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CHAPTER FOUR

For Women of Childbearing Age: Birth Control, Pregnancy, and Lactation

FINDING SMALL BREAST CANCERS during pregnancy and lactation is a huge challenge, mainly because significant changes take place in the size, shape, and texture of the breasts while women are pregnant or nursing. As a result, the diagnosis of breast cancer is often delayed, and delays can be associated with adverse consequences.

Since the problems of early detection during pregnancy are different from those of lactation, it is best to consider the two issues separately. However, this section covers a number of issues besides cancer. Amid lingering but mostly unfounded concern about birth control pills and breast cancer, we also discuss the surprising number of options for birth control that women now have available to them.

BIRTH CONTROL

The “pill” first became available to the public in 1960 and proved to be an immediate success. Despite ongoing controversies, its popularity has only increased with time. Millions of young American women are now on this medication and with good reason. Not only is the pill effective in protecting against an unwanted pregnancy, it also has other desirable benefits, including the reduction of mood swings, the limiting of heavy menstrual flow, the improvement of acne, and a lowering of the risk of developing ovarian cancer.

Although this form of birth control has proven to be safe and effective for the majority of women, it does have some limitations, and it is important that young women be aware of them. One significant concern is that the pill is not 100-percent effective. It is estimated that one in 100 women who take it will nevertheless become pregnant. The primary explanation for failure in some women is simple: Usually it’s because they forget to take it on a daily basis.

Another worry is that the pill may influence a woman’s risk of developing breast cancer. The standard combination tablet contains two hormones: estrogen and progesterone. Both are synthetic, or manmade, hormones, designed to match the two naturally occurring hormones in a woman’s body. The first BCPs (birth control pills), which were introduced in the 1960s, contained high levels of estrogen. It was subsequently shown that high-estrogen medications were associated with an increased risk of breast cancers. Today’s BCPs contain a much lower dose of estrogen—but even with these diminished doses, concerns linger about the pill’s safety.

Recent studies have clearly demonstrated that, for the vast majority of healthy young women, these fears are unfounded. The modern combination pill has become the first choice in birth control for most young women up to the age of thirty-five.

However, some users should strongly consider other options. Certainly, if you have either a personal history or a strong family history of breast cancer, an estrogen-containing BCP should be avoided. For example, if your grandmother was diagnosed with breast cancer in her eighties, the risk is inconsequential. But if your mother or sister was diagnosed before the age of fifty, alternative methods of birth control need to be considered.

Women who are concerned about their personal risk should discuss other types of birth control with a doctor, or go to a family planning clinic to get additional, specific information. It is also worth noting that women sometimes overestimate their personal risk, so expert advice on this subject is valuable in making an informed choice.

Women with strong family histories of breast cancer should be evaluated in a high-risk clinic . . . and should also be counseled on the many options of non-hormonal approaches to birth control (such as IUDs, diaphragms, and spermicidal gels).

Other health care issues should be taken into account when deciding on the best form of birth control for a specific woman. Those with clotting problems, such as a history of blood clots in the veins of the leg, should avoid the combination pill. The same is true of women with a history of heart disease, such as high blood pressure or a stroke.

Age is another important consideration. Since the possibility of a malignancy increases with age, I generally recommend that women over thirty-five consider alternatives to the standard pill. In addition, health risks for taking the combination pill are further increased in females who smoke or are overweight.

Fortunately, there are safe alternatives to the standard combination pill. The “mini-pill” is the method of choice for most high-risk women. Besides containing no estrogen, it offers only a synthetic form of progesterone. The mini-pill is extremely effective when taken daily and avoids many of the potential side effects of the combination. This medication has become the preferred birth control choice for women over thirty-five.

The mini-pill is also ideal for women who are at risk of breast cancer because of a strong family history, or who previously had a high-risk biopsy. The same can be said for women with a history of clotting or heart issues. Finally, the mini-pill is the right choice for breast-feeding mothers, since it does not reduce the flow of breast milk as does the combination pill.

Of course, there are other practical reasons for not taking either. For the medication to work, it must be taken on a daily basis—ideally, at the same time each day. If you are concerned about your potential for missing a dose, other alternatives, such as intrauterine devices (IUDs) and contraceptive implants may be the practical answer.

A second limitation is that none of these pills protect against sexually transmitted diseases (STDs). Women who want protection from that possibility should insist their partner wear a condom.

At present, there is incredible competition for creating the ideal pill. As a result, a bewildering list of choices from different manufacturers are available for both the combination and the mini-pill. Although this multitude of possibilities may seem confusing at first, there are benefits to having so many options. If the first pill you select is not well tolerated, there are many alternatives.

One of these choices will almost certainly prove to be the correct one for you.

PREGNANCY

Baseline Mammogram

One matter of importance to women in their mid-thirties who are considering future pregnancies is deciding when to obtain a baseline mammogram. Since breast cancers are more difficult to detect during pregnancy, it is common sense that patient and doctor would want to know in advance if the patient is harboring a small cancer that cannot be detected on physical exam.

A PRE-PREGNANCY EXAM THAT SAVED A LIFE

The Giuliana Rancic story was an eye opener for me. Rancic, a television personality and anchor for E! News, has been very public about her personal problems with infertility. She explained to viewers that she had failed to get pregnant on two attempts at in-vitro fertilization (IVF). She subsequently announced that she had found a world-class expert on IVF and was going to give it one more try.

Even though she was only thirty-six at the time, Rancic’s infertility specialist advised her to have a baseline mammogram before beginning IVF. Despite having no breast symptoms and no family history of cancer, she nevertheless complied with the doctor’s order. All her fans know the rest of the story: A small cancer was detected. She cancelled her IVF, and her cancer was successfully treated. Subsequently, Rancic used a surrogate, and she is now the proud parent of a little boy named Edward Duke.

Had she not gotten the mammogram and instead proceeded with IVF, the story would not have had such a happy ending.

I now think it is appropriate to recommend a baseline mammogram for women in their mid-thirties or older who are thinking about getting pregnant. Women with dense breasts should also consider a screening ultrasound. In addition, those with a strong family history of breast or ovarian cancer should opt for a baseline MRI.

Detecting Breast Issues During Pregnancy

Breast cancers and other issues can be detected early in their evolution if pregnant women follow a short list of guidelines. Having confidence in what the normal breast feels like prior to the onset of pregnancy is the first step.

In general, as we’ve noted in other chapters, we advise non- pregnant women to do monthly self-exams five to ten days after the onset of their menstrual period, since this is the time when breasts are least lumpy. Learning what your normal breast feels like should be started months, if not years, before becoming pregnant. (Guidelines for doing breast self-exams with confidence are outlined in chapter thirteen.)

Just as a non-pregnant woman can learn the pattern of her normal breasts, it is also possible for a pregnant woman to have a clear mental image of evolving, normal changes as her pregnancy progresses.

One approach for a woman to keep track of changes is to review the breast exam with her caregiver at each prenatal checkup. This self-exam should be repeated on the same night as the office exam.

The breasts should also be examined between well-woman checkups. It is normal to see changes as the pregnancy follows its usual course. As long as the changes seem symmetrical on both sides, it is reasonable to assume all is well. If, during the self-exam, one area seems to stand out from the rest, it should be rechecked daily for a few days.

If the area of concern persists, an appointment should be made to review these findings with a medical provider. In most cases, the woman will be reassured that the questionable area can be safely observed. Still, it’s important to make a one-month follow-up appointment. This short interval is vital, because breast cancers can grow rapidly during pregnancy.

If, on the first visit, the caregiver agrees there is an area requiring further evaluation, the next logical step would be a diagnostic ultrasound. If the ultrasound appears abnormal, a referral should be made to a breast surgeon or a breast imager with expertise in dealing with complex breast problems.

For the majority of women, however, that one-month return office visit would be the next step. If the patient is still concerned about a particular area, again a directed ultrasound should be ordered, even if the physical exam seems normal to the clinician. Assuming the diagnostic ultrasound is negative, the patient can then return monthly for at least two more visits.

On the other hand, if symptoms persist and the exam and ultrasound remain negative, the next step is a diagnostic mammogram. Women can be reassured that the mammogram is perfectly safe as long as the abdomen is properly shielded with a lead blanket.

When the doctor notes a problem area on either the ultrasound or mammogram, tissue sampling is suggested, which is typically done with a large bore needle to get an adequate sample. Open surgical biopsy is rarely indicated.

Lactating Adenomas

Most breast biopsies done during pregnancy turn out to be benign. One example of a common benign solid lump is called a lactating adenoma. These lumps are actually more common in pregnancy than during lactation, thus the name is misleading.

Like most benign lumps that occur during this event, lactating adenomas can be safely observed once a needle biopsy has established the diagnosis. However, lactating adenomas may rapidly enlarge, and careful follow-up by an experienced surgeon is indicated. In some cases, rapidly growing benign solid lumps require removal, which is relatively safe if done during the second or third trimesters.

Breast Cancer Treatment During Pregnancy

In the rare case in which the core biopsy does reveal a breast cancer, the patient should be referred to a team of physicians and support personnel who are experienced in meeting the complex needs of a pregnant woman with breast cancer. A comprehensive treatment plan must take multiple factors into consideration, including the health of the mother and her unborn child. Issues regarding the timing of surgery and chemotherapy must be individualized to the patient’s personal needs, based on the stage and aggressiveness of the cancer, as well as to the time period of the pregnancy.

It should be noted that both surgery and chemotherapy are considered safe for the mother and her unborn child after completion of the first trimester. Breast irradiation, however, is not safe.

BREAST ISSUES DURING LACTATION

Soon after delivery, the breasts become engorged with milk. They are swollen, lumpy, and seemingly impossible to examine with confidence. Fortunately, breast cancers are rare in lactating women. However, they do occur, and diagnostic delays are common.

During the first few weeks of lactation, the breasts are so engorged that it is impractical to attempt self-examination. However, over time the breast exam is more easily performed. The best time to do it is after nursing or pumping.

In my own practice I am often surprised by how easy it is to do a clinical exam of a woman who has “emptied” her breasts within the hour of her office visit. This observation leads me to conclude that once the early changes associated with the onset of lactation are resolved, breast self-exam is feasible, and is still the most effective method a woman has to protect herself against a delay in breast cancer diagnosis.

While breast problems are common during lactation, the vast majority are not related to cancer. One of the most frequently seen issues is a plugged milk duct, which can be relieved by applying warm compresses or breastfeeding, or with massage. Sometimes redness and pain develop, a condition called mastitis, in which case antibiotics are necessary.

For women in whom the inflammation does not resolve in a few days or seems to get worse under treatment, referral to a breast surgeon should be considered. Although inflammatory breast cancer (see chapter eleven) is rare, it should be considered in cases in which an inflammation does not respond to standard treatment.

Benign breast lumps that occur during lactation are of two basic types: cystic and solid. “Milk cysts” are those most commonly seen in my practice. They are easy to diagnose on ultrasound, and usually they will go away on their own. But if they are painful or of concern to the patient, they can be easily aspirated in the office under local anesthesia.

Solid breast lumps are also common during lactation. Ultrasound is the first step in evaluating new irregularities in nursing mothers. Solid lumps are easily distinguished from cystic lumps. Benign lumps (non-cancerous) are generally easy to distinguish from those that are suspicious.

Benign lumps are typically smooth and round, and for these I simply aspirate the lump with a fine needle and send the cells to the pathologist. If the review confirms that the cells are benign, I can easily monitor the patient’s progress in my office. If, on physical exam or ultrasound, the mass in question is hard and irregular, I typically go straight to a core needle biopsy.

That said, open surgical biopsy should be avoided whenever possible. An open biopsy during lactation is fraught with problems because of dilated milk ducts and increased blood supply to the lactating breasts.

In rare cases, a breast cancer will be diagnosed during lactation. Just as with pregnancy, a team approach is essential for optimal outcomes. A nursing woman on chemo will need to stop breastfeeding, but can safely continue while on radiation as long as she uses only the non-radiated breast.

WHAT I’D TELL MY DAUGHTER

• The combination pill is an excellent choice for most women, but women should be aware of their personal risks and discuss other options with their physician.

• Continue to do monthly self-exam during pregnancy and lactation and report any persistent major changes to your physician.