Down mammary lane

How do your breasts change as you age? We talk to five breast specialiasts to find out how the breast ages in every decade, exploring what is healthy, what is not – and when you should worry.


What to look out for in your twenties
Expert: Professor Justus Apffelstaedt is an Associate Professor for the University of Stellenbosch and head of the Breast Clinic at the Tygerberg Hospital.  He is a surgeon, with a specialised interest in breast health and is the head of the Tygerberg Breast Clinic in Cape Town. 


According to Professor Apffelstaedt, the earlier you start checking your breasts for lumps, the better. Breast cancer screening, he explains, is one of the most important contributing factors to the dropping mortality of breast cancer.  “It should be a normal health habit you begin doing once a month, ten days after your menstruation,” he says. “And, if you do find a lump, don’t panic. Most lumps in this age group are benign. Watch out for a painless lump, contour changes, changes in the size of the breast, skin changes such as areas of redness that persist for more than five days, changes of the nipple, nipple discharge, skin dimpling, retraction of the nipple and/or skin and lastly, lumps in the armpits.”


Besides conducting a routine breast self-exam, he also recommends an annual clinical breast examination by a healthcare professional. “Your breasts will be checked for a number of changes, including lumps. Mammograms are not recommended in the twenties, as the breast tissue is too dense,” he says.


During this decade, pregnancy and lactation change the breast – and when women delay family planning until after age thirty, their risk of breast cancer is also increased. Professor Apffelstaedt points out that as with all cancers, breast cancer prevention suggestions include; changing to a healthy lifestyle and sound eating habits, avoiding foods known to cause cancer, and taking prophylactic measures, such as anti-estrogens for women with a very high risk of breast cancer.


"Often women incorrectly believe that they have a very high risk of breast cancer, due to a family history, for example,” he says. “Women with a family history of breast cancer should have this history evaluated by a specialist centre to ascertain if their risk is indeed as high as they think it to be. If it is, modern risk management strategies, personalised to the individual woman’s circumstances, can reduce the risk substantially. This relieves a great amount of stress.”


Professor Apffelstaedt is positive about modern cancer management. “Thanks to constant improvements in this arena, the chance of dying of breast cancer is decreasing constantly.”


What to look out for in your thirties
Expert: Dr Rika Pienaar is a private clinical radiation oncologist for GVI Oncology in the Panorama Mediclinic in Cape Town. She is nationally recognised for her talks on breast cancer and has delivered more than 50 invited lectures at national meetings, colleges, universities and women's organisations. 


“All women are at risk for breast cancer, but that risk does not seem very real when we’re young – or in our thirties. Although breast cancer most often occurs in women over the age of 50, about 11,000 women under the age of 40 are diagnosed each year,” says Dr Pienaar. “Unlike women over age 40, most young women discover their own breast cancers. One study from Harvard, for example, found that 71% of women diagnosed with breast cancer at age 40 or younger discovered their breast cancers by self-exam. Most had never had a mammogram at the time of their diagnosis.”


Dr Pienaar explains that younger women diagnosed with breast cancer often experience a more aggressive cancer and a lower chance of survival. For this reason, women in this age group are advised to regularly check their breasts by self-exam. “You may never face breast cancer during your lifetime, particularly before the age of 40, but it is important to understand your risk and to be your own health advocate. Know the landscape of your breasts and alert your doctor right away if they look or feel unusual,” she says. 


According to Dr Pienaar, some studies have suggested that use of oral contraceptives results in a very slight increased risk for developing breast cancer, over those who have never taken them. Women who have stopped using birth control pills for more than ten years do not seem to be at any greater risk. Other studies, however, show no such effect. Researchers continue to study the conflicting results in these trials to determine if birth control pills play a role in breast cancer. 


“Experts suspect that the more a woman is exposed to estrogen, the greater her risk. That might be one explanation for the rising rates of breast cancer in younger women,” she says. “Compared to 50 years ago, women today have a greater lifetime exposure to estrogen, beginning menstruation several years earlier, sometimes as early as age nine, and starting menopause later in life. Contemporary lifestyles may also expose women to more carcinogenic environments and lifestyle behaviours, which can be modified or controlled, for example, whether or not you smoke, how much alcohol you drink and what you weigh.”


She explains that while most lumps are benign, they are often ignored by younger women – and sometimes their doctors, who often believe their patients are too young to get breast cancer – and so, decide to wait and see what happens. “These delays can adversely affect a woman’s overall outcome, because by the time the cancer is finally discovered, it may have spread to the lymph system and other organs of the body, making treatment more difficult,” she says. 

What to look out for in your forties
Expert: Dr Hugo Allison is a general surgeon with an interest in the management of benign and malignant breast disease. He has also been a member of Groote Schuur Breast Clinic for 25 years.


Women in their forties, especially in their late forties and peri-menopausal, can expect changes in their breasts, explains Dr Allison. “Breast tenderness is very common as part of the involuntary changes that take place – and breasts may get larger, especially if there is noticeable weight gain,” he says. “The glandular component starts to atrophy (get smaller) and there is an increase in fat deposition in the breast.  In peri-menopausal women, hormone levels may fluctuate, so breast sensitivity may change.  This is often normal, however, it is important that the focal areas of tenderness or pain be assessed by a doctor or specialist.”


Breast cancer shows a tendency to be more common in women who are overweight and excessive alcohol consumption has also been noted to have an increased risk of breast cancer.  Exercise is important, reducing weight and modifying alcohol consumption are essential, says Dr Allison. 


“Breast self-examination is crucial in this age group as malignancy is usually detected by the woman herself,” he says. “If you find a lump or notice a change in anything in your breast, get is seen to and don't go into denial.  Most likely it is not serious, but you don't want to miss a more serious problem!”


Dr Allison advises women in their forties to pay attention to changes in the skin, as well as dimpling, thickening or distortion of the breast contour.  He also points out that changes in the nipple area are also important to look out for, looking at puckering or retraction of the nipple. “Ulceration of the nipple or spontaneous bloodstained discharge from the breast could be quite serious – and need further investigation by a specialist,” he adds. 


He recommends that all women in this decade of age have an annual thorough breast examination and mammogram done, as a baseline, in their early forties. “If there is a family history of breast cancer, then regular annual mammograms are recommended from the age of forty onwards. This mammogram should also be backed up by an ultrasound – as a mechanism to ensure the breast is healthy,” he adds. 


What to look out for in your fifties
Expert: Dr Irene Boeddinghaus is an oncologist in private practice specialising in the treatment of cancerous and non-cancerous breast conditions. She holds a doctorate in the hormonal treatment of breast cancer, which she obtained from the University of London. She is an author and co-author of multiple papers and books on the subject and has presented breast cancer research at a number of international conferences.

“Women in their fifties should really try to accept routine mammograms as mandatory,” says Dr Boeddinghaus. “Ultrasounds are not always necessary. Some people hope that they can go for an ultrasound without a mammogram, but unfortunately, this way, a lot of cancers can be missed – and we don’t recommend that.” 

According to Dr Boeddinghaus, research has been conducted on the link between obesity in post-menopausal women and breast cancer. “The link is frighteningly clear,” she says. “Also, if you drink more than four units of alcohol a week, there is a 1.5 times higher chance of breast cancer development, so restrict yourself to two glasses of wine per week.” She also encourages women to watch their calorie-intake. “It is not about exercise as much as it is about restricting your diet, so that you can keep your weight down.”

Another common occurrence in the fifties age group is that of breast cysts. “Cysts come under the band of aberrations of normal development and involution or ANDI – in other words, they are associated with aging. They are less common in younger women – although they can occur in the younger age group, but are specifically found in early post menopausal women,” she says. “Few cysts are cancerous – but the only sure guarantee that it is benign, is to have it looked at through a mammogram and ultrasound and aspiration biopsy.” Dr Boeddinghaus explains that cysts can pop up overnight and can also disappear within a few days. For people with multiple recurrences, she advises them to wait, but that if there is ever a smidgen of doubt about a lump, it is important to have it examined by a professional and to have it scanned early. 

“In the fifties, women can experience leaky breasts. This is when the ducts that carry the milk from the breast gland to the nipple age, and you can often end up with a non-bloodstained discharge,” she says. “It is not a pre-cancerous condition, but it can impact upon lifestyle – as nobody likes leaky boobs. This is normally fixed with a small operation, but when it is blood-stained, it definitely needs to be checked immediately. One in ten women experiencing this condition can have an underlying cancer – but if it is not blood-stained, then it is not cancerous. It is just one of those aging problems.” 

In this age group, many women also start hormone replacement therapy (HRT) – and this can often affect the breasts. “HRT can definitely cause lumps and cysts, but this is not to say that HRT is negative – only that is has an effect on the breasts. HRT maintains the density of the breasts so that mammograms may be more painful – and can be less effective in pinpointing cancer,” she says. “Short term use of HRTs, that is, less than five years, does not increase the incidence of breast cancer, but prolonged use, that is greater than five years, can.” 

What to look out for in your sixties
Expert: Dr Peet van Deventer is a plastic and reconstructive surgeon in private practice in Bellville in the Western Cape and holds the post as an extraordinary senior lecturer in the division of plastic and reconstructive surgery at Tygerberg Hospital and the University of Stellenbosch. He is renowned for developing the internal bra procedure for the Breform company, one of the latest developments in cosmetic breast surgery. 


Dr van Deventer explains that as you age, especially in your sixties, all the tissues in the body, including that of the breast, undergo atrophy or wasting. The glandular component and fatty content of the breast decrease in volume, the ligaments weaken and stretch and the skin thins and loses its elasticity. The result, he says, is an ‘envelope’ too large for its contents and loss of function of the supporting structures, causes drooping of the breast, known as breast ptosis. “The attractiveness of the breast may then be lost and affect the person with loss of self-esteem and confidence,” he says. “It can also result in physical problems like the collection of moisture in the fold beneath the breast, resulting in mal-odour.”


According to Dr van Deventer, breast ptosis can be treated by doing a breast lift (mastopexy) procedure. “Excising the excessive skin and reshaping the breast can be beneficial, however, this may be a temporary solution, as the skin will stretch with time – and the breast will droop again,” he says. “In this regard, one of the latest developments in cosmetic breast surgery is the internal bra procedure.  It is a non-absorbable biocompatible mesh, used to reconstruct the ligaments responsible for maintaining breast shape and relieving the skin of that function, maintaining the breast shape and reducing the tension on the suture lines with less scarring.”


With a mammogram, breast cancer can be detected before a mass is palpable and therefore there is a better prognosis in the treatment of this condition. “The glandular component of the breast is prone to malignant change with a higher risk in the older age group. Every woman at every age must learn to do breast self-examination and perform it at least once a month.  At this age, annual mammograms and ultrasounds are also important. This will ensure early detection of abnormalities, which can be investigated and treated if necessary.”


Dr van Deventer recommends women stay healthy by maintaining a constant body mass index between 20 and 25. “Women who smoke put themselves at higher risk,” he says. “Only moderate use of alcohol is advisable.  I also advocate regular exercise and for women to be sexually active.”


Bras that fit like a glove
“Bras do not cause breast cancer, but an ill-fitting bra can lead to a development of what we call an intra-mammary ridge – a thickened area of fibrous fatty tissue on the lower part of the breast, which needs to be distinguished from breast cancer, as it feels lumpy,” says Dr Boeddinghaus. “There is such a wide range of what is considered ‘normal’ in terms of breast size and shape – there is no ‘one size fits all’ – so women need to try out different bras and find the support that is appropriate for them in terms of comfort and preference.”


According to Liezel Morkel, managing director of Lady Chatterley’s Chamber, the online Lingerie Boutique; www.ladychatterleyschamber.co.za, women should pay attention to how their bodies change, because the breast changes constantly, from having a baby, losing or gaining weight and during your period – and so, recommends an annual professional bra-fitting. “It is important to buy according to fit first and sexiness second,” she says. “A bra is the first layer of support and if it fits well, can play an important role in a woman’s confidence and femininity. Don't be afraid to spend a little more on your bra, as the money will be well-spent just to get a perfect fit.”


Arwen Swan, owner of Arwen Garmentry; www.arwen.co.za, agrees. “Don’t cheap out! You can expect to pay more than R600 for a good bra. There really is a reason that they cost as much as they do, a good bra will last you years without distorting, will fit you better from the start, and is made of higher quality fabrics,” she says. 


Swan and Morkel share the following top tips for choosing the perfect bra:

• Get yourself measured! Don’t be embarrassed by your bra size, it’s just a number and wearing the correct size makes all the difference in the world as to your comfort. 
• Try on a number of different styles and brands. Remember different bras look good under different sorts of clothing. 
• D-cups or larger should opt for a corset. Bras take the weight of your bust and hang it from your shoulders and a corset which has vertical boning is designed to take the weight of your bust and put it over your core. 
• B-cups or smaller can try a bikini or triangle bra. These are designed to give natural support, don’t ride up the body, and are usually not padded which is great if you love your small breasts. 
• When trying on a bra, move around in the changing room.  This will demonstrate the comfort of the bra. Also, make sure that it looks natural from all angles.  
• There should never ever be extra space in the cups. When buying a new bra, ensure that the cup fits your entire breast, especially when buying under-wired bras. 
• The new bra should fit perfectly on the first set of hooks. As the bra then gets worn more often, you'll start hooking the bra on the further sets of hooks. This makes a bra last longer.
• Bras differ from brand to brand. Just because you are measured to a specific size, for example, 36D, it does not mean that every bra that is marked a 36D will fit you. Always try on a bigger and a smaller size in any bra, as sizing does vary even within brands.

Author: Charlene Yared-West, Longevity Magazine, Special Supplement: Breast Health Guide: October 2010.