: Cancers are rarely the cause of discharge. Only about 4 percent of all spontaneous unilateral bloody discharges are cancerous.

You clinician should first test for blood by taking a sample, putting it on a card, and adding a chemical (hemacult test). If it turns blue, there’s blood (which may not be visible to the eye alone, because of the color of the discharge itself). The doctor may do a Pap smear, very like the Pap smear you get to test for cervical cancer. Discharge is put on a glass slide and sent to the lab for the cells to be examined. This is not as accurate as testing for blood in the discharge, but occasionally it can demonstrate the presence of abnormal cells.

Next the doctor will try and figure out the “trigger zone” by going around the breast to find out which duct the discharge is coming from, though often the woman herself can give the doctor this information. If you’re over 30 you’ll be sent for a mammogram to see if there’s a tumor underneath the duct.

You can then have your duct lavaged. If the cells are abnormal you can then be given a ductogram. The radiologist takes a very fine plastic catheter and, with a magnifying glass, threads it into the duct, squirts dye into it, and takes a picture. The procedure sounds uncomfortable, but it really isn’t that bad—the duct is an open tube already, and the discharge has dilated it. The ductogram provides a “map” for the surgeon who may do a biopsy and may also show the source of the discharge. Not every surgeon will order a ductogram or lavage, they are extremely worthwhile.

A biopsy itself is fairly simple; it’s a specialized form of the regular breast biopsy. It can be done under local anesthetic, and on an outpatient basis. A tiny incision is made at the edge of the areola; the areola is flipped up, and the blood-filled duct located and removed. Sometimes the radiologist will cut a fine suture and pass it into the duct to the point to be removed, or blue dye can be injected into the duct to help identify it. Both of these techniques will help to pinpoint the right area. Sometimes if the ductogram has shown the lesion to be far from the nipple, the surgeon will localize the area with a wire. That’s way the duct won’t get blocked, which interferes with breast feeding, or numbed, which interferes with sexual pleasure.

Because the lesion can be far from the nipple itself, the old standard surgical practice of removing all of the ductal system to make sure that the discharge has stopped and largely been abandoned. Though this procedure stops the discharge (by disconnecting the ducts from the nipple), it may or may not remove the pathology causing the discharge.
Some centers are using duct endoscopy to figure out what’s causing the discharge. An endoscope is a thin tube put directly into the nipple duct, by which the surgeon can view the inside of the ducts on a video screen. They have reported success in seeing Intraductal papillomas and other pathology.

Another form of problematic discharge is one that is spontaneous, bilateral (on both sides), and milky. If you’re not breast-feeding, and haven’t been in the past year, this is probably a condition called galactorrhea which is excessive or spontaneous milk flow. It occurs because something is increasing the prolactin levels, sometimes a small tumor in the brain. This may not be as alarming as it sounds: often it’s a tiny tumor which may not require surgery. A neurosurgeon and an endocrinologist together need to check this out. You may be given bromocriptine to block the prolactin. Galactorrhea is often associated with amenorrhea; failure to get your period. It can also be caused by major tranquilizers, marijuana consumption, or high estrogen doses.

Galactorrhea is diagnosed only when the discharge is bilateral. Many doctors don’t understand this, and send patients with any discharge for prolactin level tests. They shouldn’t; the unilateral discharges are not associated with hormonal problems. Unilateral spontaneous discharge is anatomical, not hormonal, and the money spent on prolactin tests is wasted.

Other Nipple Problems
There are a few other problems women can have with their nipples. Some women complain of itchy nipples. Usually, this doesn’t indicate anything dangerous, especially if both nipples itch.

Ductal Anatomy

All of this structure is really there to surround and support the critical ductal system. Although the ducts and lobules are the main “business” part of the breast, their anatomy has largely been ignored.

There was a study by Sir Astley Cooper. Experimenting on cadavers, he injected soft wax into the ducts through the nipple, and made casts when the wax hardened. He discovered that the ducts did not connect to one another, that there were separate ductal systems. Though he mentioned that the nipple contained between 15 and 20 holes, he found that he could only get into between five and eight milk duct openings.

From then on all the textbooks dutifully reported that there were 15 to 20 ductal systems. No one followed up on Dr. Cooper’s research, and no one thought to investigate the issue further.

So there was another doctor began to explore the possibility of an Intraductal approach to the detection of precancerous cells. He had to start at the beginning. He and his team tried to figure out an easy way to determine how many holes there were in the nipple. One of the research assistants, Jean Chou, came up with a wonderful idea: they could undoubtedly see the ductal openings best when women were breast-feeding, so why not go to meetings of La Leche League? This organization promotes breast feeding, and with their help Jean was able to examine the women who were breast-feeding and map the holes in the nipple that were squirting milk.

She examined the breasts of 219 amiable women who had agreed to have their breasts catalogued by a stranger. Examining both breasts, she mapped out the openings. She found that there were about six to eight, arranged in a fairly consistent pattern. It’s possible that she missed a few. If you’ve ever breast-fed, you know that once the milk starts coming out, it’s like a watering can—and of course it immediately becomes one big blob of milk on your nipple. Still, if she was undercounting, it was probably by two or three, not by 10 or more.

Usually, we learned, there are two or three milk duct orifices in the center of the nipples, with others scattered around them. The middle ones were consistent in all the women they examined. The number and placement of the openings around the periphery tended to be more variable: one woman might have three on the outside, and another, five. However, they never varied in an individual woman: if she had three in her left breast, she had three in her right breast.

What, then, were those other holes that Dr. Cooper found back in 1839—the ones that everybody’s been calling “ducts” ever since? They’re little glands that make a sebaceous material—a white, oily, cheesy substance. These sebaceous glands are found all over the body. No one knows what they’re for, or why there are so many around the nipple. Their theory is that the body produces them to provide a coating and protection for the skin—sort of your own little skin-care system. The nipple, designed to be sucked on, is especially vulnerable to getting chapped and sore, so it makes sense that it would have a lot of these glands.

We then explored the anatomy beyond the nipple by studying cadavers and breasts that had been removed by mastectomy. The duct opening in the nipple leads into the breast in a straight line for a very short distance—only about a centimeter. It has a small amount of keratin—dead skin—that forms a kind of plug. There’s a little sphincter muscle here that prevents a breast-feeding woman from having milk spill out when she’s not actually in the process of feeding her baby. Behind that is a little antechamber called the lactiferous sinus. From there, the ductal system, like a tree, breaks up into little branches, which go all the way to the back of the breast. These branches are the ducts. Leafing out at the end of each branch are the lobules, which make the breast milk and then send it through the ducts to the nipple. Each ductal system is independent of all the others; each creates milk separately. They coexist, but they don’t connect with one another.

In the ’70s and ’80s  Dr. Otto Sartorius, a breast surgeon in Santa Barbara, did many ductogram—a procedure in which he put a tiny catheter into a woman nipple, ran dye through it, then took x rays. He did about 2,000 of these procedures. When he died in 1994, another doctor inherited these x rays and continued his work. The research team analyzed the x rays, which gave us a good idea of where ducts tended to be within the breast. They discovered a few surprises. Until now, they’ve visualized the breast as though it were pie-shaped. Finally, the obvious occurred to them—the breast isn’t two-dimensional! Anatomy exists in three dimensions, though it appears two-dimensional in photographs and x-ray images. The breast is in reality shaped more like a giant gumdrop. What this means is that the ductal systems go from the nipple toward the chest wall. One system might cover the whole upper part of the breast, or perhaps two or three ducts cover that area. In addition, the ductal systems run throughout the breast, often as far up as the collarbone or as far down as the lower ribs. The x-ray studies of the ducts matched the findings from La Leche League, even though they involved different patients. Medically, then, it may be that they should be thinking not of a breast, but of six to nine ductal systems.

Effects on Breasts

Even though breasts of non-pregnant women are considered inactive, they undergo cyclic changes associated with normal ovulation. Some women face premenstrual enhance in breast size and density. Many women also feel the tenderness on breasts. This is probably because of the tissue edema. For older women who have fibrotic lumps might feel painful along the perimeter of breast mass. The changing levels of estrogens and progesterone during the menstrual cycle can also cause density changes.

Other factors like hormone therapies such as birth contraceptives can also affect on the breast density. Estrogens and progestins supplements simulate premenstrual breast changes and make breasts tender. At the menopause period, there many changes occur with gonadotropins, estrogens and progesterone levels as well as in both glandular and ductal components. Without the therapy, a large amount of the glandular elements reduces and volume of the breast begins to be smaller. Also, there is a loss of contour in structure because of the decreasing.

When women get pregnant, various changes occur with breasts including gradual increases in weight and size as it produces milk. Breastfeeding also continually changes the density, and nipples are extremely vulnerable to chaffing by fabric rubbing. So, pregnant and lactating women should wear appropriate bras while attending physical activities.

Lack of internal anatomical support of breast structures needs some external supports. Too much movement of breasts during exercise might also raise this need for some women due to structural changes during pregnancy and menstruation.

Early Development

Human breast tissue begins to develop remarkably early—in the sixth week of fetal life. It develops across a line known as the milk ridge, which runs from the armpit all the way down to the groin. In most cases, the milk ridge soon regresses, and by the ninth week it’s just in the chest area. (Other mammals retain the milk ridge, which is why they have multiple nipples.) So you already have breast tissue at birth, and it’s sensitive to hormones even then (your mother’s sex hormones have been circulating through her placenta). Infants may even have nipple discharge. This “witch’s milk,” as it’s called, goes away in a couple of weeks, because the infant is no longer getting the mother’s hormones. Between 80 and 90 percent of all infants of both genders, have this discharge on the second or third day after birth.

Dr. Nicholas Petrakis, a researcher in San Francisco, has been studying infants’ breast tissue. He is looking at the possibility that it’s a sign of how much estrogen the fetus is exposed to in utero. With a group of women in mainland China and a group in San Francisco, he is comparing the amount of breast tissue in babies in the neonatal nurseries, to see if the exposure that leads to cancer actually begins in the mother’s uterus. There is a very low incidence of breast cancer in mainland China, a very high incidence among white women in San Francisco, and a moderate incidence among Chinese women who have migrated to San Francisco. If indeed it proves that the babies of the women in China have less breast tissue, it could be an early tip-off about those infants who might be at higher risk as they grow older.

If your baby has a lot of breast tissue, however, don’t panic. Dr.Petrakis himself isn’t even sure his theory is correct: it’s simply an area worth studying. Even if he finds a big difference in the amount of breast tissue that has witch’s milk, it wouldn’t prove a correlation with cancer. It would simply mean this warrants further study. In any case, many other factors are involved.

Evaluating Breast Cancer Screening Tests

There have been several studies examining the value of screening for breast cancer. Accepting that not all cancers will be found early, what evidence is there that the current tools are making a difference? Before we get into the studies, it’s useful to look at a few common biases that complicate the issue of early detection.

The first is lead time bias—the assumption that catching a disease early in its existence will necessarily affect its rate of progress. This is sometimes true and sometimes not. Let’s assume you have a disease that usually kills you eight years after it starts. If the doctor diagnoses the disease in the fifth year, you’ll live three years after the diagnosis. If doctor diagnoses it in the third year, you’ll live five years and we gleefully proclaim that the early diagnosis has given you a longer survival span. Actually, it hasn’t—it’s just given you a longer time to know you’ve got the disease, which may or may not be a benefit. So just looking at years of survival after diagnosis isn’t enough— what to look for is how many people actually die of the disease with and without early detection. Most breast cancers have been around six to eight years by the time they appear on mammogram, and most women with breast cancer survive many years, so this bias can be very misleading.

The second bias is length bias. For instance, take a test done every two years on a large number of people. Fast-growing tumors aren’t around as long, so there’s less time in which they can be detected. Slow-growing tumors are around longer, so you have time to find them. If, for example, one tumor takes six years to become two centimeters, and you do a test every two years, you’re likely to find it before the six years are up. Another, very aggressive, tumor grows to two centimeters in nine months. You won’t find it in your first test, and before you do your second, it’s become a palpable lump and has been found. So screening tests select against fast-growing tumors, and catch the slow-growing ones—which have a better prognosis. It’s like a nighttime security guard going around the bank every hour. The guard will catch a slow robber who takes three hours to get the job done, but the fast robber, who can do the job in 20 minutes, will be in and out before the guard shows up. The chances are that the fast robber is also the most efficient one; the guard will only get the slower, less competent criminal.

Then there’s the selection bias. If you make mammograms available to all women over 50, and you don’t offer any extra incentives to take the test, who’s likely to take you up on your offer? For the most part, it’ll be the people who perceive themselves as high-risk: they’ve already had breast cancer, or their mother has had breast cancer. The women who don’t worry as much about getting the disease are less likely to bother getting the test. So usually the women who go for screening have a higher risk than those who don’t.

Finally there’s the overdiagnosis bias. You detect suspicious areas on a mammogram—they may or may not indicate cancer. Precancer falls into this category: if it were never diagnosed, in many cases nothing would happen and you’d never know you had it. But if it’s overheated—that is, preventive mastectomies are performed wherever it’s found—the cure statistics can get very inflated. If, as it currently appears, only 30 percent of precancers will ever become cancers, and mastectomies are performed on all women found to have precancer, huge numbers of women will appear to have been cured, whereas the majority—70 percent—would never have gotten cancer in the first place.

What’s needed for a truly accurate study is a randomized controlled study with mortality as its endpoint, to take care of the lead time bias, If you take a group of women and pick randomly who’ll get the test and who won’t—that takes care of self-selection and overtreatment. If you have the same numbers of fast- and slow- growing tumors in the overall group, this counters the length bias, and ensures that both the study group and the control group have the same risks of, and the same kinds of, cancer. The studies like this are few and far between. It behooves researchers to examine the data supporting each modality of screening against this standard, however, if they are truly to understand its worth.

The concept of “early detection” is somewhat misleading. But is it a myth? Not really: there are some cancers that truly can be detected early. The myth is the notion that every cancer has the potential to be found early by the current techniques. The study is unfortunately limited by both techniques and understanding of breast cancer. Screening is still the current best tool for changing the mortality rate of breast cancer. The researchers must take full advantage of it while working very hard to find something better.

Facts of Breasts

  • Breasts start growing at age 10 and never stop until your early 20’s.
  • Breasts are overly sexualized in Western culture which make them bigger than a part of a girls physical identity.
  • A biological purpose of breasts is for feeding babies.
  • Having a baby changes breast appearance forever, and many women get bigger breasts after pregnancy.
  • During puberty, breasts can grow rapidly causing discomfort, sensitivity and stretch mark.
  • Bigger breasts do not make a girl more feminine or sexier.
  • Very huge breasts cause back pain and bad posture.
  • Bra are necessary to keep your breasts supported and help stop injury to the breast tissue.
  • Breast cancer is rare in teenagers, but it is important to check your breasts for lumps and irregularities regularly, especially when you have a family history of breast cancer.
  • All breasts are beautiful and amazing to the opposite sex.

Facts of Very Large Breasts

Very large breasts can occur early in puberty, a condition known as “virginal hypertrophy.” After the breasts begin to grow, the shut-off mechanism, whatever it is, forgets to do its job and the breasts keep on growing. The breasts become huge and greatly out of proportion to the rest of the body. Sometimes the condition runs in families. In very rare instances, virginal hypertrophy occurs in one breast and not the other. It’s worth noting here that “large” is both a subjective and a variable term. A five-foot tall woman with a C cup is very large-breasted; a five foot-eight woman with a C cup may not feel especially uncomfortable with her size. A five foot-eight woman with a DD cup is likely to be very uncomfortable.

Large breasts have been a problem for a number of many women. One woman revealed that because people keep staring at her breasts. Another, at 71, still “hunches over” when she walks to avoid having her breasts stared at.

Huge breasts can be very distressful to a teenage girl. She faces ridicule from her schoolmates, and—unlike the small-breasted girl—extreme physical discomfort as well. She may be unable to participate in sports, and she may have severe backache all the time. She usually needs a bra to hold the breasts in, but the bra, pulled down by the weight of the breasts, can dig painful ridges into her shoulders.
If the breasts cause this much discomfort, the girl might want to have reduction surgery done while she’s still in her teens. There are a number of procedures. Though they’re all major surgery, because they’re done on the body’s surface they’re less dangerous than other equally complex operations, and the recovery period is speedier.
The procedures vary according to the size of the girl’s breasts. If they’re really huge, the nipple will have to be moved further up on the newly reduced breast. In this case, the ducts may be cut and so breast feeding will be compromised.

For this reason, some mothers refuse to let their daughters have reduction surgery, urging them to wait until they’ve had their children. This concern must be weighed against the physical and emotional damage the girl will go through first. If she decides to have children, pregnancy itself may worsen her problem. When the breasts become engorged with milk, they become even larger, and thus, in a woman with huge breasts, more uncomfortable. Though it’s unfortunate that someone so young is faced with a decision that affects her whole life, it’s important to realize that not having the surgery will also affect her life. Many girls of 15 or 16 are mature enough to make their own decisions if all the facts are carefully explained to them, including the possibility of bottle feeding. In any case, the losses and gains of either choice are the girl’s, and she should be given the right to decide for herself what to do. She should be encouraged to talk to doctors, mothers of young children, and very large-breasted women; to read all the material she can find about the pros and cons of the procedure and of breast feeding; and to make her decision only when she feels she is fully informed.

Not all problems with huge breasts appear right after puberty. Some comfortably large-breasted women find that their breasts have expanded considerably after pregnancy; others become uncomfortable after their breast size has increased with an overall weight gain. Many surgeons are reluctant to operate in this latter case, preferring to wait till the woman has lost weight. Sometimes, however, this can backfire psychologically: There were women who were so depressed by their huge breasts that they compensated by overeating, thus intensifying both problems. In such cases, the pleasing appearance of their breasts created by reduction surgery can be a spur to continue self-improvement.

In any case, the decision must be made by the individual woman; she’s the one who lives with the problem and she’s the one who can best judge its impact on her life. Some women with very large breasts don’t mind them. One woman, who admits they cause her discomfort, says that she nonetheless enjoys their size. “They feel feminine and sexy,” she says.

Fine-Needle Biopsy

If the patient has a palpable lump, the surgeon will anesthetize the breast with a small amount of lidocaine and then use a needle and syringe to try to get a few cells. Then the material is squirted onto a slide, which is examined under a microscope. This can often show whether something is benign or cancerous. However, since there’s no tissue to look at, just the individual cells, the procedure requires a good cytologist—a specialist in the field of looking at cells rather than tissue—who can look at cells out of context.

Fine-needle biopsies can also be done on lesions that can only be seen on mammogram, although usually we use a core biopsy in that setting.

The rule of thumb with needle aspiration is that three elements should be consistent to determine that the lesion is benign. So if thinking of examination that it’s a fibroadenoma, and it looks like one on the mammogram, and it also looks like one under the microscope after a needle aspiration, then that’s what it is. But if one of those elements is different—if it seems like it’s not a fibroadenoma, even though the mammogram and needle aspiration suggest it is; or if the doctor thinks it is but either the mammogram or needle aspiration biopsy suggests something different—then a larger biopsy will be needed.

Genetic Risk Factors

Hereditary breast cancer first made its appearance in medical history in 1757. A French surgeon named LeGrand told of a nun with breast cancer who was treated by a surgeon in Avignon. The surgeon wanted to perform a mastectomy, but the nun, “fearing extirpation more than death,” refused the operation. She was convinced, furthermore, that it would do no good, as her grandmother and maternal great grand uncle had died of the disease, and thus, she said, “her blood was corrupted by a cancerous vermin natural to her family.” As the pain of her disease worsened, she gave in, had the mastectomy, and was restored to “perfect health.” It would be nice to know how soon after the nun’s surgery LeGrand wrote this, and how long her “perfect health” lasted. 
Some things never change: the nun, just like many women today, tended to exaggerate her risk of breast cancer. While it’s true that breast cancer in the family increases a woman’s chance of getting breast cancer, the additional risk for most women may not be that great.

Genetically, we divide breast cancer occurrences into three groupings. The first, and most common, is sporadic that’s the 70 percent of women with breast cancer who have no known family history of the disease. The second is genetic, there’s one dominant cancer gene, and it’s passed on to every generation. Most people assume that these are the only two kinds of breast cancer: the kind that is inherited and the kind that isn’t. In fact, there is a third group that is much more common than the genetic group. It’s what we call “polygenic,” and it occurs when there is a family history of breast cancer that isn’t directly passed on through each generation in one dominant gene some members of the family will get it and others won’t. Women in this category are at greater risk for cancer than the general public, though less so than women with hereditary cancer.

Dr. Henry Lynch of Creighton Medical School’s oncology clinic did a study estimating the percentages of these genetic groupings of breast cancer within a particular population. He looked at 225 patients with breast cancer, and found that 82 percent had sporadic breast cancer (or no family history), while 13 percent had polygenic and only 5 percent had true genetic breast cancer. Other studies have put polygenic cancers at about 20 percent of breast cancers.

Most estimates are that pure hereditary breast cancer is rare, but it does occur between 5 and 10 percent of all breast cancers fall into this category. In this case, the mother (or father) has a breast cancer gene, and there’s a 50-50 chance it will be passed on to the daughters. If a daughter, or son, has inherited the gene, that gene again has a 50—50 chance of passing on to the next generation. There was one family with a dramatic instance of genetic cancer. The grandmother had it, and the mother had it. The mother was fine after the surgery, but two of her five daughters died of breast cancer, and two others have had the disease. (This is a very different situation from the more common one, when the family members with breast cancer are aunts or cousins rather than mother and sisters, and the risk is not so high.)

There was no test to pick out which women were at risk, and so doctors developed an elaborate system of guesswork based on what knowledge existed. It was sort of like searching for a criminal before the discovery of fingerprints or DNA, but with a fairly good description. If the suspect was a tall blond man with glasses, many tall blond bespectacled men might get rounded up, but only one would be the criminal.

So it was with determining cancer risk. If a woman’s mother or sister had had bilateral breast cancer, or had gotten breast cancer at an early age, or if the woman had more than two relatives with breast cancer, she was at risk. But, as we were to learn later, such a woman, though she had the risk factors, didn’t necessarily have the one element that actually made her at genetic risk—the BRCA 1 or 2 gene. Now that we have a way to test for the genes, the old rules are much less relevant.

Some women have a family history of breast cancer without having an inherited gene. About 20 percent of breast cancers fall into this category. This doesn’t mean the cancer is pure coincidence. These people may have inherited something that makes them more prone to breast cancer. What could make you more prone to breast cancer? Well, you may inherit a gene that causes you to begin menstruating at an early age, or a gene that makes you particularly susceptible to estrogen which means other family members will be likely to get breast cancer.

Another possibility is exposure to similar external risk factors. There was one who is one of five sisters who got breast cancer. The sisters were all tested for BRCA1 and 2, and were shocked to discover they didn’t have it. When all the cancer is in one generation, it’s possible that they were all exposed to an environmental factor that caused the cancer. When this is the case, the gene won’t be passed on to their children: it’s not hereditary.

Genes and Breast Cancer

When you understand DNA, RNA, and protein, you can begin to understand what can happen with cancer. The process can break down at any of these levels. The first level is at DNA. When your eggs are made, the cells divide and put only one DNA strand into each egg. So you give your child half of your DNA, the child’s father gives half of his, and the combination makes a unique whole.

A mutation occurs when the wrong nucleotide gets inserted into the new strand as it’s being made. Going back to our alphabet analogy, there’s a typo in the recipe. Mutations can occur in somatic (cells that form the tissues of the body) or in germ cells (sperm and egg) which are passed on to our offspring. Both types of mutations are important: the first to the given individual and the second to the next generation.

Mutations happen with frequency over a person’s lifetime: exposure to radiation, electricity, infrared light, and dozens of other things can create a mutation. But most are no problems. If you have a typo in a recipe no one ever uses, and it never gets retyped, it doesn’t matter. This is especially true for adults: though infants and young children have constantly changing cells, as we grow older a lot of cell division stops. We don’t, for example, make many more liver cells, and our brain cells, alas, are dying off more often than they are reproducing. So even if there are mutations, they don’t much matter; they won’t reproduce and be passed on to other cells.

There are other mutations that don’t matter either, because “the typo” doesn’t obscure meaning. If your recipe says, “Add one cup of sigar,” you may smile at it, but you know you need to add a cup of sugar. Once in a great while a mutation even creates an improvement. (If the recipe says to add a half cup of sugar, it may end up tasting just as good and being healthier.) In fact, there’s an argument that civilization itself depends on mutations—the mutations involved in evolution.

But sometimes a mutation can be completely destructive, adding a lethal ingredient to the recipe. Birth deformities are caused by mutations. The most severe are those in which the fetus miscarries, or is born dead. This occurs when the mutations are so bad that the body can’t create a person. There are the less severe ones, in which a person can be created but is born with serious deformities such as the absence of limbs, or with serious genetic diseases, like the neurological condition AT in which the child seems healthy at birth but sickens and then dies because a protein necessary for brain growth is missing. These problems tend to be a result of DNA development rather than repair failures. Of course, there are minor and harmless variants of this kind of mutation. A child can be born with an oddly shaped toe, for example. It will never cause a medical illness, nor is it likely to limit the child’s life through the years: it’s simply there. Freckles are another example of a harmless mutation.

Some mutations can be either good or bad, depending on your situation. If you have a mutation that makes you exceptionally tall, it will be helpful if you plan to become a basketball player, or a hindrance if you want to be a jockey.

Then there are the cancer genes. These are genes that normally function in cell growth but which, if altered by mutation or loss, can lead to cancer. Mutations in these cancer genes can be caused by outside forces such as radiation, toxins in food, or environmental pollutants. If you’re not exposed to these factors then the cancer-related genes won’t be activated. Even if one of these genes is activated or altered, unless other cancer genes are also altered, cancer won’t occur. In other words, cancers are due to multiple alterations in a number of genes, not just one.

It’s as though the recipe gets typed by a number of different typists at different stages. The first typist makes the mistake, which then gets built into the manuscript, and it’s always typed that way from then on. Then somewhere down the line another typist makes another error, and it too gets replicated. So now there are two mutations. And so on down the line. At some point the errors become such that the document’s original meaning is destroyed.

Luckily the body has a technique for DNA repair–its own internal proofreader, enzymes called the repair endonucleases. The proofreader reads through the recipe periodically, searching for mistakes, and then fixes them. These enzymes are responsible for quality control: they check every cell before allowing it to divide. So if, for example, you’ve been out too long in the sun and the ultraviolet rays cause a mutation, repair nucleases will catch it. It then has to decide what to do. How badly damaged is this cell? If it’s in decent enough shape, then it’s fixed. If the damage is too great, and the repair nuclease can’t repair the damage in time, the cell senses this and self destructs. It is estimated that our normal cells in the course of cell division contain thousands of DNA errors, which are fortunately detected and repaired. This self-destruction is a form of cell suicide called apoptosis. It occurs when there is something wrong with the cell itself or when the cell receives an abnormal signal from the environment. There may be too many mistakes in the DNA or a very central mistake.

The repair nucleases are usually pretty good workers, but once in a great while they fall asleep on the job, and the cell doesn’t self-destruct. Like the proofreader who’s daydreaming and misses a serious error in the text, the repair nuclease can sometimes let a mutated cell remain, and then divide. Now there are two mutated cells. Whether or not this will cause major problems depends on how important the mutation is.

The fact that this doesn’t happen much more often than it does is testimony to the body’s complex network of protection. There’s a lot of redundancy built into the system. There’s not just one pathway for repair; there are two or three.

Hormones and Breast Changes

Breasts are responsive for the complex interplay of hormones that cause breast tissues to improve, enhance and provide milk. Three main hormones that can affect on breasts breast are estrogen, progesterone and prolactin, which make the glandular tissue to change during a woman’s menstrual cycle. Due to the hormonal level reduction, breasts are less full for 1 to 2 weeks after the menstrual flow. It might be easier to search for the breast lumps at this time. Hormonal level reduction is also responsible for returning the breast shape after the breastfeeding.

Breast appearance changes when women age. For young woman, the breast skin stretches by the developing breasts. Adult breasts are usually rounded and equally full in all areas. As a woman gets older, the peak of breast tissue settles to lower position. The skin stretches and then, the breast shape changes. After the menopause, the composition of the breast changes due to the decreasing of hormones and the amount of glandular tissues.  Fat and ductal tissues become predominant components of the breast. Also, glandular volume reduction can affect on further looseness of breasts.

Hormonal Risk Factors

Aside from genetic risk factors, the other most obvious group of risk factors is hormonal. We know that hormones play a large part in breast cancer because it’s a form of cancer common in women and rare in men, and women’s breasts undergo a complex hormonal evolution that men’s don’t. We don’t yet understand what the hormonal risk factors are, but we have some interesting clues. We know that it has something to do with age and menstrual cycle: the younger a woman is at her first period, and the older she is when she goes into menopause, the more likely she is to get breast cancer, It seems that the longer a woman has reproductive levels of hormones, the more prone she is to breast cancer. If she menstruates for more than 40 years, she seems to have a particularly high risk. If your ovaries are removed early, and no hormone replacement is given, your risk of breast cancer is greatly reduced. It’s not exactly a cure-all, however, since it would also greatly increase your danger of osteoporosis. If you’ve had a hysterectomy, it may or may not influence your vulnerability to breast cancer, depending upon whether your ovaries, as well as your uterus, are removed. If you still have ovaries, your body is still going through hormonal cycles, even though you have no periods.

Pregnancy also appears to affect breast cancer risk. Women who have never been pregnant seem to be more at risk than women who have had a child before 30. And women who have their first pregnancies after 30 have a greater risk than women who have never been pregnant at all. The hormones of a pregnancy carried to term will mature the breast tissue in a young woman. The same hormones after 30 may actually stimulate breast tissue that has already been mutated. Some studies indicate that a pregnancy that ends in a miscarriage or abortion slightly increases your risk, while other studies have not been able to confirm this.

The key seems to be the amount of time between the first period and the first pregnancy. There are a lot of theories about why this is so. One possible explanation is that between menarche and the first pregnancy the breast tissue is especially sensitive to carcinogens. This seems to be true such factors as diet, alcohol consumption, and radiation exposure all seem to have a greater effect on a woman’s breasts between her first period and her first pregnancy than they do later. So it may indeed be that the “developing breast” is more susceptible to carcinogens than the breast that has gone through its complete hormonal development. This increased sensitivity may relate to the breast cells’ capability of mutating up until the first pregnancy. There may be something about the first pregnancy of a young woman that stops the cells from being able to sustain a mutation; thus, the more time cells have to sustain a mutation, the greater the chance that they’ll mutate in response to a carcinogen and in a way that develops into cancer.

Dr. Malcolm Pike thinks the total number of ovulatory cycles a woman has gone through is a factor in her vulnerability to breast cancer, since it’s the length of time between menarche and menopause that seems to count. In fact, a Swedish study found that the total number of regular menstrual cycles prior to the first full pregnancy was a better predictor of risk than age at first period or age at first pregnancy. This may be because early menarche is associated with rapid onset of ovulatory menstrual cycles. Within two years of early menarche (ages 8—11) all cycles become ovulatory; however, late menarche is associated with delayed onset of regular ovulatory cycles that is, for young women who are 13 or older at menarche, no more than 50 percent of their cycles are ovulatory four years after their first period. Estrogen doesn’t always become elevated if ovulation does not occur. Also, it is usually accompanied by a shortened luteal phase, which means less cumulative exposure to high levels of hormones. This has been shown by Leslie Bernstein at the University of Southern California. She suggests that this is another explanation for the difference in breast cancer rates in white and Japanese women in the United States. Asian women have a later age at menarche and menstrual cycles that are on average two days longer than those of white women in the US. (30 vs. 28 days). This increase in days is almost completely in the follicular phase, where estrogen levels are lower.

Another factor relating to the number of menstrual cycles is breast feeding. Recent studies have shown that women who breast-feed for a long period of time (more than six consecutive years) have a decreased risk of breast cancer. In addition, women who have had early pregnancies and have breast-fed have a decreased risk of subsequent breast cancer. This is probably related to fewer ovulatory cycles at a crucial time in reproductive life.

As you see, we’re still very much in the theorizing stage: as yet, we don’t know why there is this vulnerable time in a woman’s life and why or how internal hormones affect breast cancer. Theories are interesting, but more useful to scientists than to individual women, who can’t control heredity, ethnicity, or menarche.

How the Breast Develops

To understand how the breast typically develops, we need to know what it’s for. The breast is an integral part of a woman’s reproductive system. It actually defines our biological class: mammals derive their name from the fact that they have mammary glands, and feed their young at their breasts. Different mammals have different numbers and sizes of breasts, but the most interesting, and probably the most significant, difference between human females and the other mammals is that we’re the only ones to develop full breasts long before they’re needed to feed our young. Humans are also the only animals who are actively sexual when we’re not fertile. This suggests that our breasts have an important secondary function as contributors to our sensual pleasure.

It’s also worth noting that although women have traditionally been thought of as “other” (to use Simone de Beauvoir ’3 word) in our male dominated culture, biologically we’re the norm. The genitalia of all embryos are female. When the hormone testosterone is produced at the direction of the Y chromosome, the fetus starts to develop male genitalia. If the testes are destroyed early in fetal development, the male fetus will develop breasts and retain female genitalia. It makes sense to ask whether the basis of “mankind” is, in fact, woman.

Improvement of the Breast

Although breast growth is invisible until puberty, breast improvement starts early in the embryo and can be seen within a few weeks. Moreover, the earliest stages are similar in both male and female fetuses. Therefore, many men are able to develop functioning breasts when are offered the right hormones.

After birth, breast has only two stages of development. The first one is at puberty with the outpouring of oestrogen and progesterone. The second is on the pregnancy and lactation, when milk-producing lobules begin to be larger.

If a woman remains childless, her breasts will not develop completely. The first stage of breast improvement starts in the embryo at around six weeks with condensation in skin called the mammary ridge or milk line.

When the fetus is six months old, this enlarges from armpit to groin; however, it soon dies back, leaving two breast buds on the upper of the chest. Rudimentary mammary glands develop along the milk line shaping nipples or breasts that sometimes persist when getting old. Rarely, the two breast buds fade away so that the nipples are missing from birth.

As the initial milk development line is similar in male and female fetuses. This development can happen in both male and female.

When a female fetus age around six months old, cells grow inward from each bud. Each column begins to be a separate “sweat” or exocrine gland.

At eighth month of the development, these cells have become hollow so nipple and rudimentary milk-duct system have formed. No further development until the puberty.

The first external sign of breast improvement occur at the age of 10 or 11. The ovaries begin to secrete estrogen leading to accumulation of fat in the connective tissue which causes the breast to grow. The duct system also starts to improve but only to the point of forming cellular knobs.

The mechanism that secretes milk doesn’t develop until the pregnancy. Even though the breast might fully grow within a few years of puberty, the development is not complete until they fulfill their biological function. This is until a woman gets pregnant and breast-feeds her baby.

Breast Maturity

Once a woman reaches puberty, the breasts start to mature, forming real secretory glands at the ends of the milk ducts. These glands are very original and consist of only one or two layers of cells surrounded by a base membrane.

Between this membrane and the glandular cells are other type of cells, called myo-epithelial cells, these cells help contract and squeeze milk from the gland if pregnancy happens.

For the further growth, the lobes start to separate from one by dense connective tissue and fat deposits. This is where natural enhancement formula occurs and allows the growth, which normally happens during pregnancy swells and grows.

Duct system grows after conception and then, more glands and lobules are created. This makes the breast increase as it matures to fulfill its role of preparing food for baby.

Changes in women

For many women, their breasts enlarge and nipples are sensitive and painful before menstruation. The texture of breasts change, and they become rather lumpy with small discrete swellings that resemble orange pips in both texture and size. These lumps are glands in the breast which enlarge in preparation for pregnancy.

If pregnancy doesn’t happen, breasts return back to normal size and the glands begin to be imperceptible to touch within a few days. These changes are only one part of many changes that happen in female body as the result of the monthly ebb and flow of estrogen and progesterone .

Aging of breasts

As we grow, our breasts begin to sag and flatten; the larger the breasts, the more they sag. With the menopause there is a reduction in stimulation by oestrogen to all tissues of body; this results in a reduction in the glandular tissue. So they lose their firmness.

Regular exercise helps prevent or slow down the aging process. Connective tissue in the breast is composed of fibrous protein called collagen, which needs oestrogen. Without oestrogen, it will be dehydrated and inelastic. Once collagen has lost its shape, it could not return to its former condition.

Inflammatory Breast Cancer

“Inflammatory breast cancer” is a special kind of advanced breast cancer, and it’s a serious one. Though we see increasing numbers of cases, it is rare, accounting for only 1 to 4 percent of all breast cancers. Overall survival is worse in women with this kind of breast cancer than in others. It’s called “inflammatory” because its first symptoms are usually a redness and warmth in the skin of the breast, often without a distinct lump. Frequently the patient and even the doctor will mistake it for a simple infection and she’ll be put on antibiotics. But it doesn’t get better. It also doesn’t get worse, and that’s the tip-off: an infection will always get better or worse within a week or two. It rarely stays the same. If there’s no change, the doctor should perform a biopsy of the underlying tissue to see if it’s cancer. Women who have had this cancer had similar stories. One had been breast-feeding and developed what her doctor thought was lactational mastitis, it never cleared up and didn’t hurt much. There was no fever or other sign of infection. It hadn’t gone away or gotten worse in six months. The other one, not breast-feeding, noticed that one breast had suddenly become larger than the other; there was also redness and swelling. In both cases, the doctors at first thought the women had infections. So if the symptoms continue after treatment, you should ask to have a biopsy done of the breast tissue and of the skin itself. With inflammatory breast cancer, you have cancer cells in the lymph vessels of your skin, which is what makes the skin red; the cancer is blocking the drainage of fluid from the skin. There was an intriguing survey on the Internet, done by G. Owen Johnson, a man whose wife had died from inflammatory breast cancer. He asked women with the disease a number of questions about it. Most of the women said they wished they had known that when redness of the breast skin doesn’t respond to antibiotics it might be inflammatory cancer. Probably their doctors were not breast specialists, and didn’t know about this unusual breast cancer.

Inflammatory breast cancer is the only kind of breast cancer that virtually everyone agrees doesn’t call for mastectomy as its sole primary treatment. Because it involves the lymphatic vessels of the skin as well as the breast tissue, and the skin is sewn back together after a mastectomy, doing a mastectomy will leave a great chance of a recurrence in the skin. So we go directly to chemotherapy before we even think about local treatment.

A study published in 1998 shows that the incidence of inflammatory breast cancer doubled from 1970 and 1992. In white women, it went from 0.3 to 0.7 in a thousand, and in African American women it went from 0.6 to 1.1. (Other races weren’t included in the study.) This is reason for concern, but it’s still a small number. Women with inflammatory breast cancer tend to be significantly younger than those with other breast cancers, and African Americans with this cancer tend to be younger than whites.

The three-year survival rate from inflammatory breast cancer has improved in recent years. The study published in 1998 shows an increase in survival of 10 percent (42% survival, vs. 32% earlier), while other forms of breast cancer survival only increased 5 percent (from 80 to 85%). Since the study was done in 1998, the rates may well be even higher by now, as we increasingly use more of a multimodality approach—chemotherapy, surgery, and radiation.

As with advanced cancers, we start with three or four cycles of AC with or without Taxol or Taxotere. Then we’ll do a local treatment— usually mastectomy. Despite the studies, there are still specialists who feel that high-dose chemotherapy with stem cell rescue might have an advantage in this situation. None of the randomized studies reported out thus far focused on inflammatory breast cancer, and women with inflammatory breast cancer were not included in the 10 or more positive randomized studies discussed above. Any woman considering a stem cell transplant should be in a clinical trial.

After the mastectomy, most women will receive four more cycles of chemotherapy followed by radiation therapy to the chest wall. Serious though it can be, inflammatory breast cancer is still an extremely variable disease.

Invasion of the Breast Cancer

Oncogenes, tumor suppressor genes, and mutations are involved chiefly in the cell cycle—in division and proliferation. But they’re not involved in the next step in cancer: invasion.

To become cancer, a cell needs more than the ability to divide and grow out of control. Noncancerous, benign tumors can also do that. What is ultimately crucial is the capacity to invade outside of their own normal territory. The cells in any given area are tightly attached to each other, forming a natural guard against invasion. So for a cell to break outside of its own area and into another requires special qualities.

One of the things we’re all studying now in terms of cancer is that tight cell connection. There is a kind of “glue” called the extracellular matrix holding cells together. If a cell has an enzyme that can dissolve or consume the glue, it will have a much better chance of getting out of its area and into another.

The ability of cancer cells to invade may be caused by a number of things. One is the ability to secrete a protein, metalloproteinases, that actually tells the whole cell combination not to hang together so tightly. Then the other cells behave in a way that allows the cancer cell to escape.

Another possibility is that the cancer cell may be able to push its way out on its own. Cells that surround the ducts, may help hold DCIS inside the ducts and prevent invasion. Perhaps what happens is not that the DCIS develops the ability to get out, but that the myoepthelial cells allow it to get out. Or maybe it’s a combination. Maybe what allows it to get out is estrogen that you take. Maybe the DCIS secretes something that says, “Let me out,” and the cells obey.

There are a lot of different ways it might happen. That’s good in the long run, because there are a lot of potential ways we can interfere with the process. But it’s difficult in the short run because it makes these complicated to figure out.

With the discovery of these various cancer genes, a new paradigm for thinking about breast cancer and subsequently treating it has emerged. To illustrate this paradigm, we need to switch metaphors temporarily. We’re leaving the cozy world of cookbooks and jumping into the world of crime. Scientists take cancer cells and grow them in petri dishes and then study their behavior. It’s a little like putting criminals in isolation chambers and then studying their personalities. They’re not interacting with anyone, so there’s really no way to measure how they behave. They’ve finally begun to realize that if we study cancer cells in their own environment they can learn a lot more, because the cancer cells interact with the surrounding cells (stroma) and the surrounding cells have an effect on them.

Let’s look at a hypothetical murderer. To begin with, maybe she’s born with a sociopathic character—like the girl in The Bad Seed. But how is she raised, and in what environment? Let’s say her parents are too busy with their social lives to pay much attention to her and there are no strong, loving family members; kind, responsible neighbors; solid school, or good community activities, to offer positive behavioral guidance. There are drug dealers at her school and she’s impressed with them. Nothing prevents her from hanging out with them, and soon she’s in a world where she learns criminal skills. Each of these factors plays its part in her ultimate criminal behavior. Had the original sociopathic tendencies been absent, the environment might not have made such a difference: she wouldn’t be predisposed toward criminal acts. But even with the sociopathic tendencies, early training might have worked against the predisposition, developing a strong conscience that would prevent her acting on her instincts. Finally, even with the sociopathic tendencies and the amoral background, she might not have learned the skills to become an efficient criminal. Of course, her basic predisposition might not be permanently countered by the wholesome influences in childhood. As an adult, away from those influences, she might find herself in circumstances that nourish her basic character—“fall in with a bad crowd.” And so that good little girl be- comes a middle-aged murderer.

This may be how it works with cancer. Mina Bissel, a researcher in Berkeley, California, has begun studying breast cancer cells in a breast tissue environment. She has taken breast cancer cells that have the mutations of breast cancer and grown them in a culture of normal breast extracellular matrix. In that environment the cancer cells behaved like normal cells—they made ducts and did the other things that healthy breast cells do. The healthy influence of the surrounding cells caused the cancer cells, even though they were genetically altered, to conduct themselves properly—like the sociopath in the perfect environment. When Dr. Bissel and her associates put the same cells in an artificial environment, the cells went back to behaving like cancer.

How does this work? As the cells grow, they make certain proteins—growth factors, cytokines, enzymes—that are messengers telling the surrounding cells what to do. The surrounding cells then respond to these messages with messages of their own. This cross-talk is called epigenetic interaction. It results in a change in a gene expression rather than structural alterations in the genes themselves. Epigenetic interaction is probably an important determinant of cancer cell growth and metastases, and thus it is likely to respond to therapeutic intervention. For an analogy, let us say there is a certain plant that can be pollinated only if there is a particular kind of bee in the environment that will take some of the pollen on its body to another plant. The original flower secretes a message, in the form of a smell, that attracts the bee. The bee then responds by cross-pollinating the plant. If you could block the scent of the flower, that species might well die out. Or you could change the environment so that it was inhospitable for the bee but not the flower. This also would eliminate the species. We don’t want to eliminate any species of flower, of course. But it would be wonderful to be able to eliminate any species of cancer cells by blocking this type of interaction.

This means that, if we find the right tools, cancer may be reversible, or at least controllable, and we won’t have to try to kill every last cancer cell. The ability to control or reverse cancer may also explain a phenomenon known as tumor dormancy. This is thought to happen in women who have had all of their treatment and appear to be cured, but then have a recurrence 10 years later. What were the cells doing for 10 years? They were asleep. What put them to sleep? What woke them up?

There was one cancer patient. She had been trying to do visualization to help work with her therapy, but all the images suggested to her were aggressive ones: sharks inside her body attacking the cancer cells, bullets being shot at them. She had never been comfortable with the idea of these violent battles inside her. Now, she could change that. She could sing a lullaby to her tumor, sending all the cells peacefully off to sleep. It’s an interesting idea.

Joy of Your Breasts

One of the most useful concepts to come out of the women’s health movement in the 1970s was the idea that women should become fully acquainted with their own bodies. This had a twofold purpose. The first was a medical one: if we knew what our bodies normally felt like, we’d be better able to know when something was wrong with them.
The other, more profound purpose was to help us know, accept, and cherish our bodies. In our culture, people, and particularly women, have been taught to feel shame and alienation around their bodies. And we’re taught this early in childhood.

Babies, unconditioned as yet by social constrictions, are wiser than their elders. Watch a baby gleefully playing with its toes. We smile at this, without learning its real lesson. Too often we stop smiling when the baby’s joyful self-discovery begins to include genitals. Early on, children learn that body parts associated with sexuality are taboo. We need to reverse this process, to teach little children to respect and cherish their bodies. And as adults, we need to reclaim that lesson for ourselves.

This is as true for breasts as for any other part of the body. Little girls should be encouraged to know their breasts, so that when the changes of puberty come about, they can experience their growing breasts with comfort and pride, and continue to do so for the rest of their lives. Most of us have not been raised that way, however, and it’s often hard for an adult woman to begin feeling comfortable with her breasts. Yet it’s important to become acquainted with your breasts to know what they feel like, and what to expect from them. No part of your body should be foreign to you.

This part helps you to get acquainted with your breasts, and learn how to explore them yourself. It isn’t as easy as it might seem because of all the taboos about “erogenous zones.” Our culture both overemphasizes and negates sexual arousal, and that makes it difficult to allow yourself to touch your breasts unself-consciously.

There are two things to remember as you read this section. One is that breasts are a body part, just as elbows and ribs are, and there’s nothing shameful about exploring them. The other is that for many women they are centers of erotic feeling, and in the process of exploring them you might experience some sexual arousal. So what? That’s a perfectly reasonable response. We’ve finally come to realize, in child rearing, that it’s a bad idea to teach kids to be ashamed of their sexual feelings, rather than help them to understand and cherish them. Similarly, we need to give ourselves permission to feel the entire range of reactions to our own bodies—sexual as well as nonsexual reactions.

To begin getting acquainted with your breasts, simply look at them. Stand in front of a mirror and look at yourself. See how your breasts hang, and get a sense of how they project. If you’re young they’ll tend to stick out more; if you’re older they’ll tend to be more droopy. Look at your nipple—what color is it? Does it have hairs or little bumps on it? If so, that’s perfectly normal. You might want to swing your arms around and watch how your breasts move, or don’t move, with the motion. Put your hands on your hips; flex your muscles; stretch your arms up. How do your breasts look with each change of position?

It’s important to do this nonjudgmentally. You’re not evaluating your possibilities of becoming a Playboy centerfold; you’re learning about your body. Forget everything you’ve learned about what breasts are supposed to look like. These are your breasts, and they look fine.

Then the next step is to feel the breasts. It’s best to do this soaped up in the shower or bath. Your hands slip very easily over your skin. You can put the hand on the side you want to explore behind your head. This shifts the breast tissue that’s beneath your armpit to over your chest wall. Since the tissue is sandwiched between your skin and your chest bones you have good access to the tissue. If you’re very large breasted you may want to do it lying down, in the bathtub or even in bed. You can then roll on one side and then the other to shift the breast closer to your chest wall so you can get a better feel for it.

Breast tissue generally has a particular texture: it’s finely nodular, or granular, like large seeds, or cobblestones. A lot of this more or less bumpy feeling is simply the normal fat that intermingles with the breast tissue.

In the middle part of your chest you can feel your ribs. They jut out from your breastbone. If your ribs are very prominent, you may even feel them under the breast tissue. Many women have congenital deformities in their ribs, which affect the flatness of the rib cage. This can show in different ways. One is the condition called “chicken—breasted” in which the ribs arch outward. Then there’s a sunken chest, in which the breastbone is depressed. Women can have either of these conditions and not realize it because their breasts camouflage their chest structure. Sometimes, when the doctor would do a mastectomy, the patient would discover this unusual rib cage formation and think the doctor created it in surgery.

Another common variation in the rib cage occurs with scoliosis. Many women have minor scoliosis and never realize it. As you feel your breast tissue you may notice that your ribs are more prominent on one side or the other. This occurs because your back is not entirely straight. It has no real significance except that it can cause your ribs to be asymmetrical. Like the breasts themselves, everybody’s rib cage is a little different, and it affects the feel of the breast area differently in different women.

Usually you’ll feel more tissue up toward your armpit than in the middle of the breast. The breast is really tear-shaped. The tissue toward the armpit is often the part that tends to get lumpier premenstrually and less lumpy after your period. There are lymph nodes in the armpits, as there are in many other parts of the body, and if you’ve had any sort of infection you might feel these nodes. The inframammary ridge is an area of thickening, and the older you get, the thicker that area gets. It usually has some fat globules that are larger than in other areas. There’s a hollow spot under the nipple, where the ducts all join together to exit the nipple. Around this area is a ridge of tissue—shaped rather like the crater edge of a volcano.

All of this you can easily get to know with the pads of your fingers just by running your hand over your breast area, getting a sense of how it feels. There’s no point in grabbing at the breast. You won’t get a good idea of its texture because you’re pulling it forward into a big wad.

You can squeeze your nipple if you’re curious about how that feels. Don’t be surprised if there’s some discharge—squeezing the nipple can produce discharge in many women.

To be thoroughly acquainted with your breasts, explore them during different times of the month. Hormones affect your breasts and they’ll feel different at different points in your menstrual cycle. It’s interesting to be aware of these changes. Are they lumpier, or more tender, before your period? If you’ve had a hysterectomy but still have your ovaries, the hormone patterns continue: monitoring your breasts may even help you to know where you would have been in your menstrual cycle. If you’re postmenopausal, or if you’ve had your ovaries out and aren’t taking hormones, the changes no longer occur. Your breast tissue in general will be less sore, less full, less lumpy. If you take hormones—Premarin, or Premarin and Provera—postmenopausal, that too will affect your breasts. They often become more sore and bigger although not necessarily firmer. Similarly, if you’re on birth control pills, your breasts may respond to those hormonal changes by becoming more sore or less lumpy.

There’s a good practical as well as psychological reason for knowing your breasts. Such knowledge can help prevent needless biopsies. In our mobile era, you rarely have the same doctor all your life. If you’ve got a lump from, say, silicone injections or scar tissue from a previous operation, and you go to a new doctor who doesn’t know your medical history, the doctor may well feel a biopsy is necessary. If you can say with conviction, “Yes, I know about that lump: it formed right after my operation ten years ago, and it’s been there ever since,” the doctor will know the lump is okay. If a doctor thinks a lump is okay, but the patient doesn’t know whether or not it’s been there a long while, the doctor has to assume it might be dangerous, and will want to operate. If you know it’s an old lump, your doctor won’t have to worry.

If the doctor argues with you, argue back. Remember that you are a perfectly valid observer of your own body. You don’t need to be a medical expert to know that you’ve had the same lump in the same place and it hasn’t grown at all in 10 years. There was one 80-year-old patient who looked for another new doctor after her doctors insisted that she’d been wrong about a lump in her breast that looked troublesome on her mammogram. Sexism and ageism can unite into a potent force, and obviously the doctors had decided that the “little old lady” didn’t know what she was talking about when she told them her breast had been that way since her last child was born, 50 years earlier. They intimidated her enough so that she decided they must be right and had a biopsy. What the doctor found was a congenital condition, perfectly harmless, that she’d probably had all her life and noticed after breast feeding. She knew her body, as her doctors couldn’t.

Women with disabilities may have a more difficult time getting to know their bodies. Often, as in the case of one woman, they have less mobility and thus don’t reach all the areas of their bodies when they bathe. This woman and many others use adaptive equipment to help them bathe—which is wonderful for its purpose, but of course can’t feel lumps, the way one’s hand does. (For those who wish to do breast self-exam, this is also a problem.) In such cases, more frequent physician examination is a good idea.

Justify Types of Breast Cancer

Another concern is the survival of women who get breast cancer while they’re on hormone therapy. This is fairly complicated. Studies show that women who take hormones get more breast cancer, but the mortality rate among these women is actually between 10 and 15 percent lower than that of other women with breast cancer. The Iowa Women’s Health Study helped explain some of this finding. It showed that the cancers of the women on estrogen tended, not surprisingly, to be more sensitive to estrogen and to have a less aggressive pathology. The tumors were more likely to be colloid, tubular, or medullary than the standard infiltrating ductal. This has been used to justify hormone therapy: if it only causes the “good” kind of cancer, who cares if they get it? Though the mortality is lower, it’s hardly nonexistent: more women are still dying.

Furthermore, breast cancer is no fun, even if you survive it. It’s a bit disingenuous to say that it’s no problem if it’s not a killer cancer. You still need surgery, radiation, and possibly chemotherapy, because you can’t be sure it isn’t going to spread. And you still experience all the fear that goes with having had cancer: the worry that the itch on your breast might be a new cancer, or the gas pain might really be metastasis to the liver. No one who survives cancer ever takes it lightly.

All in all, although we do not as of yet know for certain whether estrogen and its companion progesterone increase breast cancer, there is a lot of circumstantial evidence.
If you’re thinking of going onto hormone therapy, you need a full discussion with your doctor of all the pros and cons, and you should sign a consent form. For the woman with breast cancer or at high risk, the decision about long-term estrogen use is clearer, because the benefits, even to the extent that they’re thought to exist, just aren’t that great. And we have proven alternatives.

Knowledge of Bras

In our society breasts and their coverings have become almost a fetish. The bra is a relatively recent invention—it became popular in the 1920s. As a replacement for the uncomfortable and often mutilating corsets of the 19th century, it was certainly an improvement. However, while wearing a bra is never physically harmful, it has no medical necessity whatsoever. Many of my large-breasted women have found it more comfortable to wear a bra, especially if they run or engage in other athletic activities. As one of them said, “These babies need all the support they can get!”

Many women, however, find bras uncomfortable. Interestingly, there was one woman who got a rash underneath her breasts when she didn’t wear a bra and her breasts sagged, and another who had very sensitive skin and got a rash when she did wear a bra, because of the elastic, the stitching, and the metal hooks (she switched to camisoles). Except for the women who find bras especially comfortable or uncomfortable, the decision to wear or not wear one is purely aesthetic—or emotional.

For some women, bras are a necessity created by society. One woman revealed that she enjoyed going without a bra, but, she said, “Men made nasty and degrading comments as I walked down the street.” Another one, a high school teacher, felt obligated to wear a bra, although she described it as “a ritual object, like a dog collar. . . . I take it off immediately after work.”

But to other women bras can be enjoyable. Some of them like the uplift and the different contours a bra provides. A woman quoted in Breasts said she was “crazy about bras—I think of them as jewelry.” She and others find them sexy and enjoy incorporating them into their lovemaking rituals.

A mistaken popular belief maintains that wearing a bra strengthens your breasts and prevents sagging. But yours sag because of the proportion of fat and tissue in your breasts, and no bra changes that. Further-more, breast feeding and lactation increase the breast size, and when the breast tissue returns to its normal size the skin is still stretched out and saggy. Except for the small muscles of the areola and lobules, the only breast muscles are behind your breast—muscles that will not be affected by whether or not you wear a bra. If you’ve been wearing a bra regularly and decide to give it up, you may find that your breasts hurt for a while. Don’t be alarmed. The connective tissue in which the ducts and lobules are suspended is suddenly being strained. It’s the same tissue that hurts when you jog or run. Once your body adjusts to not wearing a bra, the pain will go away.

No type of bra is better or worse for you in terms of health. Some women who wear underwire bras have been told they can get cancer from them. This is total nonsense. It makes no difference medically whether your bra opens in the front or back, is padded or not padded, is made of nylon, cotton, or anything else, or gives much support or little support. The only time to recommend a bra for medical reasons is after any kind of surgery on the breasts. Then the pull from a hanging breast can cause more pain, slow the healing of the wound, and create larger scars. For this purpose, a firmer rather than a lighter bra is recommended.

Otherwise, if you enjoy a bra for aesthetic, sexual, or comfort reasons, by all means wear one. If you don’t enjoy it, and job or social pressures don’t force you into it, don’t bother. Medically, it’s all the same.

Levels of Sagging Condition

There are different levels of ptosis which are needed certain lifting for correction. Information below is the common ptotic levels for women who experience the sagging breast condition.

How to determine the level of ptotic problem?

Start measuring at your mammary crease as it is directly underneath breasts. You can also use ruler if you wish. The highest part of the ruler should be against junction of breasts and ribcage. Levels of the sagging condition are already listed below.

Mild Ptosis: If the center point of your nipple is above or in front of top of the ruler (your breast crease), you may have level 1 ptosis.
Mild to Moderate: This is when the center point of your nipple is 1 – 3 cm lower top of the ruler.
Severe Ptosis: The center point of your nipple is more than 3 cm lower the top of the ruler.
Pseudo – ptosis: This is when your nipple is above your inframammary crease but it still appears droopy and somewhat flattened. Commonly, ones with pseudo-ptosis have smaller areolas that do not stretch during the pregnancy or weight gain.
Asymmetry: Although your breasts pass the above levels, you may still feel that your breasts are too low or that your areolae have stretched out. This is because of the asymmetry of the breasts themselves.
Low Breast: Some women’s breasts are actually just lower for the chest wall. They have good volume and proper infra-mammary crease, but the entire breast is quite low on torso.


Lumpy breasts have inspired some of the most unfortunate misconceptions about our bodies. Women have been told their lumpy breasts are symptoms of “fibrocystic disease” and have suffered from needless anxiety, fear, and even at times disfiguring surgery.

Lumpy breasts are caused simply by the way the breast tissue forms itself. In some women the breast tissue is fairly fine and thus not perceived as “lumpy.” Others clearly have lumpy breasts, which can feel somewhat like cobblestone paving. Still others are somewhere between the extremes—just a bit nodular. There’s nothing at all unusual about this—breasts vary as much as any other part of the body. Some women are tall and some short; some women are fair-skinned and some dark; some women have lumpier breasts and some have smoother breasts. There can also be differences within the same woman’s breasts.

Your breasts might be a little more nodular near your armpit, or at the top, for example, and the pattern may be the same on both breasts, or may occur only in one. You’ll find, if you explore your own breasts, that there’s a general pattern that stays fairly consistent. It’s important to become acquainted with your breasts and get a sense of what your pattern is.

Myths about Breasts

  • Breasts start growing as early as age 10 and don’t stop until you reach 20’s.
  • Breasts have been sexualized in Western culture which makes them too big a part of girls’ physical identities.
  • Breasts actually have a biological purpose such as for feeding babies.
  • Having a baby changes women breasts forever. Many women get bigger breasts after pregnancy.

Miracle of Breastfeeding without Giving Birth

If you’ve never breast-feed or been pregnant before, you can still do a form of breast feeding. This must be done in conjunction with bottle formula (or milk from another woman’s breast, as in the case of lesbians raising the biological child of one partner together). Stimulated by suckling which increases prolactin, the breast will produce a kind of pre-milk fluid, which can provide a small amount of nutrition to the child.

Since many women find breast feeding pleasurable and since breast feeding intensifies the bonding of mother and infant, this can be a good idea, as long as the baby is given other forms of nutrition. (Men, by the way, don’t have this fluid, since their breasts haven’t developed through puberty the way women’s have.) This kind of breast feeding can be enhanced by using an invention called a Lactaid kit. It has a bag into which formula (or pumped breast milk) is placed, and a long plastic tube that winds around the breast and ends up at the nipple. The child sucks the milk from a catheter next to the nipple, thus creating the bonding effect of breast feeding.

The kit might also help a woman who has had a baby (or been pregnant for several months) in the past to revive her own milk-producing abilities. In this case she will eventually produce full milk. But the chief virtue of the kit is that it helps you to bond with the child and experience breast feeding, even if your own milk isn’t available. Hormones and other drugs have also been used to stimulate breast feeding, with varying results.

Nipples Inversion

There is an operation that can reverse inversion of nipples, but it doesn’t always work, and the inversion may recur. It’s a very simple procedure, usually done under local anesthetic with no intravenous medication, and you can go back to work the next day. The stitches will come out in about two weeks.

Nipples are usually inverted because they are tethered down by scar or other tissue from birth. To reverse it, the surgeon will reach down and pull the nipple, stretch it, and make an incision, releasing the constricting tissue. There are a number of procedures, and each one has its advocates. If the inversion recurs, the operation can be redone.

This operation can make a psychological difference for teenagers, who often feel extremely self-conscious about their inverted nipples. It definitely interferes with breast feeding, but women with inverted nipples usually already have difficulty with breast feeding.

Other Nipple Problems

There are a few other problems women can have with their nipples. Some women complain of itchy nipples. Usually this doesn’t indicate anything dangerous, especially if both nipples itch. You can get dry skin on your nipples as elsewhere. You may be allergic to your bra, or to the detergent it’s washed in. Pubescent girls with growing breasts often experience itching as the skin stretches itself. Otherwise, we don’t know what causes itchy nipples. If they bother you, you can use calamine lotion or other anti-itch medication.

There is a form of cancer known as Paget’s disease that doctors and patients often confuse with eczema of the nipple. It looks like an open sore area, and it itches. If it’s only on one nipple, and it doesn’t go away with standard eczema treatments, check it out. A biopsy can be performed on a small section of the nipple.

If the rash is on both nipples and you tend to get eczema anyway, don’t worry. Anything that can happen to other parts of the skin can happen to the nipple.
Most of these various infections and irritations are benign–they’re more of a nuisance than anything else. If they appear, get them checked out, just to make sure they’re what they appear to be, and to get the relief available.

Procedures of Breast Enlargement

To understand how breast enlargement product works, one should have knowledge of what causes a woman body to develop breasts first.

The research has revealed that breast tissue growth happens as a result of effects on estrogen, progesterone, prolacin, prostaglandins, and hormones that affect on the growth. All of these hormones in the body offer proper balance for breast tissue development.

At the childhood, estrogens are produced in small amount. Then, the quantity of estrogens secreted under the pituitary hormones when one reaches the puberty. During this, sexual organs also improve their abilities. Estrogen level affects on fat deposition, development of the stromal tissues and the growth of extensive ductile system. Hormones include estrogen, progesterone and prolactin are produced more after puberty. These hormones are responsible for increasing lobules and alveoli of the breast by determining the growth and function of the structures.

Progesterone supports the development of the lobules and alveoli. It allows the alveolar cells to proliferate and enlarge. By the way, it does not force the alveoli to produce milk. However, it can also causes breasts to swell due to these changes in lobules and alveoli.

Many scientists have proven that stimulating the estrogen in the breast with estrogen like substance (phytoestrogens) can enhance the size of woman breast as much as 150%.


Estrogen stimulates the growth of breasts and takes responsible for external appearance of the mature lady breasts.

If the ovaries don’t conduct estrogen and progesterone, breasts may not be developed fully. As females get older, ovaries slowly produce hormones which cause sagging breasts. Scientific evidence presents that additional estrogen and progesterone might help increase the breast growth.

Phytohormones are estrogen compound. It shares some biological activities with oestrogens in body. Even though Phyto-estrogens are much weaker than natural estrogens, estrogen-like effects can occur after the consumption of Phyto-estrogens.


After early infancy, not much happens to the breast until puberty. Then the ductal tissue begins to grow and create the beginnings of ducts. Though they aren’t yet capable of making milk, the general outline of the ductal system is there. The cells that make this happen are called stem cells-cells capable of turning into other cells. They’re sort of great-grandmother progenitor cells that can become a lot of things. The stem cells can become duct cells or lobular cells growing along the ductile system.

Soon after the pubic hair begins to grow, the breasts start responding to the hormonal changes in the girl’s body. (Typically, her period won’t start until a year or two after her breasts have begun growing.) They begin with a little bud of breast tissue under the nipple – it can be itchy, and sometimes a bit painful. The rudimentary ducts begin to grow, and the breasts expand more and more until they’ve reached their full growth – usually by the time menstruation begins. One little girl quoted in Breasts, a book of photos and text about women’s relationship to their breasts, described it beautifully: “At first they were flat, then all of a sudden the nipples came out like mosquito bites. And three or four days ago I noticed that my breasts were coming out from the sides. When I first started they were just little lumps by the nipple.”

The first tiny breasts can be confusing to children, and to their parents as well. There was an 11-year-old girl whose mother had breast cancer, and they found what they were sure was a lump under the girl’s nipple. It was just the beginning of her breast development, but everyone, including the child, was so upset so a needle aspiration is performed just to reassure them. It’s never advisable in a situation like that to remove this newly forming breast tissue, since it won’t grow back, and the child will never have that breast.

The rate at which breasts grow varies greatly from girl to girl; some start off very “flat-chested” and end up with large breasts; others have large breasts at an early age. Often one breast grows more quickly than the other.

The emotion confusion around all of puberty can be intensified for the girl growing up in a society that both mystifies and obsesses about breasts. For the adolescent girl, the growth of her breasts can be a source of extreme pleasure or extreme dismay – and often both at once. In a 1980 British survey researchers learned that 56 percent of the women they questioned had been pleased with their breast development, while 33 percent were shy and 24 percent, embarrassed. Ten percent had been “worried” or “unhappy.” Of 165 patients who filled out a questionnaire, 70 recalled having been happy or proud of their budding breasts; 61 had been embarrassed and angry; 20, confused; and 9, ambivalent. One had been “amazed.” Not surprisingly, only four were “indifferent.”

When talking with people about their memories of how they felt when their breasts began to develop, two of the youngest ones had opposite reactions to their breasts’ growth. One, 13, said that when her breasts began to grow, “I felt older and I felt mature, that I was becoming a woman.” She was proud of her new breasts: “I think that for my age, my boobs are just right,” she said. But a 16-year-old girl told that she was embarrassed when her breasts began to grow, because she “always felt as if people were staring at me and talking about me.” She didn’t like her breasts, which she saw as “too hard and lumpy, and triangular, not round.”

One 48-year-old recalled the first day she wore her bra to school: “I was so proud – I was the second girl in the sixth grade to have one. All the other girls gathered around me and I showed them my bra.” A 44-year-old remembered “anticipating with joy and awe that my body was changing, and the blossoming of my breasts was such a delightful, exciting period for me. I was becoming a woman!” Others were less delighted. A 39-year-old remembered thinking, “Oh, shit, now I’m supposed to be a girl!” To her, developing breasts represented confusion and “the world getting much worse.” Another, 45, hated her new breasts so much that she would fantasize about ways “to cut them off with my grandmother’s long, thin embroidery scissors.” She was ashamed of them, and angry at her mother for making her drink milk, which she was convinced had caused her breasts to grow. A 65-year-old woman said that she hadn’t been “ready for this sign of growing up. It was like going down a roller coaster and not being able to stop it.” A middle-aged mother recalled that for many years she wore overlarge sweaters to hide the breasts that embarrassed her. “My teenage daughter does the same thing now,” she said, “and it makes me a bit sad to remember that stage of my life.” For many women, breasts represented enforced femininity: they could no longer play ball with the boys, and felt they had lost forever a kind of freedom little boys still had.

On the other hand, a delay in the appearance of breasts can be equally upsetting. A woman, whose breasts didn’t begin developing until her mid-teens, recalled her feelings of inadequacy. “I was so upset,” she said. “My grandmother had told me that I’d get breasts if I rubbed cocoa butter on my chest. So for months, every night, before I went to sleep, I rubbed cocoa butter on my flat little chest, hoping I’d wake up with breasts.”

Sometimes, because of their hormonal development, adolescent boys develop a condition called gynecomastia – which translates to “breasts like a woman.” For obvious reasons, the boys’ reactions don’t parallel the ambivalence of the developing girls – for them, breast development is uniformly embarrassing. There was a seventh-grade boy who was so humiliated by it that he paid another boy to push him into the swimming pool: that way, he didn’t have to take off his shirt to swim, and didn’t have to explain to the other kids why he was swimming with his shirt on. Some people are suffering from gynecomastia, and their mental anguish, as well as their acute embarrassment at having to show their chests. Fortunately the condition usually regresses on its own in about 18 months; if it doesn’t, it can easily be helped through surgery.

Quality of Mammograms

Today, all mammography units must be accredited by an FDA-approved accreditation body (certified by the FDA as meeting the standards) and prominently display the certificate issued by the agency. The initial quality standards for mammography facilities to meet FDA certification went into effect in December 1994. They include the following: radiologic technologists who perform mammography, physicians who interpret mammograms, and medical physicists who survey equipment must all have adequate training and experience; each facility must have a system for following up on mammograms that reveal problems and for obtaining biopsy results. In 1996 the FDA along with the National Mammography Quality Assurance Advisory Committee developed additional and more comprehensive final standards, which include: (1) a consumer complaint mechanism to provide women with a process for addressing their concerns about mammography facilities; (2) special techniques and personnel qualifications related to mammography of women with breast implants; (3) communication of mammography results to referring physicians and all examinees (that means you) in writing; and (4) additional clinical image review and examinee notification requirements when a facility’s images are determined to be substandard. In addition, there is standardized reading of mammograms (called the BIRADS system) whereby all mammograms are classified according to five categories.

Mammography now is the one place where we really do have quality control—something we have of in the rest of breast care, and indeed in much of medicine.

Reduction of Breasts

Most women come for this operation because they’re embarrassed by their large breasts or because they have discomfort from neck and back pain. As with the other operations described in this chapter, if a woman is over 35 she should have a mammogram to make sure there’s no cancer.

The doctor will explain what sizes are possible; many women want to be a B, and some want to be a C. It is difficult to be sure that the patient and the surgeon both have the same idea of what a “B” or “C” cup is. Normally, women often bring in pictures from magazines to be sure the doctor knows what their expectations are. It’s not always possible to get exactly the size you want, but a good surgeon can approximate it well. Then the operation is scheduled. There are a number of variations of the breast reduction operation, but all start with the same basic procedure.

The operation is usually done under general anesthesia and takes place the day you’re admitted to the hospital. It may last up to four hour. Your nipples can be either removed and grafted back, or left on breast tissue and transposed. Most doctors today prefer not to graft the nipples except in extremely large reductions, since they lose sensitivity if all the nerves are severed.

Most procedures involve some variation of the “keyhole” technique. The amount of tissue to be removed is determined and a pattern drawn on the breast. The nipple is preserved on a small flap of tissue while the tissue to be removed is taken from below and from the sides. This allows the surgeon to elevate the nipple and bring the flaps of tissue together, giving both uplift and reduction. The resulting scars are below the breast in the inframammary fold and come right up the center to the nipple. In recent years, there is a preference for shorter incisions under the breast. In some cases only a circular scar around the nipple is used—the so-called doughnut, or concentric, reduction pattern.

Patients experience pain the first day after the operation, but there’s not much pain after that. You can go home the next morning, wearing a bra or some form of support. The stitches are out in one to two weeks, and you can go back to work; in three to four weeks you can be playing tennis.

Side effects include infection, which can occur with any operation. There’s a slight risk that you’ll need blood transfusions, but it’s very rare. If you’re worried, however, give your own blood to the hospital two or three months in advance, and it will be there in case you need it. There’s some danger of the operation interfering with the blood supply of the nipple and areola; if this happens the nipple and areola die and need to be artificially reconstructed. It’s not a very great danger – it happens in less than 4 percent of operations. The larger your breasts are, the greater the danger. Reduction does not affect a woman’s risk of cancer. Your ability to breast-feed will be decreased; studies show that about half of women who have had reductions can still nurse their babies.

Some of the erotic sensation in your nipples may be reduced, though for many women the increased relaxation actually makes sex more pleasurable after reduction surgery. Also, because the nerves in the nipple of the overlarge breast are so stretched out, the nipple is unlikely to have much sensitivity to begin with, and the loss of sensation—in terms of both sexual activity and breast feeding—will probably go unnoticed. There’s also a possibility of some reduction of sensitivity in the breast itself, although again this is minimal. There’s no way to know in advance whether or not you’ll experience reduced sensation, so you have to decide for yourself how important full sensation is, compared to whatever physical or emotional discomfort your large breasts create for you. In any case, you’ll still retain most of your breast sensation.

If you do decide to get reduction surgery, be aware that if you later gain weight, your breasts will probably also gain weight, just as they would without the surgery. This happened to a number of women. One woman had her size 36EE breasts reduced to a 36B, but they ended up a 36D. The more the patient sees the operation as reconstructive, the happier she’ll be, while the more she sees it as cosmetic, the more critical she’ll be about the result. When it’s only cosmetic, she’s more likely to focus on the scars; if it relieves pain and discomfort, she’ll focus on how much better she feels.

Sagging Condition (Ptosis)

Normally, breasts lose their perk when women get older, and women with extremely will be affected earlier. However, the reasons aren’t related to ligaments or dependent on breast cup size. Inherited characteristics such as skin elasticity and breast density reflect the ratio of lightweight fat to heavier glands.

There is tendency for older women to show sagging breasts. The sagging is caused by partial deterioration of glandular tissues that provide firmness for breasts and some stretching of the tissues connects the breasts to their muscles. Breast sagging occurs for several reasons like pregnancies, breast feeding, rapid weight loss, genetics, gravity and age. Wearing supportive brassieres during pregnancy, breastfeeding, and exercising are recommended.

All body tissues are affected by gravity over time, especially the breasts, because it is an outer organ so it is not protected from external forces. The connective tissues that help support the breast are normally under constant stretch because of the effects of gravity on the weight of breast. This effect causes the sagging effect. Breast feeding is also a factor on breast sagging. The expansion and contraction of the breast tissue over months of breast feeding results in drooping breast appearance changes. Some women may be prone to ptosis due to the changes of weight, genetics or multiple pregnancies.

One reason of breasts sagging condition is lack of estrogen, which normally occurs with the menopause. This estrogen reduction affects all tissues of the body such as breast tissue, and results in reduction in cup size and fullness. Milk secretion process is also stopped by this time. Connective tissue in a breast is composed of fibrous protein called collagen that needs estrogen to keep it strong or else, it becomes dehydrated and loses elasticity.

During pregnancy, the hormones estrogen and progesterone stimulate the development of 15 to 20 lobes of milk-secreting glands in breast’s fatty tissues which are the permanent changes. Although the glands might not be needed to produce milk, they still add volume and firmness to breasts. Once menopause occurs, the decreasing in estrogen and progesterone signal the breast that its milk ducts and lobes to retire. Therefore, the breasts begin to sag over the effects of gravity.

Premature sagging happens as result of stretching Cooper’s ligaments that help support the breast. Breast ptosis can result from loose skin and suspensory ligaments. Ptosis also comes from a reduction of breast tissue amount, which normally occurs after pregnancy and weight loss. One important factor of the sagging breasts is age. As we grow up, our skin ages too because it loses some of its elasticity. The elastic of our skin depends on our ages. That is why many older women have sagging breast condition. For a young woman with sagging breasts, it may be for several reasons. If you are not wearing a proper bra, your breasts can start to sag due to the lack of support, especially for large breast women, and women who may participate in sports without a sports bra. Third cause of sagging breasts in some younger women is the change in breast size after having a baby. A woman’s breasts become bigger and prepare for the milk in production. When breastfeeding is over, her breasts may not turn back in normal shape.

When we start losing collagen and elastin, the breast envelope begins to thin, weaken which is how the skin becomes ptosis (saggy). Although the breasts increase due to pregnancy, they normally sag after the delivery. Other changes can also be caused by breastfeed, estrogen and progesterone supplementation in form or shots, implants or medications, hormonal disorders, menopause and lastly age. We lose breast volume due to shrinking of the lobules that is caused by hormones reduction.

Sex and Breastfeeding

There’s no reason for breast feeding to interfere with an active sex life. Breast stimulation may cause some milk to flow out. Sometimes your lover will actually enjoy sucking at your breast and getting some milk. If this is pleasing to the two of you, it’s fine—your lover won’t be using up your child’s milk, only stimulating the breast to produce more. Orgasm can also cause squirting of milk. If either of you finds stimulation of the breast unappealing at this time, you can adjust your sexual practices accordingly. On the other hand, you may find that your general libido is markedly reduced while you are breast-feeding, and you’re not as interested in sex as you usually are. You may also note that the sudden decrease in estrogen has led to vaginal dryness; lubricants like Astroglide can fix this temporary problem. You and your partner should be aware of this possibility, so your partner doesn’t feel rejected and you don’t feel like you’ve suddenly become “frigid.” In fact, most nursing mothers would much rather sleep than have sex.

Many women feel sexual stimulation during breast feeding, and it’s perfectly natural—oxytocin causes the uterus to contract. Don’t worry about it: it doesn’t mean you’re a potential child molester. It’s usually a “fairly mild form of sexual feeling, and there’s no reason not to just enjoy it. (If you don’t feel it, don’t worry about that either; just enjoy the sensations you do feel.)

The Breast Shapes

Swooping breast is actually common. It might occur due to lack of volume. Among the shapes of breasts, it is the better one to have if you need to get implants. Nipples point upwards is major asset in breast surgery.

The sagging breast with some volume is also very common. After pregnancy, you normally lose the breast tissue, get enlarged areolae and thinned skin. Breastfeeding can also affect on nipple structure as well by causing it to elongate.

Many young mothers may experience the sagging condition after pregnancy and breast feeding. However, it also depends upon individual factors. Anyway, this condition is more common than you think. This is more of a breast anomaly than a shape. It is usually called “tubular breasts” or “constricted breasts”. This kind of breast shape usually occurs due to the position of herniation of tissues, lobules and fat without proper containment by the connective tissue.

Pectus carinatum congenital chest deformity with ptosis is not exactly a breast shape. However, it is deformity or divergence of chest. Sometimes, the ribs stick out much further than the sternum and causes lack of self-esteem or self-consciousness of breasts.

Thinking About Plastic Surgery

None of these operations is medically necessary. Still, we’re lucky to live in an age when they’re available. For a woman deeply unhappy with the way her breasts look, plastic surgery offers a solution that can make a major psychological difference in her life. No operation will make you look “perfect” (whatever that is), but all of these procedures will help you look more normal and feel more comfortable in your body.

If you’re thinking about plastic surgery, you should ask yourself a few questions. The first and probably most important is, who wants the surgery? If you’re contented with your breasts, but your mother or boyfriend or someone else is pressuring you into surgery, you probably shouldn’t do it. It’s your body, not theirs.

The second question is, how realistic are your expectations, and how clear an idea do you have about the kind of breasts you want? Dr. John T. Heuston, a noted plastic surgeon, has written some wise words about reduction surgery that can equally well apply to all forms of cosmetic surgery for the breasts. “The concept of an ideal operation,” he writes, “carries with it the concept of an ideal breast. The surgeon seeks the best means to construct the breast form—but for whom? For him or her, or for the patient, or both?” As Heuston notes, there is no objectively ideal breast; each of us has her or his own ideal. So you should have a clear sense of what size and shape breast you want, and what your own goals are. The surgeon can’t make your breasts absolutely perfect, but if your goals are fairly reasonable, they can come pretty close to being met. If you do decide on plastic surgery make sure you know the range of possible results. Some plastic surgeons like to “sell” their operation—a practice Dr. Goldwyn abhors. “Too often doctors use pictures to seduce patients into surgery,” he says.         “I think it’s a form of hucksterism. If you’re shown pictures of a surgeon’s best result insist upon seeing pictures of the average and worst results as well.” Dr. Shaw concurs. “Communication between plastic surgeon and patient can be very tricky,” he says. “It requires a tremendous amount of honesty and self—restraint. Both the patient and the surgeon constantly need to separate wishes for perfection from the reality of what can be reasonably expected.”

Once you know what you want, don’t hesitate to shop around for the right plastic surgeon. You should choose someone you feel absolutely comfortable with and confident in. Above all, it should be someone who respects your ideal and doesn’t seek to impose her or his ideal on you. The surgeon’s “beautiful breast” and yours may be very dissimilar. Make sure you find someone who will construct your breast. And make sure you find someone who respects who you are, and why you’re making your decision. One woman went to a plastic surgeon when she was 20, hoping to have her painfully large breasts reduced. The surgeon wanted her to wait until she had children and had breast-fed them. She told him she was a lesbian and didn’t plan to have children. “In that case,” he told her, “you won’t need your breasts – why don’t we just cut them both off?” The experience so embittered and intimidated the woman that she still, more than 30 years later, hasn’t had her breasts reduced. Remember that you don’t have to submit yourself to the surgeon’s prejudices. If the surgeon you’ve approached acts insulting or condescending, go out and find someone with a more professional, more humane approach.

Of course, there’s no guarantee that you’ll be happy with your operation after it’s done, even if you have taken every precaution possible. But the odds are on your side. One woman was an 80-year-old woman with huge, uncomfortable breasts. When she was younger, she went to a surgeon to try and get her breasts reduced. He told her she shouldn’t have the operation. She took his advice—those were the days when doctors were gods; you didn’t question them—and since then had been uncomfortable and unhappy with her breasts. After that, she decided to have the surgery done. She was very happy with her small breasts—and very sad about all the years she could have been this comfortable.

Another one was a sophisticated career woman in her early 30s. Her breasts were extremely asymmetrical, she was asked if she’d ever thought about plastic surgery and she was really interested in. After getting the surgeon list, she didn’t even wait till she got home to call them; she found a phone booth downstairs, made an appointment, and had her implant within the month. She’s absolutely delighted with it. Then she had silicone injections for her asymmetry, but it was found that her breasts are no longer perfectly matched, and, as she grows older, the augmented breast sags much more than the natural one. But she is very happy about her decision and says she would make the same choice again today. She keeps in her closet an old V-necked sweater her mother gave her after she finished her injections—a symbol of a freedom she hadn’t known before.

We have seen so much news in the past few years about women who are unhappy with their silicone implants that it’s easy to forget that the vast majority of patients—those that don’t get in the news—are happy with their decision to alter their breasts. Psychologist Sanford Gifford writes about a patient feeling she had “gained something lost in early puberty.” He observes that the degree of satisfaction is much greater among women who have had plastic surgery for their breasts than among those who have had face-lifts or nose jobs—they don’t have the same unrealistic expectations. Often they’re happier with their still-imperfect breasts than the surgeon thinks they should be. For some reason people don’t go into this kind of plastic surgery with the same dreams of impossible perfection they bring to facial surgery.

If you want plastic surgery for your breasts, make sure you have all the information you need about risks, dangers, and reasonable expectations—and then do what you want. And don’t let age deter you from the cosmetic surgery you want. The 80-year-old patient was delighted with her belated operation, and many women in their 50s, 60s, and 70s who have had their breasts reduced or augmented. If your health is good enough to sustain surgery, it doesn’t matter how old you are.


In the ultrasound method, high-frequency sound waves are sent off in little pluses, like radar, toward the breast. A gel is put on the breast to make it slippery, and a small transducer (a device which picks up sound waves) is slid along the skin, sending waves through it. If something gets in the way of the waves, they bounce back again, and nothing gets in the way, they pass through the breast. It never picks out the small details, as an x ray can, but it can show other characteristics of a lump. Ultrasound is appealing because it doesn’t use radiation.

This technique is used mostly for looking at a specific area; if we know a lump is there, we can use ultrasound to get more information about it. It can help determine whether a lump is fluid-filled or solid—if it’s fluid-filled, like a cyst, the sound waves go through it, and if it’s solid, like a fibroadenoma, pseudolump, or cancerous lump, the sound waves will bounce back. So if a lump shows up on a mammogram that we can’t feel in a physical examination, and we want to determine whether it’s a cyst or a solid lump, ultrasound can give us the answer.

Ultrasound can also be quite useful in helping us interpret a mammogram. If the doctor feels a lump and the mammogram shows just dense breast tissue, the ultrasound can sometimes see if there’s a lump within the dense breast tissue, Mammography will only show overlapping shadows, but ultrasound can sometimes distinguish differences in the density of the tissues causing the shadows. Ultrasound isn’t perfect, but it adds another dimension to the imaging possible with mammography. Many cancer centers, therefore, if there is a lesion on a mammogram, will also do an ultrasound.

Because there is no radiation involved, and, as far as we know, sound waves are harmless, ultrasound is also often the best tool for studying benign problems at length, particularly in women under 35. So if a doctor has a younger patient who has a lump, and wants to determine if it’s likely to be a fibroadenoma or just dense breast tissue, ultrasound in that area can differentiate between a distinct lesion with edges or a mixed area without any definite lumps.

A limitation of ultrasound is that it is more dependent than mammography on the experience of the person operating the equipment. Unlike mammography, which shows the whole breast on each picture, each ultrasound picture shows only a small section of the breast. Therefore, the technologist or physician who operates the ultrasound equipment must be able to first find the abnormality and then demonstrate it well on the pictures he or she takes. The technologist or physician holds the transducer directly over the lesion, and the angle at which it is held changes the image. Looking at the photograph of the image at another time can be difficult. The technologist or physician needs to be standing at the patient’s side looking at the screen while performing the examination and taking the pictures. It may be hard for the physician to pick up an ultrasound picture after the fact and be able to interpret it accurately.

Ultrasound might appear like the ideal test, with no radiation and the capacity to tell cyst from solid tissue. Why then don’t we just use ultrasound and not mammography? One problem is that it is not easy to accurately ultrasound the whole breast. There are a few ultrasonographers who are doing it, but it takes a lot of time, patience, and experience. It shows so many changes in contour and density that it becomes very difficult to differentiate normal breast tissue from a lesion. Also, microcalcifications or other lesions visible on a mammogram may not be identifiable on an ultrasound. It may be worth it for women who have dense breasts and are high risk, but other imaging techniques such as MRI may be just as good and less operator dependent. The best use of ultrasound is in investigating one lump or area that has already been detected by physical exam or mammography.

We can also use ultrasound in much the same way we use mammograms to guide needle biopsies. Sometimes ultrasound is a more effective tool for guiding us into the lesion than mammography. Physicians experienced in breast ultrasound can approach the lesion from different directions, which can make it easier to biopsy hard-to-reach areas in the breast, and many find the ultrasound method faster and more comfortable for the patient.

Ultrasound has also been used to look at women with silicone implants to decide whether the implant has ruptured or leaked with a highly skilled technologist and radiologist, it’s very accurate for that purpose.

Just as digital mammography is attempting to make mammography clearer, there are many scientists working on improving the resolution of ultrasound. Three-dimensional ultrasound with even better resolution will be more useful in the diagnosis of breast problems, especially in young women with dense breasts. Color Doppler ultrasound and power Doppler ultrasound are used to show whether there are increased blood vessels associated with a mass. Cancers often have an increase in blood supply, but so do some benign lesions. One study compared the color Doppler images with later examinations of the tumors under the microscope. They found that increased blood flow shown on the color Doppler ultrasound correlated with the size of the tumor and the number of involved lymph nodes but did not correlate with the tiny new blood vessels in the tumor (micro vessel density). In other words, color Doppler ultrasound is better at picking up bigger blood vessels than at showing the very new ones that we think are important at predicting the behavior of tumors.

Whether these new and improved ultrasound technologies will finally prove to be useful for detecting more abnormalities or in making diagnostic decisions will depend on clinical research studies. Meanwhile, ultrasound continues to be an important diagnostic tool for breast cancer diagnosis.

Very Small Breasts

Like “large-breasted,” the notion of “small-breasted” is subjective and relative, and to some extent culturally determined. Some women, however, have breasts so small that their chests look like men’s. This causes no physical or medical problems. Yet it can cause psychological ones, making a woman feel unattractive and sexless. Plastic surgeons often inaccurately call very small breasts a “disease,” contributing even further to the woman’s lack of comfort with her anatomy.

For many women, these problems are solved simply by the use of “falsies” or padded bras. Others want to have the breasts altered. For years there was nothing that could be done for women who wanted larger breasts. Some surgeons experimented with paraffin injections, with fairly awful results. In the 1960s, the silicone implant and silicone injections were introduced.

Drs. Andrew and Penny Stanway in their book The Breast suggest a somewhat surprising alternative to augmentation surgery—hypnosis and visualization. Visualization is a form of self-hypnosis in which you put yourself in a state of deep relaxation and then see yourself, as vividly as possible, achieving the state you want to be in.

The Stanways describe a study in which volunteers, put into a trance, were asked to visualize a wet, warm towel over their breasts. They were told to concentrate on the warmth of the towel and on the breasts’ pulsation. They did this exercise every day for weeks. At the end of that time half the patients reported having to buy bigger bras! The authors suggest that the deep relaxation and visualizing might effect a hormonal change that influences breast size. While the study is handily conclusive, it’s certainly interesting, and you might want to give visualization a try before considering surgery. It’s painless, it has no harmful side effects, and it might just produce the results you want in a less expensive and physically invasive way than surgery.

What to Do If You Think You Have a Lump

If you have something that feels like it might be a lump, the first thing to do, obviously, is go to your doctor. Chances are that the doctor will Check it out, tell you it’s not a lump, and send you home. But a doctor who’s a general practitioner or a gynecologist and hasn’t spent years working on breasts might not be sure, and may send you to a breast surgeon for further examination. Often when you hear the word “surgeon” you get scared—sure that the doctor knows you’ve got something awful and that you will have to undergo major surgery.

Probably you won’t. The doctor is simply, and sensibly, taking no chances, and sending you on to someone with more experience with breast lumps who is thus better able to determine whether or not it’s a true dominant lump. But sometimes even the surgeon can’t be sure. In this case, depending on your age, the surgeon will probably send you for a mammogram to get additional information. The mammogram might show evidence of a real lump, or a pseudolump. If it doesn’t—if even the combination of an examination and a mammogram doesn’t give the surgeon the necessary clarification—it’s wise to do a biopsy to find out what it is. In the past we were afraid of unnecessary surgery and didn’t want to biopsy these “gray-area” lumps. The problem is, you don’t know until you have done the biopsy that it is a pseudolump, so it isn’t unnecessary surgery at all. It’s far wiser to risk a fairly safe operation than to take a chance on letting a cancer go.

One thing is important to stress. If you’re certain that something is wrong with your breast, get it biopsied, whatever the doctor’s diagnosis. Often a woman is sure she has a lump, the doctor is sure she doesn’t, and a year or two later a lump shows up on her mammogram. She believes the doctor was careless. Usually that’s not the case: a cancer that shows on a mammogram probably wasn’t a lump two years earlier, or it would be a huge lump at that point. But it’s very likely that the patient—who, after all, experiences her breast from both inside and outside, while the doctor can only experience the patient’s breast from outside—has sensed something wrong, and interpreted that in terms of the concept most familiar to her, a lump. This is the basis of many of the malpractice suits that arise when a doctor has “failed” to detect what later proves to be cancer. If you really feel something is wrong in your breast, insist on a biopsy. If you’re wrong, you’ll put your mind at rest—and if you’re right, you may just save your own life. It’s a minor procedure with low risks and potentially high gains.

X Ray and Mammograms

A mammogram, like any other x ray, presents a two-dimensional view of a three-dimensional structure. Denser areas appear as shadows. Breast tissue, for example, is very dense, and shows up white on the mammogram. Fat, which is not very dense at all, shows up gray.

When you’re young—in your teens and early 20s—your breasts are usually made up mostly of breast tissue, and are very dense. As you grow older, the breast ages, much as your skin does, and as it ages there’s less breast tissue and more fat. When you’re in your 30s and 40s, it’s about half and half. (This varies with your weight; if you’re very heavy there’ll bea lot more fat; if you’re thinner, there’ll be more breast tissue.) Once you’re in menopause, the breast tissue goes away, and there are usually only a few strands of it left. However, women vary in the proportion of breast tissue remaining after menopause. And if they take hormone replacement therapy, their tissue may remain as dense as it was, or may even become dense.

How does this affect the reading of a mammogram? Cancer and benign lumps are the same density as breast tissue. So if you’ve got a white lump in the middle of an area of dense tissue, it won’t show upon the mammogram—the tissue will hide it. It’s like looking for a polarbear in the snow. But if the same lump is sitting in the middle of fat, it’ll be very obvious—a white spot in the midst of gray. So mammography is more accurate in older women, who have more fat, than in younger women, who have more breast tissue. Sometimes when a patient who’d been for a mammogram and glad been told that her breasts were so dense that mammography wasn’t useful to her. That’s ridiculous—what it means is that mammography wasn’t as useful to her, now as it would have been if she had fatty breasts. Often the woman is around 30, when her breasts should be dense. What it really means is that there’s a higher chance that sometime could be missed (9-20 percent; but there’s also an 80-90 percent chance of picking up something. This isn’t to say screening mammogram is recommended for women at 30, but that a diagnostic mammogram may have some value if there is a breast problem that needs to be explored.

When mammograms show something round and smooth, it’s likely to be a cyst or a fibroadenoma. The mammogram can’t distinguish between cysts and fibroadenomas; you’d follow up with an ultrasound to see if it’s a cyst. If a mammogram shows jagged, distinct, radiating strands, pulling inward, it’s more likely to be cancer. But until it is biopsied, we can’t tell for sure. Several benign conditions can mimic cancer on a mammogram. Scarring or fatnecrosis (dead fat) will look very suspicious; as will a noncancerous entity called a radial scar. This lesion can be confusing even under themicroscope and often requires an expert breast pathologist to be sure it is not cancer.

A mammogram may also show intramammary (in the breast) lymph nodes. In fact, until the invention of the mammogram, we didn’t know there were lymph nodes in the breast. We now know that about 5.4 percent of women will have them. Sometimes you’ll hear about a ’“normal” mammogram. But there’s really no one pattern you can call normal, since there’s no real “normal” breast.

In mammography reports, some radiologists use words loosely—as if they can see what the pathology is when they’re looking at theshadows on the mammogram. So they’ll tell you you’ve got “cystic changes,” which is a variation of our old nemesis fibrocystic disease.All that means is that you’ve got dense breast tissue. Or they’ll tell youyou’ve got “mammary dysplasia,” which sounds very serious and means you’ve got abnormal cells. But the cells aren’t visible on the mammogram—only a biopsy can show cells.What they really mean is, once again, you’ve got dense tissue in your breasts. All a radiologist can tell you is how much breast tissue there is and how much fat tissue, and whether there are abnormal areas of density.

Just as 20 percent of women have some degree of variation in the size of their breasts, variation exists on the inside as well. It will appearon the report as “asymmetry,” and it probably doesn’t mean anything at all—though sometimes, rarely, an asymmetry can be caused by cancer, so you might want to get a second mammogram several months later, just to make sure. If it’s cancer, it’s likely to have changed somewhat during that time. One of the most absurd cases was a patient who’d had a mastectomy on one side, with a reconstruction. She visited the doctor because the report on the mammogram said it showed “marked asymmetry.” Of course it did! The breasts were completely different in their composition; they were meant to look the same on the outside, not the inside.

Years of Menstruation

A girl’s initial breast development is soon followed by the establishment of the menstrual cycle as her body begins to prepare for reproduction. Hormones play a crucial part in this development, as they do in all aspects of reproductive growth. On the ovary are follicles with eggs encased in their developmental sacs. These stimulated by FSH (follicle stimulating hormone) in the pituitary gland, produce estrogen. The resulting high levels of estrogen in the blood in the blood tell the pituitary to turn off the FSH and start secreting LH (luteinizing hormone). When the estrogen and LH are both at their peak, you ovulate – the follicle bursts and releases its egg into the fallopian tube.

The follicle is now an empty sac, but it still has a job to a job to do: it becomes what is known as the corpus luteum, and it starts producing progesterone, which prepares the lining of the uterus for pregnancy (“progesterone” means “pro-pregnancy”). Normally, the egg doesn’t get fertilized: the progesterone level falls off, the lining of the uterus is shed, and you start all over again. If the egg is fertilized, it starts to produce HCG (human choriogonadotropin), which maintains the progesterone level until the placenta takes over the production, and you’re well on your way to a baby.

In addition to maintaining fertility, these cyclical hormones are preparing the breast for a potential pregnancy each month. In a very general sense, estrogen cause the increase of ductal tissue in the breast, and progesterone causes the increase in lobular tissue. This obviously has something to do with the cyclical changes women’s breasts go through – swelling, pain, tenderness – but exactly how does it is still unclear.

Zoom in the Breast Lift

As mentioned earlier, sagging breasts (known medically as “ptosis”) can be made firmer through an operation called a mastopexy, which Dr. Goldwyn describes as “a face-lift of the breasts.” A mastopexy can give your breasts uplift, but Dr. Goldwyn warns that it will not make your breasts look like a 20-year-old’s. And it will leave scars—sometimes bad ones, depending on how your body usually scars. Like a face-lift, it won’t last forever: remember, you’ve got gravity and time working against you.

Your first step is to set up a meeting with your plastic surgeon, who will take a very thorough medical history. You should get a mammogram before proceeding further, if you haven’t had one recently. Be sure to get a full description of both the best and the worst possible results of a mastopexy.

This operation usually involves removing excess skin and fat and elevating the nipple. If you’re very large-breasted, you may want reduction surgery as well, especially since a mastopexy is less effective on very large breasts: gravity pulls them down. If you’re very small-breasted, you may want an augmentation.

If your operation doesn’t involve reduction or augmentation, it’s a simpler procedure, and can be done either in the hospital under general anesthetic or in the doctor’s office with local anesthesia. Since insurance won’t pay for it, most women prefer the latter. The operation lasts about two and a half hours; the stitches are removed in two weeks. By three weeks, you’ll be able to participate in sports. You should wear a bra constantly for many weeks after surgery. Follow-up is minimal—three or four visits during the year after surgery.

You may experience some very slight loss of sensation in the nipple or areola. Other than that, there are no particular side effects to mastopexy.