BREASTS A to Z

Breasts A TO Z
A simple guide to the breasts, their anatomy, symptoms, investigation, diseases, management, function and physiology

Dr. Warwick Carter

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BREASTS
Also known as the mammary glands, the breasts are glands that develop on the chest wall of women at puberty. Some women have breasts that are higher or lower on the chest, but when kneeling on all fours so the breast is hanging down, the nipple is usually over the fourth to sixth rib on each side. Some women have round breasts, while others have a more tubular shape. The size, shape and position of the breast is determined genetically, so women are likely to have a similar shaped and sized breasts to that of their mother and both maternal and paternal grandmothers.

The primary function of breasts is to produce milk to feed babies, but they also have a very important role to play as secondary sexual characteristics and thereby to attract a suitable male partner. The milk glands are arranged into 15 to 20 groups (lobes), each of which drains separately through ducts in the nipple. The amount of milk producing glandular tissue is similar in all breasts, regardless of their size. Larger breasts merely have more fat in them. During pregnancy the glandular tissue increases to enlarge the breasts, and make them tender at times. The same phenomenon occurs to a minor extent just before a period in many women due to the increased level of oestrogen (sex hormone produced by the ovaries) in the bloodstream. The breast also contains fibrous tissue to give it some support. The stretching of these fibres causes the breast to sag after breastfeeding and with age. When stimulated by suckling, muscles in the nipple contract to harden and enlarge it so that the baby can grip and suck on it. A similar response occurs with sexual activity, cold or emotional excitement.

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ALLOPLASTY Alloplasty is the use of non-human artificial material in a surgical procedure. This may include silicone breast implants, steel joint replacements or plastic heart valves. AMINOGLUTETHAMIDE Aminoglutethamide is a medication used orally to treat breast cancer and Cushing syndrome. It must not be used in pregnancy unless the mothers life is at risk. Breastfeeding must be ceased before use but it may be used with caution in children. Regular blood tests for thyroid gland function and blood chemistry and, and checking of blood pressure are essential. Do not take it if suffering from porphyria. Side effects may include tiredness, incoordination, dizziness, rash, nausea and less commonly confusion, vomiting and a fever may occur. Interactions are possible with dexamethasone, anticoagulants and hypoglycaemics (used for diabetes). An overdose may cause incoordination, sedation, difficulty in breathing and coma, but death is unlikely. See also BREAST CANCER ANASTROZOLE Anastrozole is an antineoplastic medication used in the treatment of advanced breast cancer. It must not be used in pregnancy, breastfeeding or children, and must be used with caution before the menopause and in patients with liver and kidney disease. The side effects include hot flushes, dry vagina, nausea and thinning of the hair. Unusual effects include vaginal bleeding, tiredness, headache, rash, vomiting, diarrhoea, an increase in blood cholesterol and rarely liver or kidney failure. It interacts with oestrogen. It was introduced in 1996 and acts to destroy oestrogen producing cells in the body. See also BREAST CANCER ANTIOESTROGENS Antioestrogens are medications (eg. tamoxifen, toremifene) that block the action of oestrogen in the treatment of hormone sensitive breast cancer. See also BREAST CANCER; TAMOXIFEN AREOLA The areola is the area surrounding the nipple of the breast that is of a different colour to the normal skin colour and is slightly raised and roughened. Darkening of the colour of the areola occurs with pregnancy and use of the contraceptive pill due to hormonal changes. The actual colour of the areola varies with the natural skin tone of the woman. Specialised sebaceous (oil) glands in the areola give it the characteristic bumpy appearance and secrete an oily fluid that lubricates the nipple. See also BREAST; MONTGOMERY GLANDS; NIPPLE ATYPICAL DUCTAL HYPERPLASIA Atypical ductal hyperplasia is a diagnosis made on a biopsy from a breast lump when the tissue being examined exhibits some, but not all, of the characteristics of a ductal carcinoma of the breast. With these findings it is usually prudent to remove the lump surgically in order to prevent the condition from progressing to a cancer. See also BREAST CANCER; DUCTAL CARCINOMA IN SITU BABY FEEDING A baby will normally be introduced to solids at about four months. These will consist of strained vegetables and fruits. At the beginning they are not a substitute for milk but are simply to get the baby used to them. Gradually solids become an integral part of the diet, and by six months the amount of milk can usually be reduced in proportion to solids in each meal. Breast milk is the best possible food for a baby from birth, and no other milk is needed until one year of age, when cow's milk may be introduced. If the baby is not breast fed, infant formula is recommended for most of the first year, although many babies cope with ordinary cows milk from six months. From the age of about six months it is safe to stop sterilising the bottles. Many babies are able to master the art of drinking out of a cup at about nine months. By the time a baby is a toddler, they should be eating much the same meals as the rest of the family, assuming these are nutritious and well balanced. It is important that food is attractively prepared and presented so 4 !

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that it looks appetising. Some parents become excessively anxious because their child seems to be a fussy eater, and they worry that the child will not receive adequate nutrition. This is usually because meals have become a battleground with a parent insisting on every last scrap being consumed. Once mealtimes become unpleasant, the child not unnaturally tries to avoid them. Children are like adults. Sometimes they are hungrier than other times, and they like some foods and dislike others. If you allow your child some individual choice in what and how much they eat, it is unlikely that problems will arise. If a child goes off a particular food for a period, respect their wish - it will usually be shortlived. It is unknown for a child voluntarily to starve itself to death. There is growing evidence that children should not be overfed. A chubby child has long been regarded as desirably healthy and a tribute to its mother. No-one would suggest that children ought to be thin and that a little extra fat does not provide the necessary fuel for a growing and energetic youngster, but increasingly it is being realised that fat children grow into overweight adults. See also BREASTFEEDING BONDING Effective bonding between a mother and her baby is critical form the wellbeing of both. If an infant is deprived of maternal care, although fed and kept comfortable, it will develop slowly in all areas including physical, intellectual and emotional. Such infants are small for their age, poorly nourished, apathetic, respond inappropriately to stimuli, do not develop language skills and become inactive. Bonding begins before birth as the mother feels foetal movements within her. After birth, the mother and baby become extraordinarily emotionally involved with each other, with the attachment beginning within minutes, and intensifying hour by hour. It is important not to separate the mother and baby during the first few hours after birth except for essential bathing, testing and cleaning procedures. The baby responds to the mothers actions and sounds in order to ensure the bonding develops and continues. There is even a hormonal component to early bonding, as the baby sucks on the breast to stimulate milk production. The baby is even colonised by the same bacteria, viruses and fungi that inhabit the mothers skin, mouth and gut. Immunologically they are almost identical for the first few weeks until other people begin to interact. The bonding can also involve the father, who will become very close to his child, and participate fully in its life and upbringing, but fathers can never know the complete intimacy that exists between a mother and her very own baby. See also BABY FEEDING BRAWNY OEDEMA In medicine the term brawny refers to an area or structure (usually an arm or leg) that is firmly swollen with fluid (oedema) due to an obstruction to the lymphatic drainage. It may occur after the lymph nodes in the armpit are removed for the treatment of breast cancer. BRCA1 BRCA1 is the abbreviation for a gene that produces a protein that prevents excessive cell growth in the breast and protects against breast cancer. Its absence or inactivity leads to a dramatic increase in the incidence of breast cancer in a woman. See also BREAST CANCER BREAST ABSCESS A breast abscess is a collection of pus in the breast that forms due to infection. The usual cause is untreated mastitis during breastfeeding, when a milk duct becomes blocked and the trapped milk and surrounding tissue becomes infected and breaks down to form pus. It is treated with antibiotics and surgical drainage of the pus. See also BREASTFEEDING; MASTITIS BREAST AUGMENTATION Women desiring breast enlargement (augmentation) fall into three broad groups. Those who were born with small breasts, those who have suffered a sagging or shrinkage of the breasts after breastfeeding or with age, and those who have had a breast removed because of cancer (breast reconstruction). Provided the patient is healthy, will benefit from the procedure, and is willing to have the operation there are no other criteria to be met. The operation involves a two or three day stay in hospital. Techniques vary from one surgeon to another, but normally a small cut is made under each breast or in the armpit, and through this a plastic bag of silicone or saline gel (a prosthesis) is inserted to increase the size and improve the shape of the breast. Often a small tube is left behind in the wound to drain off excess fluids that may accumulate. Bandages are tightly bound around the chest and breasts for a few days. The patient should rest for a week to ten days after the operation before returning to normal duties. The stitches 5 !

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are taken out in two stages about one and two weeks after the operation. After six weeks the breasts feel and look completely natural, and the tiny scar is hidden under the breast fold when standing, or in the armpit, so that the briefest bikini can be worn. Complications are unusual, but include excess bleeding and infection. The most common postoperative problem is breast capsule contraction. This occurs months after the procedure and is caused by the body laying down too much fibrous tissue around the implant, which results in the breast feeling firmer than normal. There has never been any link demonstrated between this operation and the development of breast cancer, the woman can still breast feed after the operation, and can still check herself routinely for breast lumps. An attractive bust may improve a woman's self image and esteem, but the operation should not be done for the wrong reasons. It will probably not save a dicey marriage, men will not start rushing to the door and her sex life is not suddenly going to improve. BREAST BIOPSY If preliminary examinations of a lump in the breast indicate that there is a suspicion of cancer, the doctor may order a breast biopsy. This may be performed inserting a hollow needle into a cyst or lump in the breast to extract fluid that contains cells, or some of the tissue may be removed with a knife. A needle biopsy may or may not require a local anaesthetic and takes only a few minutes; it is usually done in the outpatient's department of the hospital, or sometimes in a doctors surgery. An open surgical biopsy may also be done in the outpatient's department with a local anaesthetic, but more frequently it involves admission to hospital and a general anaesthetic. See also BREAST CANCER; BREAST LUMP BREAST CANCER Mammary carcinoma is the technical name for this all too common cancer that affects one in every eleven women at some time in their life. The absolute cause is unknown but it is more common in women who have a close relative (mother, sister, daughter) with the disease, in women who have not had a pregnancy, have not breast fed, have had a first pregnancy after 35 years, in white women, those who have had uterine cancer, and in higher socio-economic groups. On the other hand, women who start their periods late and those who have an early menopause have a lower incidence of breast cancer. About 2% of all breast cancers occur in men as they have a tiny amount of breast tissue present just under the nipple. Extraordinarily, left-handed women have double the risk of developing breast cancer compared to those who are right handed. The symptoms are a hard, fixed, tender lump in the breast. The nipple skin itself can become cancerous (Pagets disease of the nipple) causing a thick, firm, rubbery feeling to the nipple. There are many other causes of lumps in the breast and less than one in ten breast lumps examined by a doctor is cancerous. One method of detecting breast cancer is monthly self-examination. The diagnosis is confirmed by an x-ray mammogram, ultrasound scan of the breast and needle biopsy. The most common form of treatment is a lumpectomy in which only the cancer itself is removed, but if it is too large for this procedure a simple mastectomy, in which only the breast is removed, may be performed, leaving a cosmetically acceptable scar and scope for later plastic reconstruction of the breast. Often the lymph nodes under the arm will be removed at the same time. A course of radiotherapy and/or chemotherapy (drugs) may also be given. Tamoxifen, letrozole, cyclophosphamide, 5-fluorouracil, anastrozole, trastuzumab and toremifene are some of the antineoplastic drugs that may be considered. Preventive chemotherapy with medications such as tamoxifen or trastuzumab may be continued for years. A radical mastectomy in which the breast, underlying muscle and all the lymph nodes in the armpit and other nearby areas are all removed is done rarely, and only for very advanced cancer. More than 3/4 of all patients with breast cancer can now be cured. In early cases the cure rate rises to over 90%. In advanced cases the cancer may spread to nearby lymph nodes, the lungs and bones. See also ATYPICAL DUCTAL HYPERPLASIA; BRCA1; BREAST LUMP; DUCTAL CARCINOMA IN SITU; FIBROADENOMA OF THE BREAST; CYSTOSARCOMA PHYLLODES; HUMAN EPIDERMAL RECEPTOR 2/neu; MAMMOGRAM; NIPPLE DISCHARGE; ONCOTYPE DX BREAST CANCER ASSAY; PAGETS DISEASE OF THE NIPPLE; PEAU DORANGE; TAMOXIFEN; TRASTUZUMAB

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BREAST CYST See MAMMARY DYSPLASIA BREAST DEVELOPMENT See THELARCHE BREAST DISCHARGE See NIPPLE DISCHARGE BREAST ENLARGED Breasts are normally a female characteristic, developing at puberty in the early teenage years, but any human, of any age or either sex, is able to develop breasts if given the sex hormone oestrogen. Those men who have decided to change their apparent sex, and those who wish to be transvestites, may take oestrogen in order to develop breasts, but there are a number of medical conditions that can also cause gynaecomastia (abnormal breast enlargement). Some boys going through puberty find that they are developing small lumps of tissue behind their nipples. This is caused by an imbalance in the sex hormones during this delicate stage of development. Most settle in a few months or a year, but a small number continue to develop excessive amounts of breast tissue and require an operation to remove it. In men the menopause (andropause) occurs in the seventies, while in women it occurs in the late forties and early fifties. As testosterone levels drop in elderly men, the small amount of oestrogen that is present in the system of all men, may no longer be suppressed by the testosterone, and start stimulating breast tissue development. Women taking oestrogen as a hormone replacement therapy after the menopause, or in the oral contraceptive pill, may notice an increase in their breast size. Obesity is an often overlooked cause for breast enlargement in both sexes, as fat may deposit in the breast area more easily than in the surrounding chest tissue. Other causes of breast enlargement include liver failure (oestrogen normally produced by a man or woman may not be broken down and removed from the body at the normal rate), cancer or tumours of the testicle may prevent the normal production of testosterone, or in some cases (eg. teratoma) may start to produce oestrogen instead, Klinefelter syndrome (only affects males who have additional X chromosomes matched with a single Y chromosome), Addison's disease (adrenal glands do not produce sufficient quantities of vital hormones), and a rare form of lung cancer (oat cell carcinoma) will affect sex hormone balance and cause breast enlargement in both sexes. See also BREAST REDUCTION; GYNAECOMASTIA BREAST ENLARGEMENT See BREAST AUGMENTATION BREAST EXAMINATION! It is commonly advised that women are taught how to check their breasts for lumps by a doctor, and perform this easy procedure every month. Women who are still menstruating should do this after their period has just finished. The first step in breast self examination (BSE) is inspecting the breasts in a mirror, with the arms at the sides and then raised above the head. Women should get to know the shape and size of their breasts, and note any changes that occur. The next step is to lie down, and with one hand behind the head, examine the opposite breast with the free hand. This should be done by resting the hand flat on the chest below the breast, and then creeping the fingers up over the breast by one finger breadth at a time. Do this twice, once over the inside half of the breast, and then over the outside half. Check under the nipple with the fingertips and finally check the armpit for lumps. Repeat the procedure on the other breast. See also MAMMOGRAM BREASTFEEDING Breastfeeding is technically known as lactation. After birth, a womans breasts automatically start to produce milk to feed the baby. The admonition breast is best features prominently on cans of infant formula and on advertising for breast milk substitutes in many thirdworld countries, and there is little doubt that it is true. Because of poverty, poor hygiene and poorly prepared 7 !

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formula, bottle-feeding should be actively discouraged in disadvantaged areas. Unfortunately, for a variety of reasons, not all mothers are capable of breastfeeding. Those who can't should not feel guilty, but should accept that this is a problem that can occur through no fault of theirs, and be grateful that there are excellent feeding formulas available for their child. Breastfeeding protects the baby from some childhood infections and the stimulation it also helps the mother by stimulating the uterus to contract to its pre-pregnant size more rapidly. Babies don't consume much food for the first three or four days of life. Nevertheless, they are usually put to the breast shortly after birth. For the first few days the breasts produce colostrum, a very watery, sweet milk, which is specifically designed to nourish the newborn. It contains antibodies from the mother, which help prevent infections. Breastfeeding may be started immediately after birth in the labour ward. All babies are born with a sucking reflex, and will turn towards the side on which their cheek is stroked. Moving the baby's cheek gently against the nipple will cause most babies to turn towards the nipple and start sucking. Suckling at this early stage gives comfort to both mother and child. In the next few days, relatively frequent feeds should be the rule to give stimulation to the breast and build up the milk supply. The breast milk slowly becomes thicker and heavier over the next week, naturally compensating for the infant's increasing demands. After the first week, the frequency of feeding should be determined by the mother and child's needs, not laid down by any arbitrary authority. Each will work out what is best for them, with the number of feeds varying between five and ten a day. Like other beings, babies feed better if they are in a relaxed comfortable environment, with a relaxed comfortable mother. A baby who is upset will not be able to concentrate on feeding, and if the mother is tense and anxious, the baby will sense this and react, and she will not be able to produce the let-down reflex which allows the milk to flow. The milk supply is a natural supply and demand system. If the baby drinks a lot, the breasts will manufacture more milk in response to the vigorous stimulation. Mothers of twins can produce enough milk to feed both babies because of this mechanism. While milk is being produced, a woman's reproductive hormones are suppressed and she may not have any periods. This varies greatly from woman to woman, and some have regular periods while feeding, some have irregular bleeds, and most have none. Breastfeeding is sometimes relied upon as a form of contraception, but this is not safe. The chances of pregnancy are only reduced, not eliminated. The mini contraceptive pill, condoms, and the intrauterine device can all be used during breastfeeding to prevent pregnancy. It is important for the mother to have a nourishing diet throughout pregnancy and lactation. The mother's daily protein intake should be increased, and extra fresh fruit and vegetables should be eaten. Extra iron can be obtained from egg yolk, dark green vegetables (eg. spinach), as well as from red meat and liver. Extra fluid is also needed. See also BREASTFEEDING FAILURE; BREAST MILK; BREAST MILK INADEQUATE; BREASTS ENGORGED; MASTITIS; NIPPLE CRACKED; NIPPLE DISCHARGE; NIPPLE INVERTED; WEANING BREASTFEEDING CESSATION See WEANING BREASTFEEDING FAILURE Most women hope to feed their newborn child for the first few months of life, but unfortunately not all women succeed. The most common reason for failure is emotional or physical stress. The harder the woman tries to succeed, the more she fails. Being relaxed with the baby, the concept of breastfeeding, and the physical and emotional surroundings is vital. To increase the breast milk supply the nipples should be stimulated as much as possible by the baby suckling. The medications domperidone or metoclopramide can also be used to increase breast milk production as they stimulate the release of prolactin from the pituitary gland in the brain. There are medical reasons for being unable to breast feed. A mother who has a significant illness, be it an infection, dietary problems, cancer or any other form of debilitation, is not going to be as successful at breastfeeding as a woman who is in perfect health. In primitive areas of the world, malnutrition may be a factor, but even in developed countries, a fad diet may lack vital nutrients and have an adverse effect. Rarely, damage to the pituitary gland under the brain may be responsible. 8 !

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See also BREASTFEEDING; BREAST MILK INADEQUATE; PROLACTIN; WEANING BREAST FIBROADENOMA See FIBROADENOMA OF THE BREAST BREAST IMPLANT See BREAST AUGMENTATION BREAST INFECTION See MASTITIS BREAST LUMP Breast lumps probably arouse more concern among women than any other condition. This is because of the fear of cancer in an organ that is so significantly associated with femininity and sexuality. It is important to understand that there are many other causes of lumps in the breast, so if a lump develops, particularly in a young woman, the chances are that it is NOT a cancer. Fewer than one breast lump in ten seen by a doctor proves to be malignant. The most important method of detecting breast cancer and lumps is selfexamination by the woman. All women should be taught how to check their breasts for lumps by a doctor, and should perform this easy procedure every month. After examining the breast, a general practitioner may arrange for an x-ray mammogram, ultrasound scan of the breast or a needle biopsy. These tests show the inside structure of the breast and can sometimes differentiate between cysts, cancers and fibrous lumps. If all the features of the examination and investigations in a young woman indicate that the lump is benign, it is safe to watch the lump, with regular checks by a doctor, because many disappear after a few months. In an older woman, or if the lump persists, it should be removed by a small operation. In the majority of cases this is the only treatment necessary, and the scar should be almost invisible on even the most liberated beaches. If the lump is found to be cancerous, a more extensive operation may be necessary. The earlier a cancer is diagnosed, the better the chance of cure, so surgeons have good reason for advising removal of a lump which appears to be benign, rather than waiting until an obvious cancer appears. Infections in the breast (mastitis), particularly during breastfeeding, will cause hard, tender, painful, red lumps. Blocked milk ducts during breastfeeding might also be felt as a lump. If not cleared rapidly, mastitis is a possibility. Other causes of breast lumps include cysts, cystadenoma (a benign cystic tumour involving glandular tissue), a mucocoele, over stimulation of the breast by hormones (eg. hormone replacement therapy, contraceptive pill, pregnancy), collections of fibrous tissue (fibroadenoma), mammary dysplasia, pseudoangiomatous stromal hyperplasia, a blood clot in a breast vein (Mondor disease) and lumps of scar tissue in damaged fat caused by an injury to the breast. See also BREAST CANCER; BREAST EXAMINATION BREAST MILK Breast milk is the perfect food for babies, and can be used alone up to three months of age. It is cheap, easily digested, results in minimal faeces production, protects against numerous infections (eg. gastroenteritis, bronchiolitis) and is conveniently packaged for immediate use without any messy preparation. Colostrum is the type of milk produced from one to five days after the birth of a baby, transition milk from five to ten days after birth and mature milk after that. Breast milk can be scientifically analysed to detect the reason for infant feeding problems, a failure of the infant to thrive and inadequate or inappropriate milk production. The normal results are summarised below:UNIT kJ/100 mL calories/100 mLs mg/100 mL mg/100 mL. mg/100 mL. mg/100 mL SG g/100 mL. mEq/L. mg/100 mL. COLOSTRUM 239 57 1460 to 6800. 1100 to 7900 700 to 4000 2740 to 3180. 10 to 16 26 to 135 0.02 to 0.05 TRANSITION MILK 264 63 1270 to 1890 6100 to 6700 600 to 1000 2730 to 5180 1.034 to 1.036 10.5 to 15.5 19 to 53 0.04 to 0.07 MATURE MILK 272 65 730 to 2000 4900 to 9500 900 to 1600 1340 to 8290 1.026 to 1.037 10.3 to 17.5 6 to 43 0.02 to 0.09

Energy Total protein Lactose (milk sugar) Amino acids Total fats Specific gravity Total solids Sodium Iron

See also BREASTFEEDING; BREAST MILK INADEQUATE; NIPPLE DISCHARGE; WITCHS MILK

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BREAST MILK EXCESS See CHIARI-FROMMEL SYNDROME BREAST MILK INADEQUATE If the milk supply appears to be inadequate, increasing the frequency of feeds will increase the breast stimulation, and the reflex between the breast and the pituitary gland under the brain is also stimulated. This gland then increases the supply of hormones that cause the production of milk. Sometimes, medications (eg. domperidone, metoclopramide) that stimulate the pituitary gland can be used to increase milk production, or even induce milk production in mothers who adopt a baby. A mother who is tense and anxious about her new baby may have trouble breastfeeding. The mother should be allowed plenty of time for feeding and relaxation so that she becomes more relaxed and never feels rushed. A lack of privacy can sometimes be a hindrance to successful breastfeeding. Lots of reassurance, support from family, and advice from doctors, health centre nurses or associations that support nursing mothers can help her through this difficult time. The best way to determine if the baby is receiving adequate milk is regular weighing at a child welfare clinic or doctor's surgery. Provided the weight is steadily increasing, there is no need for concern. If the weight gain is very slight, or static, and increasing the frequency of feeds fails to improve the breast milk supply, then as a last resort supplementation of the breast feeds may be required. It is best to offer the breast first, and once they appear to be empty of milk, a bottle of suitable formula can be given to finish the feed. See also BREASTFEEDING; BREASTFEEDING FAILURE; BREAST MILK; DOMPERIDONE BREAST MOUSE See FIBROADENOMA OF THE BREAST BREAST PAIN The medical term for breast pain is mastalgia. There are many possible causes for mastalgia. Any direct injury or blow to the breast may cause bruising and pain. Many women experience painful tender breasts for a few days before each menstrual period. If this becomes a significant problem, medications are available to ease the discomfort. In early pregnancy, one of the first signs of the pregnancy, other than missing a menstrual period, may be unusually sore and enlarged breasts. The hormonal disturbances of the menopause may over stimulate breast tissue to cause varying soreness. In the same way, excess oestrogen in hormone replacement therapy or the contraceptive pill will have the same effect. Infections in the breast (mastitis), particularly during breastfeeding, will cause hard, tender, painful, red lumps. If left untreated, an abscess may develop in the breast tissue. Breast cancer may present as a painful lump in the breast, but sometimes there may be a firm painful area behind the nipple, with virtually no lump that can be felt. Large breasted women may not be able to feel a cancerous lump, but may experience pain on pressing on the affected area. See also BREAST LUMP; NIPPLE PAIN BREAST REDUCTION

Women with very large breasts can find them to be both uncomfortable and embarrassing. They develop fungal and heat rashes under the breast, and tired shoulder and back muscles from supporting them. They get in the way when performing some tasks, and make the woman look fatter than she is. Many women gain enormous benefit by

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having a breast reduction operation performed, and the sooner such a procedure is undertaken, the better. There are a number of different ways of reducing the breast size, but in the most common operation, a slice of tissue and fat is removed from the underside of the breast, so that the resulting scar is in the fold under the breast, and barely noticeable. If nothing further was done, the nipple would be left pointing at the floor instead of straight ahead, so a further vertical cut must be made, to allow the nipple to be moved further up the smaller breast. The resultant vertical scar is below the nipple on an area of the breast that is rarely exposed to public view. After the operation, the woman will feel much more comfortable, she will still be able to breast feed, and no one except her most intimate friends will ever know. See also BREASTS UNEVEN BREASTS ENGORGED One of the most common breast problems is engorgement, which is not only uncomfortable but may lead to difficulty in feeding and to infection. If the breasts are swollen and overfilled with milk, expressing the excess milk usually relieves the discomfort. This can be done by hand under a shower or into a container, or with the assistance of a breast pump. At other times, expressed milk may be kept and given to the baby by a carer while the mother is out or at work. Breastfeeding need not tie the mother to the home. The infant may find it difficult to suckle on an overfilled breast, so expressing a little milk before the feed may be helpful. A well-fitted, supportive bra is essential for the mother's comfort. Mild analgesics such as aspirin may be necessary, particularly before feeds, so that the feeding itself is less painful. Heat, in the form of a warm cloth or hot shower, will help with the expression of milk and with releasing milk from blocked areas of the breast. Engorgement usually settles down after a few days or a week, but if the problem persists, fluid tablets can be used to reduce the amount of total fluid in the body and make it more difficult for the body to produce milk. In severe cases, partial suppression of the milk supply may be necessary. See also BREASTFEEDING; MASTITIS BREASTS UNEVEN Most women have slight differences in the sizes of their breasts, in the same way that most of us have one foot or hand a fraction larger than the other. All humans (male and female) have a tiny nodule of breast tissue present behind the nipple from birth. At puberty, the oestrogens in women stimulate this tissue to grow into a breast. The degree of stimulation, the size of the original nodule, and (most importantly) hereditary tendencies will determine your breast size. In some women the breast tissue on one side does not react as much to the stimulating hormones as the other side. Some women are born with no nodule of breast tissue behind one nipple, and therefore there is nothing there for the hormones to stimulate at puberty. There is no magical medication, cream or diet that will correct uneven breasts, but plastic surgery will improve a womans self image and appearance dramatically. See also BREAST AUGMENTATION; BREAST REDUCTION BROMOCRIPTINE Bromocriptine (Parlodel) is an antiparkinsonian medication used as a tablet or capsule to treat Parkinson disease, acromegaly, the abnormal production of breast milk and to stop the production of breast milk after childbirth. Tumours of the pituitary gland in the brain cause both acromegaly (excess bone growth) and abnormal breast milk production (in both sexes). It is safe to use bromocriptine in pregnancy but it is not to be used during breastfeeding. Use it with caution in psychiatric conditions, high or low blood pressure, heart disease, diabetes, peptic ulcer, eye disease and liver disease, and women who wish to fall pregnant as bromocriptine may reduce fertility. Do not take it if suffering from high blood pressure in or immediately after pregnancy, after pregnancy if breastfeeding desired, experiencing toxaemia of pregnancy or with significant heart disease. The side effects of bromocriptine may include nausea (very common), dizziness, headache, nasal congestion, vomiting, tiredness and reduced blood pressure (fainting). Unusual effects may include hallucinations, confusion, behavioural disturbances, unwanted muscle movements, psychiatric disturbances, a peptic ulcer, vomiting blood and severe psychiatric disturbances. Interactions are possible with medications that lower blood pressure, erythromycin and alcohol. An overdose may cause vomiting, tiredness, low blood pressure and hallucinations but is not likely to be life threatening. See also BREASTFEEDING; CABERGOLINE; WEANING BSE The abbreviation BSE has two very different meanings in medicine:- breast self examination - bovine spongieform encephalitis (mad cow disease). See also BREAST EXAMINATION

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CABERGOLINE Cabergoline is a medication with a wide range of uses from treating Parkinson disease to stopping breast milk production and reducing excess production of the hormone prolactin. It must be used with caution in heart disease, kidney disease, liver disease and peptic ulcer disease. It may aggravate some psychiatric conditions and high blood pressure after childbirth may be made worse. The side effects may include low blood pressure, fainting, dizziness, headache, tiredness, fatigue, depression, stomach upsets, breast pain and hot flushes. Interactions may occur with ergot alkaloids, methylergotamine, dopamine agonists, drugs that inhibit liver function and metoclopramide. See also BROMOCRIPTINE; PARKINSON DISEASE; PROLACTIN CANCER Cancer, the crab of astrology, is so named because the ancients could see the abnormal cancer cells clawing their way into the normal tissue, destroying everything in their path. Doctors now understand a great deal about cancer, but do not fully understand what starts the process. Although the specific cause of cancer is unknown in many cases, sun exposure, a low-fibre diet and smoking are well-known precipitating factors. Cancer (malignancy or neoplasm) occurs when otherwise normal cells start multiplying at an excessive rate, and the cells made!"#!$%&!'()*+!)',-&..!,/!'&)',+0-$*,1!('&!("1,'2(3!*1!.%()&4!.*5&!(1+!/01-$*,16!! Although they may have some slight resemblance to the cells around them, cancer cells cannot perform the correct work of that type of cell, and they prevent the normal cells around them from working properly, thus enabling the cancerous cells to spread. Cancer is not just one disease process - dozens of different types of cancer occur in different parts of the body, and each type causes different problems and responds differently to treatment. Several different types of cancer can be found in the lungs for example. There are however two main groups of cancers according to the type of tissue affected :- Sarcomas are tumours originating in connective tissue (bone, cartilage, muscle and fibre). - Carcinomas are tumours originating in the epithelial cells (tissue comprising the external and internal linings of the body). The most common types of non-skin cancer are:CANCER INCIDENCE PER 100,000 PEOPLE Prostate 142 Breast 137 Lung 67.3 Colon and rectum 54 Bladder 21 Lymphatic system (lymphomas) 20 Ovary 16 Melanoma of skin 15 Kidney 11 Leukaemia (white blood cells) 11 Pancreas 10 Cervix 9 Stomach 7 Thyroid 7 Brain 6 Testes 5 Oesophagus 4.9 Liver 4.8 Larynx 4.3 Tongue 2.5 Vulva 2.5 Gums 1.6 Small intestine 1.6 Tonsils 1.4 Throat 1.4 Anus 1.3 Salivary glands 1.2 Bones and joints 0.9

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Pleura (membrane around lung) Lip Uterus Mouth Vagina Nose Penis Eye Thymus Ureter Peritoneum (abdomen lining) 0.9 0.9 0.8 0.8 0.8 0.7 0.7 0.7 0.6 0.6 0.5

The early signs of cancer are:- a lump or thickening anywhere in the body - sores that will not heal - unusual bleeding or discharge - change in bowel or bladder habits - persistent cough or hoarseness, - change in a wart or mole - indigestion or difficulty in swallowing - loss of weight for no apparent reason. Investigation of a cancer depends upon the organ involved and may include blood tests, urine tests, sputum tests, faeces tests, x-rays, endoscopy, radioactive scans, ultrasound scans, microscopic examinations and magnetic resonance imaging. Treatment may involve surgery to remove the growth, drugs that are attracted to and destroy abnormal cells, irradiation of the tumour with high-powered X-rays, specifically developed vaccines or combinations of these methods. Over half of all cancers can be cured, and that excludes the skin cancers that rarely cause death. The cure rate is far higher in those who present early to a doctor, because the less the cancer has spread, the easier it is to treat. As a side curiosity, sharks never develop cancer, and medical scientists are still trying to work out why. CANCER ASSOCIATED ANTIGEN Blood tests are available for specific antigens that are produced against some types of cancer (eg. breast, pancreas, liver, colon, ovary, uterus and prostate cancer). The most commonly ordered of these tests is the prostate specific antigen (PSA). The cancer associated antigen (CA or carbohydrate antigen) tests are unreliable as a way of detecting cancer as there is no absolute value in any one person above which a cancer can be said to be present, but a series of tests over a period of months or years may show increasing levels of the antigen which may indicate the presence of a particular cancer. The tests are particularly useful in following the progress of treatment in a patient (if successful, antigen levels should decrease steadily), or in watching a patient who has a bad family history of a particular type of cancer. Raised levels may also occur with infection, inflammation or enlargement of the organ. Most of the different CA tests are differentiated from each other by number and an above normal result can be!

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CA 15-3 - Metastatic breast cancer (70%+), localised breast cancer (10%+). False positive with liver failure. CA 19-9 - Cancer of the pancreas (80%+), bile duct cancer (66%+), stomach cancer (50%+), liver cancer (hepatoma - 50%+), large bowel (colorectal) cancer (25%+). False positive with liver cirrhosis, cholangitis (inflamed bile duct) and pancreatitis. CA 50 - Cancer of the pancreas (75%+), large bowel (colorectal) cancer (45%+). False positive with pancreatitis. CA 125 - Some types of ovarian cancer (85%+), cancer of the uterus (endometrial cancer). False positive with endometriosis. CA 195 - Cancer of the pancreas (85%+), bowel (gastrointestinal) cancer . CA 549 - Breast cancer (50%+), lung cancer, large bowel (colon) cancer, prostate gland cancer. False positive with endometriosis, liver and ovarian disease. CAPECITABINE Capecitabine is an antimetabolite medication that was introduced in 2002 and is used orally to treat advanced breast cancer not responding to other treatments. It is not for use in pregnancy, breastfeeding or if suffering from severe kidney disease, and must be used with caution in heart disease, liver disease, children and the elderly. Side effects are numerous, including diarrhoea,

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nausea, vomiting, hand and foot discomfort, mouth ulcers and soreness, loss of appetite, rashes, tiredness, abdominal pain, insomnia, dizziness, taste changes, excessive skin sensitivity, pins and needles sensation and swelling of tissue. Rarely damage to blood cells (regular blood tests necessary) and liver damage occur. Capecitabine interacts with warfarin and phenytoin. See also BREAST CANCER CARCINOEMBRYONIC ANTIGEN The carcinoembryonic antigen (CEA) is produced by tumours arising from specific types of tissue (endodermal tissue). Its presence in blood can be measured and the normal value is less than 2.5 g/L. Higher levels occur in patients who may have colorectal cancer, stomach cancer, thyroid gland cancer, breast cancer, lung cancer, cervix cancer, testicular cancer (a seminoma), cancer of the pancreas, liver cancer (hepatoma), cirrhosis of the liver or are heavy smokers. False positive results are common. It is a useful to follow the progress of cancer therapy, but the test is not for diagnosis or screening of cancer. CASEIN Casein is the natural protein found in the breast milk of all mammals. It contains all essential amino acids. See also BREAST MILK CHIARI-FROMMEL SYNDROME The Chiari-Frommel syndrome is a late complication of pregnancy and breastfeeding, usually caused by a tumour in the hormone controlling pituitary gland under the brain, but there are other rare causes. The menstrual periods of affected women fail to restart after breastfeeding has finished, and they cannot stop their production of breast milk. Blood tests show abnormal hormone production by the pituitary gland, and a CT or MRI scan reveals the pituitary tumour. Surgery to remove the pituitary tumour is usually very successful. CHLOASMA Chloasma (melasma) is a pigmentation disorder of the skin that occurs almost invariably in women, and more commonly in those with a dark complexion. The deposits of pigment on the forehead, cheeks, upper lip, nose and nipples are often triggered by pregnancy or starting the oral contraceptive pill. Treatment is unsatisfactory. Numerous blanching agents have been tried with minimal success, but the pigmentation usually fades slowly over several years. See also NIPPLE; NIPPLE PIGMENTATION CHLORAMBUCIL The alkyllater medication chlorambucil is used as a tablet to treat leukaemia, breast and ovary cancer, Hodgkin disease, lymphoma and other malignant conditions. The dosage is complex and must be individualised by a doctor for each patient. Chlorambucil must not be used in pregnancy unless the life of the mother is at risk as serious damage to the foetus is likely. Adequate contraception must be used during treatment. Breastfeeding must be ceased before use and use it in children only when medically essential. Regular blood tests to monitor blood cells and liver function are essential. It must be used with extreme caution in all patients. Serious side effects are possible including bone marrow damage, nausea, vomiting, diarrhoea, mouth ulcers, lung damage, convulsions in children and yellow skin (jaundice) due to liver damage. Chlorambucil interacts with phenylbutazone and other cancer treatments. An overdose causes damage to blood and bone marrow cells, convulsions, incoordination and irrational behaviour. Although serious side effects are possible, chlorambucil may be life saving in some patients. See also BREAST CANCER; VINCA ALKALOIDS COLOSTRUM See BREASTFEEDING; BREAST MILK CONGENITAL ADRENAL HYPERPLASIA Congenital adrenal hyperplasia (or the adrenogenital syndrome) is a condition affecting the adrenal glands, which sit on top of each kidney, in which they are over stimulated to produce abnormal steroids in the body that affect sexual development. The condition is familial (runs in families), but both parents must be carriers for the condition to be present. In girls the clitoris becomes enlarged, high blood pressure occurs, and at puberty the breasts are very small, 14 !

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pubic hair pattern is masculine, hair may develop excessively on the body, and female characteristics are reduced. A rare form causes excessive development of male characteristics in boys. The diagnosis is confirmed by specific blood and genetic tests. Surgical correction of abnormal genitalia can be performed, and medication is given to correct hormonal imbalances. Infertility and confused gender assignment can occur if treated late, but there are good results if treated very early. Patients have a relatively normal life expectancy. CONTRACEPTIVE PILL The development of the oral contraceptive pill in 1959, and its widespread release in 1962, revolutionised the lives of modern women, and changed society as a whole forever. For the first time there was an effective, safe, reliable, easy to use, reversible contraceptive that did not interfere with lovemaking and had no aesthetic drawbacks. The oral contraceptive pill is the safest and most effective form of reversible contraception. There are many different dosage forms and strengths, so that most women can find one that meets their needs. The main types are the monophasic (constant dose) two-hormone pill, the biphasic (two phase) and triphasic (three phase) hormone pills in which the hormone doses vary during the month, and the one hormone mini-pill. The pill has several positive benefits besides almost perfect prevention of pregnancy. It regulates irregular periods, reduces menstrual pain and premenstrual tension, may increase the size of the breasts, reduces the severity of acne in some women, and libido (the desire for sex) is often increased. It even reduces the incidence of some types of cancer. Two different hormones control the menstrual cycle. At the time of ovulation, the level of one hormone drops, and the other rises, triggering the egg's release from the ovary. When the hormones revert to their previous level two weeks later, the lining of the uterus (womb) is no longer able to survive and breaks away, giving the woman a period. The pill maintains a more constant hormone level, and thus prevents the release of the egg. In fact, it mimics the hormonal balance that is present during pregnancy, so the side effects of the pill are also those of pregnancy. The body, being fooled into thinking it is pregnant by the different hormone levels, does not allow further eggs to be released from the ovaries. With the triphasic pills, the level of both hormones rises at the normal time of ovulation, and then drops slightly thereafter to give a more natural hormonal cycle to the woman, while still preventing the release of an egg. The hormones commonly used in contraceptive pills include ethinyloestradiol, levonorgestrel, norethisterone, gestodene, and mestranol. Other less commonly used hormones are the oestrogen ethynodiol diacetate and the progestogens norgestimate, desogestrel, drosperidone and norgestrel. There are some specialised types of contraceptive pills, which have added benefits such as the improvement of acne when the hormones cytoperone and ethinyloestradiol (Diane) are combined. When the pill is stopped (or the sugar pills started) at the end of the month, the sudden drop in hormone levels cause a hormone withdrawal bleed (period) to start. If the woman stops taking the pill, her normal cycle should resume very quickly (sometimes immediately) and she is able to become pregnant. If taken correctly, the pill is very effective as a contraceptive. But missing a pill, or suffering from diarrhoea or vomiting can have a very pregnant result. Some antibiotics can also interfere with the pill. If any of these things occur, continue to take the pill but use another method of contraception until at least seven active pills (not the sugar ones taken when you have your period) have been taken. In its early days there were some questions raised about the wisdom of long-term reliance on the pill, but a woman on today's pill is taking a hormone dose that is only 4% the strength of the original. It is much safer to take the contraceptive pill for many years than it is to have one pregnancy, and that is the realistic basis on which to judge the safety of any contraceptive. A few women do have unwanted side effects from the contraceptive pill. These can include headaches, break through bleeding, nausea, breast tenderness, increased appetite and mood changes. If these problems occur, they can be assessed by a doctor, and a pill containing a different balance of hormones can be prescribed. Rarely, a serious complication such as a blood clot in a vein, may occur. Although the contraceptive pill is very safe, there are some women who should not use it. Those who have had blood clots, severe liver disease, a stroke or bad migraines must not take the pill. Heavy smokers, obese women and those with diabetes must be observed closely, and probably should not use the pill after 35 years of age. There is no need these days to take a break from the pill every year or so. This may have been the case in 15 !

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earlier years, but is no longer necessary. It is possible (and safe) to take the active pills of a monophasic (constant dose) contraceptive pill without a break for three months or more, then have a one week break when a period will occur. This way the woman will only have four periods a year, but some women have break through bleeds when attempting this. In its most commonly used forms, the pill is a combination of the hormones oestrogen and progesterone. There is also a mini pill which contains only a progestogen hormone and is suitable for some women, including breastfeeding mothers, who cannot take the combined pill. The mini pill is less reliable than the combined pill and is more likely to give rise to irregular bleeding, but serious side effects are much less common. It is vital to take it at the same time each day. The effects of the pill are readily reversible. If a woman decides to become pregnant, she could find herself in that state in as little as two weeks after ceasing the pill, with no adverse effects on the mother or child. It is easier to summarise the pros and cons of the contraceptive pill in a table:-

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Risks and problems Break through bleeding Nausea Breast tenderness Increased appetite Mood changes Increased breast size in large breasted women Headaches Increased risk of thrombosis (15/100,000) Increased risk of stroke in migraine sufferers Very slightly increased risk of breast cancer Increased risk of cervical cancer Fails to work with vomiting and diarrhoea Antibiotics reduce effectiveness Benefits Very good protection against pregnancy Regulation of menstrual cycle Reduced menstrual flow and pain Reduced premenstrual tension Increased breast size in small breasted women Reduced severity of acne Increased libido Easily reversible contraception Menstrual periods can be skipped if desired Halves the risk of ovarian cyst development Halves the risk of pelvic inflammatory disease Reduced long-term incidence of infertility Reduces excess facial and body hair Reduced risk of ovarian cancer (-40%) Dramatic long-term reduction in endometrial cancer (-60%) Reduced incidence of endometriosis (-30%) Reduced incidence of uterine fibroids (-20%) Reduced mammary dysplasia (breast lumps)(-50%)

Overall women who take the contraceptive pill have longer lives, and are less likely to die from cancer or heart disease than women who have never used it. See also SEX HORMONES COSMETIC SURGERY Any form of surgery that is performed solely to improve the appearance of a person is referred to as cosmetic surgery. It may vary from removing an ugly mole or a nose reshaping (rhinoplasty) to a breast augmentation or a tummy tuck (abdominoplasty). It is often performed to remove the natural signs of ageing. The risks of cosmetic surgery are the normal risks of any general anaesthetic, infection, abnormal scar formation and more seriously fat embolism that may kill some patients. Cosmetic surgery may be performed by a plastic surgeon or a less well-trained doctor who performs these procedures on request. See also BREAST AUGMENTATION; BREAST REDUCTION; C-REACTIVE PROTEIN C-Reactive protein (CRP) is released from most tissue that is inflamed or under stress. It is a non-specific test but usually indicates significant disease. The normal amount found in the blood is less than 5 mg/L (less than 5 g/mL). Higher levels indicate the presence of inflammation anywhere in the body, tissue injury, rheumatoid arthritis, infections, pneumonia, a heart attack (myocardial infarct), widespread cancer, breast cancer, acute gout, ankylosing spondylitis, rheumatic fever, SLE (systemic lupus erythematosus), a blood clot in a vein (thromboembolism), bacterial meningitis, polyarteritis nodosa or inflammatory bowel disease (eg. Crohn disease). There is now evidence that those with a persistently elevated CRP are at increased risk of heart disease and may benefit from aggressive cholesterol lowering using statin medication. The ultrasensitive C-Reactive protein is an additional test that is useful in the assessment of angina. Variations in C-reactive protein as low as 0.1 mg/L are measured and rising levels give a poor prognosis for angina, and

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increasing tissue damage in other organs. In patients with angina slowly increasing levels are associated with increasing heart tissue damage even though the total level of CRP may be quite low. CYSTADENOMA A cystadenoma is a combination of an adenoma (a benign tumour involving glandular tissue) and a cyst. They are a common abnormality of the breast. They are further subdivided depending on the type of fluid contained in the cysts. See also BREAST LUMP CYSTOSARCOMA PHYLLODES Cystosarcoma phyllodes (a phyllodes tumour) is a rare form of breast tumour that is usually benign but may be malignant. It arises from a fibroadenoma in the breast. The tumour takes its name from its leaf-like (phyllodes means leaf in Greek) structure as seen under a microscope. Affected women have a firm breast lump that enlarges rapidly to several centimetres in diameter. Mammography (breast x-ray) and ultrasound may be used initially in investigation, but in most cases a needle biopsy is necessary to confirm the diagnosis. The tumour is surgically excised with a wide margin of normal tissue. With very large tumours, this may require a mastectomy (breast removal). Recurrence is common after excision and rarely the tumour may become cancerous. See also BREAST CANCER; FIBROADENOMA OF THE BREAST DANAZOL Danazol (Danocrine) is a progestogen sex hormone used orally to treat endometriosis, severe intractable period pain, severe breast pain, and a rare form of severe tissue swelling (familial angioedema). The normal dose is one capsule two to four times a day for three to nine months. It must not to be used during pregnancy, breastfeeding or in children. Women taking danazol must use adequate non-hormonal contraception. Its use is also prohibited if suffering from undiagnosed genital disease, severe liver disease, a pelvic infection, cancer of any sex organs, heart failure, a recent blood clot or porphyria. It must be used with caution by patients with liver disease, high blood pressure, heart disease and diabetes. Regular blood tests to check liver function are recommended. Common side effects include acne, weight gain, fluid retention, excess body hair growth, voice deepening, flushing, sweating, dry vagina and menstrual period irregularities. Unusual effects may include oily skin, hoarseness, reduced breast size, enlargement of clitoris and nervousness. Rarely yellow skin (jaundice), a blood clot in vein and chest pain (embolism) may occur. Interactions are possible between danazol and warfarin, carbamazepine, cyclosporin, oral contraceptives, phenytoin, steroids and diabetes medications. An overdose causes vomiting, tissue swelling and indigestion. Danazol is a very effective medication, but significant side effects a problem for some patients. It is used for six to nine months only and does not cause addiction or dependence. See also SEX HORMONES DOMPERIDONE Domperidone (Motilium) is an antiemetic medication used to treat nausea, vomiting and delayed stomach emptying. Strangely, it can also be used to increase the breast milk supply in women who are having trouble breastfeeding as it increases the level of prolactin in the blood. The normal dose is one tablet, three or four times a day, 30 minutes before meals. It may be used with caution if pregnant or breastfeeding, and patients with breast cancer, liver and kidney disease. Do not take it if suffering from some forms of pituitary gland tumour. The side effects are minimal, but uncommonly a dry mouth and stomach cramps may occur. Domperidone may interact with antacids, anticholinergics, imidazole antifungals, macrolide antibiotics and nefazodone. It is a remarkably safe and effective medication introduced in the mid-1980s that is marvellous for motion sickness. It does not cause dependence or addiction, but is designed for short-term use. See also PROLACTIN DUCTAL CARCINOMA IN SITU Ductal carcinoma in situ (DCIS) is an early stage of a specific form of breast cancer that arises from the lining of the milk ducts within the breast. Bleeding from the nipple may be an early symptom. See also ATYPICAL DUCTAL HYPERPLASIA; BREAST CANCER EAR WAX Technically, ear wax is known as cerumen. It is secreted naturally in the outer ear canal by special glands, and slowly moves out to clear away dust and debris that enters the ear. It also acts to keep the skin lining the canal 17 !

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lubricated and to protect it from water and other irritants. The ear is designed to be self-cleaning, and attempts to clean it may pack the wax down hard on the eardrum or damage the ear canal. Strangely, it has been discovered that women who have soft ear wax have a much higher risk of breast cancer than those with hard ear wax. ECTASIA Ectasia is an abnormal dilation, distension or increase in size. Often used with reference to over dilated milk ducts in the breast (mammary duct ectasia) due to the collection of secretions in these ducts after the menopause. ENGORGED BREASTS See BREASTS ENGORGED EXCESS BREAST MILK See BREASTS ENGORGED EXEMESTANE Examestane is a medication released in 2001 for the treatment of advanced breast cancer. Common side effects include hot flushes, liver damage, tiredness, pain, nausea, diarrhoea, sweating, dizziness, sleeplessness, tissue swelling and fluid retention. See also BREAST CANCER EXOCRINE GLANDS Exocrine glands are those that have ducts to carry their secretions out of the gland to various parts of the body. They include the liver (produces bile), breasts (mammary glands - produce milk), sweat glands, sebaceous glands (oil glands in the skin), lacrimal glands (produce tears), salivary glands (produce saliva), Meibomian glands (lubricate eyelashes), Bartholin glands (lubricate the vagina), prostate gland (produces part of the semen), apocrine glands (produce thick sweat and pheromones in the armpit and groin) and areola glands in the nipple (lubricate the nipple in breast feeding). FIBROADENOMA OF THE BREAST A fibroadenoma of the breast is a common benign growth of the breast, often affecting young women. The cause is usually unknown, but it may be the result of an injury to the breast. It is possible to feel one or more round, firm (but not hard) lumps within the breast tissue that are hard to catch hold of and tend to slide out from between the fingers when squeezed (thus sometimes known as a breast mouse) and are therefore not attached to surrounding tissue. They are not usually tender or painful. Mammography (breast x-ray) and ultrasound may be used initially, but in most cases a needle biopsy is necessary to confirm the diagnosis. If the diagnosis is confirmed to be benign, they may be left untreated, but if there is any doubt, they should be surgically removed. They persist long term if not removed. See also BIOPSY; BREAST CANCER; BREAST LUMP; CYSTOSARCOMA PHYLLODES; MAMMARY DYSPLASIA; PSEUDOANGIOMATOUS STROMAL HYPERPLASIA FIBROCYSTIC DISEASE OF THE BREAST See MAMMARY DYSPLASIA FLUOROURACIL Fluorouracil (also known as Efudix) is a medication used as a cream to treat skin cancer and sun damaged skin, and as an injection for cancer of the breast, colon, rectum, stomach and pancreas. The cream should be applied to affected skin once or twice a day with a metal applicator or using a rubber glove for four to six weeks, and must not be allowed to come into contact with eyes, mouth, lips, nose, anus or vagina. Avoid using cosmetics or other skin preparations on areas of skin being treated, and avoid sun exposure to areas of skin being treated. It should not be used in pregnancy (D) unless mothers life is at risk as the safety of this medication (including lotion and cream) in pregnancy, has not been established. Breastfeeding should be ceased before use of the injection, and it should be used in children only if medically essential. Regular blood tests are necessary to check blood cells and liver function essential for patients receiving injections. Common side effects of the skin preparations include redness, itch, burning and skin pigmentation, while less common reactions may include scarring, dermatitis and skin soreness. Injection side effects may include a sore mouth, pain on swallowing, diarrhoea, loss of appetite, vomiting, hair loss, itch, rash, dry skin, skin pigmentation, sun sensitivity, disorientation and nail changes. Fluorouracil is very effective and useful in many forms of skin cancer but must be used carefully. Despite 18 !

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serious side effects from injection, it may save or prolong life in patients with some types of cancer. FOLATE Folate is an essential nutrient found in many foods in the form of folic acid (vitamin B9), but is converted to folate in the body. The amount present in the body can be estimated by blood tests. The normal amount present in blood is 3.6 to 20 g/L (7 to 40 nmol/L), while in red blood cells the normal range is 225 to 800 g/L. The test is normally done as part of the investigation of anaemia. The recommended daily total folate dietary intake is 50 g. in infants, 100 g. in children and 200 g. in adults. Low levels may be present in the elderly, infancy, poor diet, pregnancy and breastfeeding, alcoholism, scurvy (lack of vitamin C), kwashiorkor (protein starvation), tropical sprue, coeliac disease, malabsorption syndromes, Crohn disease, partial removal of stomach, heart failure, blood infection (septicaemia), Whipple's disease, scleroderma, chronic haemolytic anaemias, cancers, multiple myeloma, leukaemia, myelofibrosis, TB, psoriasis, haemodialysis for kidney failure, active liver disease, malaria, premature babies and with some drugs (eg. barbiturates, oral contraceptive, trimethoprim, tetracyclines, nitrofurantoin, primidone, methotrexate) A false low blood level may occur with severe vitamin B12 deficiency, while a false normal level may follow a blood transfusion. Blood folate levels reflect folate absorption from the diet in the past week only. Red blood cell folate is a more accurate measure of total body folate levels and is less affected by diet than blood folate levels. Folate is stored mainly in the liver. FOLIC ACID Folic acid is sometimes classed as vitamin B9 or vitamin M. It is essential for the basic functioning of the nucleus in cells, and extra amounts may be needed during pregnancy, breastfeeding, and in the treatment of anaemia and alcoholism. It assists in the uptake and utilisation of iron. During pregnancy, supplements may prevent spinal cord defects in the baby. It is found naturally in liver, dark green leafy vegetables, peanuts, beans, whole grain wheat and yeast. The level in blood can be measured and the normal range is 9.1 to 57 nmol/L (4 to 25 ng/mL). The amount in red blood cells can also be measured (normal range is a level greater than 318 nmol/L or 140 ng/mL), which gives a longer term picture than the normal folic acid level in blood which may be affected by recent changes in diet. Low levels can be due to long-term alcoholism, oral contraceptive use, anticonvulsant medications, malnutrition, sprue (poor food absorption), sickle cell anaemia, cytotoxic drugs (used to treat cancer), pregnancy and food malabsorption syndromes. On the other hand, a low intake in the diet can cause pernicious anaemia. FOLLICLE STIMULATING HORMONE Follicle stimulating hormone (FSH or follitropin) is a sex hormone produced naturally in the pituitary gland under the brain. It acts with luteinising hormone to stimulate the production of eggs in women (ovulation) and sperm in men. The level of FSH in blood can be measured. The normal ranges are:Before puberty 0 to 3 IU/L. Adult female 1 to 9 IU/L. Female at ovulation 10 to 30 IU/L. After menopause 40 to 200 IU/L. Adult male 1 to 5 IU/L. A low level in the blood may be due to Stein-Leventhal syndrome and may be a cause of infertility. A very high level may be due to disease or failure of the testes or ovaries. Levels normally rise at mid-cycle in ovulating women. It may be used as an injectable medication to treat female and male infertility. Common side effects include nausea, diarrhoea and headache, while less common ones may include multiple pregnancies, breast tenderness and/or enlargement, acne and weight gain. See also OVARY FRUSEMIDE Frusemide is known as furosemide in the United States, and commonly by the trade name Lasix. It is a loop diuretic that acts in the kidneys to increases the production of urine. As a medication it is used in tablet or injection form to treat excess fluid in the body, high blood pressure, and heart failure causing a build up of fluid in lungs. It should only be used in pregnancy if medically essential. It will reduce production of breast milk, and may be used to assist in drying of breast milk in women who have stopped breastfeeding. It is safe in children and infants. Frusemide should be used with caution in diabetes, diarrhoea and gout, and regular blood tests to assess levels of chemicals (electrolytes) in blood are recommended. Do not take if suffering from severe kidney failure, liver failure, jaundice, low blood pressure, difficulty in passing urine, or low potassium or salt levels. Potassium supplements may be needed. Passing increased amounts of urine is an obvious side effect, while others related to overuse include weakness, 19 !

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dizziness, thirst, muscle cramps, flushing and dehydration, blood clots. Frusemide interacts with digoxin, aspirin, steroids, salicylates, lithium, antibiotics, ethacrynic acid, NSAID, sucralfate and medications that lower blood pressure (eg. ACE inhibitors). The herbs celery, dandelion and uva ursi can also interact with it. Its use in competitive sports is illegal as it can act as masking agent for other illegal drugs. Frusemide is a widely used, safe, and extremely effective medication that has been available since the 1960s. GALACTORRHOEA Galactorrhoea is a term used in medicine for an abnormal or excessive discharge of milk from the breast. See also NIPPLE DISCHARGE GLAND A gland is an organ or group of cells that secretes (produces) various substances used in keeping the body functioning. Lymph nodes are often referred to as glands, particularly in the neck, but this is incorrect terminology. EXOCRINE GLANDS Some glands have ducts to carry their secretions to various parts of the body, and these are called exocrine glands. There are dozens of different exocrine glands, some of which include the:- liver, which produces bile - mammary glands (breasts), which produce milk - sweat glands - sebaceous (oil) glands in the skin - lacrimal glands (above the outer corner of the eyes), which produce tears - salivary glands (produce saliva) in the mouth - Meibomian glands in the eyelids (lubricate eyelashes) - Bartholin glands in the vulva (lubricate the vagina) - Cowper glands in the male urethra (lubricate the urethra) - prostate gland (produces part of the semen) - apocrine glands in the armpit and groin (produce thick sweat and pheromones - sexual stimulants) - areola glands in the nipple (lubricate the nipple in breast feeding) and numerous other glands within the intestine and other organs of the body. ENDOCRINE GLANDS Glands without ducts are called endocrine glands and secrete hormones (chemical messengers), which are released directly into the bloodstream. Some glands are large organs such as the liver, pancreas and kidneys, but more commonly they are very tiny. The endocrine glands are enormously important in the functioning of the body. Endocrine glands generally work in conjunction with one another, so that the release of a hormone in one gland will influence the operation of a different gland. Among other things they influence growth, metabolism (rate at which body functions) and sexual development. The other endocrine glands are the:- pituitary gland at the base of the brain - pineal gland in the centre of the brain - thyroid gland in the front of the neck - parathyroid glands, four of which lie behind the thyroid gland - adrenal glands on top of the kidneys - islets of Langerhans in the pancreas, under the stomach - thymus in the lower neck - ovaries in women and the testes in men. GOSERELIN ACETATE Goserelin acetate is a cytotoxic medication used as implants to treat metastatic and severe prostate cancer, advanced breast cancer, fibroids of the uterus and endometriosis. An implant is inserted every one to three months. Common side effects may include infertility, impotence, decreased libido, hot flushes, headaches, dry vagina, cessation of menstrual periods, changes in blood pressure, breast formation in males and a temporary increase in bone pain. See also BREAST CANCER GYNAECOMASTIA Gynaecomastia is a medical term for enlarged breast(s). It is usually used in reference to men who have abnormal breast development as a result of hormonal imbalances or drug side effects. The most common reason is the onset of puberty in teenage boys, when there may be a temporary hormone imbalance. Male breasts sometimes enlarge in old age, with an increase in weight, and with oestrogen hormone 20 !

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treatment in men wanting to change sex. It may also be a symptom of a significant underlying disease including cirrhosis of the liver, cancer in the adrenal glands, overactivity or cancer of the thyroid gland, an uncommon form of lung cancer, a tumour in the testicles or a genetic condition called Klinefelter syndrome in which there is an extra sex chromosome. See also BREAST ENLARGED; THELARCHE HAILEY-HAILEY DISEASE Hailey-Hailey disease (also known as benign familial chronic pemphigus) is a rare, inherited skin condition that starts in middle age and involves the armpits, groin and under the breasts. It is characterised by small blisters that break down into a red, moist or crusted sore with tiny cracks across it. The diagnosis is confirmed by a skin biopsy. Secondary fungal and bacterial infections are common. Drying agents may be applied to affected areas, while small areas may be surgically excised, but there is no cure, although it usually settles in old age. HIDRADENITIS SUPPRAVITA Hidradenitis suppurativa is an uncommon skin disorder caused by hair follicles blocked by keratin, in which painful boil-like lumps develop in the groin, armpits and under the breasts and around the anus and vulva. It is more common in women. Abscesses may develop due to secondary bacterial infection and fistulas (channels) may form into the anus and vagina. Treatment is unsatisfactory. Patients should wash with antiseptics to reduce skin bacteria, use antibiotics (eg. tetracycline, clindamycin, metronidazole) long term, and doctors may surgically remove persistent lumps. Some women benefit by taking the oral contraceptive pill. Roaccutane tablets and radical surgery to excise the entire affected area are used in very severe cases. Unfortunately, the condition often persists long term. See also ABSCESS; BOIL; FISTULA; KERATIN HORMONE Hormones are chemicals that move from the producing gland directly into the blood, to act upon every cell in the body and affect the function of cells. They are produced naturally in the body by many different glands, including the thyroid and parathyroid glands (in the neck), the pancreas (in the abdomen), the pituitary gland (in the brain), the adrenal glands (on top of the kidneys), the ovary and testes (sex hormones). Most of these are listed under their individual type of hormone (eg. sex hormones). Hormones are chemicals that travel from the producing gland, directly into the bloodstream, and then around the body. They reach and act upon every cell in the body through the bloodstream. The thyroid gland in the neck produces the hormone thyroxine, which acts to control the rate at which every cell in the body works. It is the accelerator of the body. If thyroxine is lacking, the patient becomes tired and slow. This is a common condition in middle-aged and elderly women. The thyroid hormone not being produced by the thyroid gland can be given as a tablet (thyroxine) by mouth. If used at the correct dosage, as determined by regular blood tests, there should be minimal side effects. The pituitary gland produces a range of hormones, most of which control other glands. The pituitary gland is therefore the conductor of the glandular and hormonal orchestra of the body. There are more than a score of hormones in the body, many of which are composed of several subtypes, but the most common are shown in the following table.
HORMONE SOURCE Adrenocorticotrophic (ACTH) Pituitary gland Antidiuretic (vasopressin) Pituitary gland urine production. Calcitonin Thyroid gland Follicle stimulating (FSH) Pituitary gland Gastrin Stomach Glucagon Pancreas Glucocorticoid (steroids) Adrenal glands tone, FUNCTION Controls level of steroid production by the adrenal glands. Controls blood pressure, contraction of intestine, contraction of uterus and Balances parathormone to control calcium and phosphate levels. Controls sperm production in males and egg (ova) production in females. Stimulates production of hydrochloric acid in the stomach. Controls release of glucose into the blood from the liver. Regulate carbohydrate, fat and protein levels in the body, affect muscle aid in blood pressure control, stimulate healing, reduce inflammation and allergy responses, and shrink lymphatic tissue. Includes cortisol, cortisone and corticosterone. Controls childhood growth and bone repair. Excess causes acromegaly. Controls glucose levels in cells and blood.

Growth hormone Insulin

Pituitary gland Pancreas

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Luteinising (LH) Oestrogen Parathormone Placental lactogen Progesterone Prolactin Releasing hormones Secretin Somatostatin Testosterone Thyroxine Thyroid stimulating (TSH) Pituitary gland Ovaries Parathyroid glands Placenta Ovary, placenta Pituitary gland Hypothalamus Duodenum Hypothalamus Testes Thyroid gland Pituitary gland Controls ovulation and menstruation in female and testosterone production in males. Causes female sexual features to develop and controls menstruation. Controls balance of calcium and phosphate in blood and bones. Controls supply of nutrition to the foetus. Controls lining of uterus (endometrium). Controls milk production in the breasts. Stimulates release of hormones from anterior pituitary gland. Stimulates pancreas to release specific digestive fluid. Controls growth hormone, thyroxine, insulin and gastrin production. Causes male sexual features to develop. Controls the metabolic rate of the body. Controls the function of the thyroid gland.

See also SEX HORMONES HUMAN EPIDERMAL RECEPTOR 2/neu HER2 (human epidermal factor receptor 2/neu) is a protein found on the surface of breast cells that regulates cell growth. If extra HER2 protein receptors occur on a cell due to a mutation, this over-expression of HER2 causes increased cell growth and an aggressive form of breast cancer. HER2 positive breast cancer occurs in 20% to 30% of patients, and this form of breast cancer may not be as responsive to standard breast cancer chemotherapy, but the new monoclonal antibody medication Herceptin (transtuzumab) has been very effective in treating this particular type of breast cancer. HER2 testing is performed on cancer cells that have been removed during breast biopsy or breast cancer surgery. It involves staining the tissue sample with a specific solution in a pathology laboratory. The pathologist then examines the cells within the tissue sample, checking for highlighted areas where high levels of HER2 overexpression are present. The test targets a gene located on chromosome 17. Depending on the level of staining, the patients cancer may be classified as HER2 positive or HER2 negative. See also BREAST CANCER; CANCER ASSOCIATED ANTIGENS; CARCINOEMBRYONIC ANTIGEN; PROTEIN; TRASTUZUMAB HYPERPROLACTINAEMIA Hyperprolactinaemia (Forbes-Albright syndrome) is the excessive production of the hormone prolactin by the pituitary gland in the centre of the brain. Prolactin is the hormone, which is responsible for breast milk production. The disease may be due to underactive ovaries or testes, or more commonly a tumour in the pituitary gland. Uncommonly, it may be due to side effects of some drugs or an underactive thyroid gland. Abnormal milk production by the breasts occurs in both women (much more commonly) and men, and women usually stop their menstrual periods. The blood level of prolactin is increased, and a pituitary gland tumour can be detected by a CT scan. The disease is controlled by the drugs bromocriptine or quinagolide, while surgery or radiotherapy to the pituitary gland can be used to treat a tumour. See also BROMOCRIPTINE INCONTINENCE Incontinence is an inability to control the release of bodily fluids. It usually refers to incontinence of urine and faeces, but may also refer to breast milk. INTERTRIGO Intertrigo is an inflammatory skin condition caused by heat, sweat and friction in those who are overweight, have poor personal hygiene, live in the tropics, or suffer from diabetes. Red, damaged, moist, itchy and burning skin occurs in places where the skin folds back upon itself, such as under the breasts, in the groin and armpit, and in skin folds of the abdomen and neck in obese people. In advanced cases, the skin may crack, bleed, become painful and fungal and/or bacterial infections may develop on the damaged skin. Treatment involves scrupulous hygiene, controlling diabetes, using antibiotics and antifungals to remove infection, losing weight, and applying drying powders to the affected areas. A piece of soft cloth placed under bulky breasts, and a well fitted bra may help. Plastic surgery to reduce large breasts or excessive skin on the belly may be appropriate. Unfortunately most patients remain overweight, are not consistent in their hygiene, and the problem persists or recurs.

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INTRADUCTAL CARCINOMA An intraductal carcinoma is one that occurs within a duct (tube) leading from an organ or structure. The most common intraductal carcinomas occur in the milk ducts of the breast in and around the nipple. See also BREAST CANCER; PAGETS DISEASE OF THE NIPPLE ISOFLAVONE Isoflavone is plant oestrogen obtained commercially from soybeans and other legumes, which acts in humans as a phytoestrogen and an antioxidant. It is used by some orthodox and many alternative practitioners to treat the symptoms of menopause, infertility and to act against cancer in the breast and prostate. The clinical benefits of isoflavone for these indications varies from nil to slight in clinical trials. High levels can be found in tofu. See also OESTROGEN LACTATION See BREASTFEEDING LACTOGEN Lactogen is a chemical that increases milk production by the breasts. See also PLACENTAL LACTOGEN, HUMAN LACTOGEN, HUMAN PLACENTAL See PLACENTAL LACTOGEN, HUMAN LEFT-HANDED In the past, there has been something of a stigma attached to being left-handed. Southpaws make up nearly 10% of the population, and there are more left-handed males than females. Other unflattering words have also been used to describe these people, including the Australianism mollydooker which literally means womanhanded. The word sinister is the Latin word for left, while dexterity, implying a high level of manual skills and ability, comes from the Latin word for right. Since biblical times the left hand has been reserved for the damned. It has been suggested that the bias against the left-hander may have its origin in early civilisations when the left hand was used for toilet purposes and the right for more hygienic activities. The lefties in our society should not feel apologetic for their preferred laterality, to use the correct medical term for left-handedness. There is an impressive list of left-handed leaders, artists and sports people including Queen Victoria, Harry Truman, Gerald Ford, Michelangelo, Paul McCartney, Judy Garland, Picasso, Jimmy Connors and John McEnroe. There is good evidence that left-handedness is more common in persons with reading disabilities, stuttering and poor coordination. American ex-president Ford was noted for his clumsiness both on and off the golf course. Stuttering may be precipitated if a naturally left-handed child is forced to use the right hand, but of course many people in the past have made this transition without problems developing. Extraordinarily, left-handed women have twice the risk of developing breast cancer compared to those who are right handed. LET DOWN REFLEX The let down (or milk ejection) reflex is the ejection of milk from the breast. Women have a pleasant sensation in the breast as milk flows into the milk ducts behind the nipple as the baby starts to suckle. It may also occur at other times when a breastfeeding mother thinks of her child, hears the child cry, or is sexually stimulated. See also BREASTFEEDING LETROZOLE Letrozole is an antineoplastic medication used as a tablet to treat some types of advanced breast cancer in postmenopausal women. It is not to be used in pregnancy, breastfeeding or children, and used with caution in kidney and liver disease. Do not take it if still having menstrual periods. Common side effects may include headache, nausea, diarrhoea, swelling of hands and feet, tiredness, hot flushes, hair thinning, rash, vaginal discharge. Unusual side effects may include weight change, muscle pain, vaginal bleeding, sweating, dizziness, tiredness, increased appetite, joint pain, urgent desire to pass urine, acne, breast enlargement. A blood clot in a vein (thrombosis) is a rare but severe complication. It interacts with tamoxifen. Letrozole was introduced in 1998 for treatment of severe relapses of some types of breast cancer. See also BREAST CANCER; TAMOXIFEN; TOREMIFENE LI-FRAUMENI SYNDROME The rare Li-Fraumeni syndrome in an inherited (autosomal dominant) condition that significantly increases the risk of an affected person developing cancer of many organs including brain, breast, bone (sarcoma), adrenal 23 !

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gland and blood (leukaemia). The cancer usually occurs at a young age and repeatedly in different organs throughout life. The diagnosis is suspected if multiple members of a patients family have developed cancer at a young age. Genetic testing can be performed to detect the abnormal gene and confirm the diagnosis. The tumour suppressor gene TP53 is the gene that is abnormal. Once diagnosed the patient and their doctor must obviously be very alert for any new cancers that may develop. LUMPECTOMY A lumpectomy is the surgical removal of a lump (tumour, cancer etc.) from tissue or an organ, with minimal amounts of the surrounding tissue being removed. It is commonly used in removing benign lumps from the skin, or small cancers or cysts from the breast. See also BREAST CANCER LYMPHOEDEMA Lymph is a waste product of all cells that returns to the circulation through a complex network of fine tubes that eventually drain into a major vein near the heart. The lymph ducts pass through the lymph nodes that are concentrated in the armpit, groin and neck, and act to remove any bacteria or abnormal cells. Lymphoedema (lymphedema in the USA) is a common complication of surgery when lymph channels are disrupted by the removal of lymph nodes in the armpit or groin because of breast or other cancers. The lymphatic fluid is unable to return to the circulation normally and accumulates in the limb. The limb becomes very swollen, tense and sore. In severe cases the arm is rock hard and three times its normal size, and ulceration and infection of the skin and deeper tissues in the affected limb may occur. The Stewart-Treves syndrome is another complication. Lymphoedema is a very difficult problem to treat. Elevation, exercises, pressure bandages and a plastic sleeve that envelops the arm and is rhythmically inflated by a machine, can be tried. The severity varies dramatically from one patient to another, with only a partial relationship to the severity of the surgery. It often persists for many years before gradually subsiding as new lymph channels are formed. See also BREAST CANCER MALE BREASTS Both boys and girls start producing both oestrogen (female hormone) and testosterone (male hormone) in their early teen years. These hormones are responsible for the changes from child to adult. Boys produce far more testosterone, and girls far more oestrogen to create the characteristic differences between the sexes. In the early stages of puberty, the balance between the two hormones may not be quite right. This results in irregular periods in girls, and breast bud development in boys. After a few months, the imbalance settles down, and the womans periods become regular, and the breast buds disappear in men. In a very small number of cases the breast development in young men may be significant enough to warrant a small operation to remove them. Boys to whom this occurs should be reassured that what is happening is completely normal, and will have no effect upon their sexual preferences or masculinity. Men can also get breast cancer, and it is just as serious in men as women. This can be another cause of a lump under the nipple in men. About 2% of all breast cancers occur in men. Male breasts sometimes enlarge in old age, with an increase in weight, and with oestrogen hormone treatment in men wanting to change sex. It may also be a symptom of a significant underlying disease including cirrhosis of the liver, cancer in the adrenal glands, overactivity or cancer of the thyroid gland, an uncommon form of lung cancer, a tumour in the testicles or a genetic condition called Klinefelter syndrome in which there is an extra sex chromosome. See also GYNAECOMASTIA MAMMMamm- is a prefix derived from mamma, the Latin word for breast, and is used in medicine to indicate the breasts (mammary glands), or diseases or investigations relating to the breasts (eg. mammogram). MAMMARY CARCINOMA See BREAST CANCER MAMMARY DYSPLASIA Mammary dysplasia is also known as chronic cystic mastitis and fibrocystic disease of the breast. It is a common cause of breast lumps and cysts, and breast discomfort in middle-aged women, and is caused by overactivity of the ovaries in producing too much oestrogen. It is often an inherited characteristic. Affected women develop multiple, tender, painful, small lumps in the breasts that vary in size and severity with the monthly hormonal cycle. They are usually worse just before a menstrual period. Large cysts may form permanently in the breast, and persistent pain and discomfort may significantly affect the womans lifestyle. 24 !

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Mammography (breast x-ray) and ultrasound may be used initially, but in most cases needle or surgical biopsy is necessary to confirm the diagnosis. Initially a firm bra should be worn day and night. Individual cysts may be drained through a needle when they become too large or uncomfortable. Medical treatment involves using drugs such as the contraceptive pill to regulate the menstrual cycle, nonsteroidal anti-inflammatories, danazol and progestogens. Avoiding caffeine helps some patients. The condition often persists until menopause, when it naturally subsides. See also BREAST CANCER; BREAST LUMP; FIBROADENOMA OF THE BREAST MAMMARY GLAND The medical term for the female breast is the mammary gland. MAMMOGRAM A mammogram is an X-ray of the breast using a special technique to reveal the structure of the breast. It is one of the most significant diagnostic tools available for the detection of breast cancer. A mammogram may be ordered to investigate a lump that has been found during a physical examination of the breasts, either by the patient herself, or by her doctor. However, women are being urged to have routine mammograms since it is the only reliable method of detecting cancer at the earliest possible stage, even before a lump can be felt. Unfortunately they are not 100% reliable, and a mammogram should always be preceded or followed by a breast examination by a doctor. Cancer cells are denser than ordinary cells and are impenetrable to certain X-rays. A tumour will therefore appear as a white patch on the mammogram picture. Mammography can sometimes detect the difference between benign and malignant tumours. The rate of breast cancer rises markedly in women above 50, and regular mammograms are recommended for all women over this age, generally once every two years. Women younger than this should have regular mammograms if there is a high risk of developing breast cancer. Studies carried out in various parts of the world estimate that the death rate from breast cancer is reduced by up to 70% in screened women.

To have a mammogram, the woman will strip to the waist and sit or stand in front of a small table, leaning in such a way that her breast is resting on the table, where it will be placed in various positions and photographed by the X-ray machine above. The breasts will be compressed to reduce the distance the X-rays must pass through them, and to reduce distortion caused by the curvature of the breast surface. The technique is especially valuable in the examination of large breasts, because the contrast is greater. However, a trained radiologist will detect any abnormalities in even the smallest breasts. Having a mammogram is painless, although some women find the compression of their breasts uncomfortable. For routine mammograms, it is better to make the appointment in the first two weeks of the menstrual cycle when the breasts are not swollen and painful because of normal hormonal changes. 25 !

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Modern mammography equipment delivers very little radiation and so is considered safe. Nevertheless, even small amounts of radiation increase the likelihood of getting cancer to a degree, and this needs to be taken into account when deciding on the frequency of routine tests. The older a woman gets, the less she is at risk from radiation, so those for whom a mammogram is of most value are at least risk from exposure to radiation. If an abnormality is detected, it may be further investigated by an ultrasound and biopsy. See also BREAST; ULTRASOUND; X-RAYS MAMMOPLASTY A mammoplasty is any operation on the breast that alters the shape or size of the breast. See also BREAST AUGMENTATION; BREAST REDUCTION MASTALGIA The medical term for breast pain is mastalgia. See also BREAST PAIN MASTECTOMY Mastectomy is the surgical removal of the breast, usually because of breast cancer. A mastectomy may be described as a:- partial mastectomy - only part of the breast is removed. - simple mastectomy -only the breast tissue, and none of the deeper tissues or lymph nodes are removed. - radical mastectomy - the breast, underlying muscle and tissue, some overlying skin, and surrounding lymph nodes are all removed. After the procedure, which is performed under a general anaesthetic, a drainage tube is normally left in place for several days. After a simple mastectomy the patient usually leaves hospital after two or three days, but after a radical mastectomy, five days is more common. The immediate complications are infection, bruising and a blood clot. Long term, lymphoedema may be a complication of a radical mastectomy. A prosthetic (artificial) breast may be implanted during the initial operation in some patients, or may be inserted in another operation at a later date. Some women prefer to use an artificial breast worn in the bra. See also BREAST CANCER; LYMPHOEDEMA MASTITIS Mastitis (milk fever) is an infection of the breast tissue, almost invariably in a breastfeeding woman. It usually occurs if one of the many lobes in the breast does not adequately empty its milk, and may spread from a sore, cracked nipple. Women nursing for the first time are more frequently affected. The breast becomes painful, very tender, red and sore, and the woman may become feverish, and quite unwell. Antibiotic tablets such as penicillin or a cephalosporin usually cure the infection rapidly and the woman can continue breastfeeding, but if an abscess forms, an operation to drain away the accumulated pus is necessary. In recurrent cases, bromocriptine may be used to stop or reduce breast milk production. See also BREASTFEEDING; MAMMARY DYSPLASIA MEGESTROL Megestrol is a medication used as a tablet to slow the progress of breast cancer as a last resort after it has spread to other organs. It is not to be used in pregnancy and women must use adequate contraception while taking megestrol. Regular blood tests to check the blood sugar level are recommended. Side effects may include nausea, weight gain, fluid retention, abnormal vaginal bleeding, and less commonly vomiting, tumour pain, bone pain, hot flushes and a blood clot in a vein (thrombosis). See also BREAST CANCER MELPHALAN Melphalan is a medication in the alkylater class used as a tablet to treat cancer of the breast and ovary, sarcoma, melanoma, multiple myeloma and polycythaemia vera. The dosage must be individualised by doctor for each patient depending on disease, severity, age and weight of patient. It must not be used in pregnancy, breastfeeding or children unless essential for the life of the child. Use with caution in kidney disease and if given radiation or cytotoxic treatment recently. Regular blood tests to check blood cells are essential. 26 !

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Side effects may include damage to bone marrow and white blood cells, nausea, vomiting, diarrhoea, sore mouth, hair loss, anaemia, lung damage, and rarely severe abnormal bleeding or bruising. Melphalan interacts with cyclosporin and nalidixic acid. An overdose is very serious with destruction of bone marrow possible, which may lead to fatal infections. See also BREAST CANCER METHENOLONE Methenolone is an anabolic steroid that is used as a prescription tablet or injection to treat osteoporosis and uncontrolled breast cancer, and illegally by body builders. It must not be used in pregnancy, breastfeeding, adolescents or children, or if suffering from prostate disease or a liver tumour. Use with caution in patients with diabetes and high blood calcium. Common side effects include nausea, headache, altered libido, fluid retention and premature cessation of growth in adolescents. In women it may also cause menstrual irregularities and increased body hair, and in men infertility, impotence, shrinking of testes and breast enlargement are possible. Liver damage and jaundice is a rare complication. Methenolone interacts with anticoagulants (eg. warfarin), corticosteroids, insulin, hypoglycaemics and echinacea. Although it does not cause dependence or addiction, short term gains in muscle bulk when used inappropriately by body builders, may result in long term permanent body damage that may lead to early heart attacks, infertility, bone weakness, liver disease and premature death. Bottom line is - dont use it except under strict medical supervision when indicated for specific diseases. METHOTREXATE Methotrexate is a very useful medication for the management of numerous types of cancer (including cancer of breast and uterus), leukaemia, severe psoriasis, severe rheumatoid arthritis and several other unusual diseases. The tablet dosage must be individualised for each patient by doctor depending on the disease, severity and weight of patient. It is often given once a week. Methotrexate must not be used in pregnancy unless mothers life is at risk, as the foetus may be damaged. Breastfeeding must be ceased before use, but it may be used in children if medically essential. Use it with caution in infection, active infection, peptic ulcer and ulcerative colitis, and not at all if suffering from severe liver or kidney disease, significant infection, bone marrow disease, low level of white blood cells, low level of blood platelets, significant anaemia, immune deficiency (eg. AIDS) or alcoholism. Regular blood tests to check blood cells and liver function are essential, and adequate contraception must be used by women while methotrexate is being taken. Common side effects include mouth ulcers, nausea, belly pains, diarrhoea, while less commonly tiredness, chills, dizziness, reduced resistance to infection, rash and infertility occur. Yellow skin (jaundice), unusual bleeding or bruising, bone marrow damage and vision changes are serious complications. This medication interacts with NSAID, aspirin, sulfonamides, phenytoin, tetracyclines, chloramphenicol, folic acid, probenecid, co-trimoxazole, NSAIDs, drugs used to lower cholesterol levels, other cytotoxics, echinacea and willow bark. Most patients are required to take folate while using methotrexate in order to prevent some side effects. Despite risk of significant side effects, methotrexate may save the life, or improve the quality of life, of many patients. See also BREAST CANCER MILK Milk is secreted by the mammary glands (breasts) of all female mammals and marsupials in order to feed their young. It contains nutrients such as protein, fats, carbohydrates, vitamins and minerals that are ideal for the young of each species. Dairy products are a staple food in the diet of nearly every civilisation around the world, either in its original liquid form or as cheese, butter, yoghurt, cream, or in many other forms. The intake varies from one place to another. The Japanese have relatively little, Europeans quite a lot, and some Arab tribes live almost entirely on dairy products. Milk is an excellent source of carbohydrates, protein and fat, and the sugar lactose. Man can virtually live on milk alone if necessary. Some specialised dairy products, such as yoghurt and junket, are excellent aids to digestion and bowel function. Cheeses are compressed energy, and are included in survival rations. As with all foods, too much can be harmful. Those who have a high cholesterol level in their bloodstream and the more obese members of the community should not eat whole milk products, but skim milk and fat reduced dairy products can still be consumed. The theory that milk increases mucus production in the nose and throat is a myth. There is no benefit in stopping dairy products to ease mucus congestion. See also BREASTFEEDING; BREAST MILK; CASEIN; WITCHS MILK 27 !

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MILK EJECTION REFLEX See LET DOWN REFLEX MILK FEVER See MASTITIS MILK INADEQUATE See BREASTFEEDING FAILURE MONDOR DISEASE The rare Mondor disease is the formation of blood clots (thromboses) in the superficial veins of the breast. It may even more rarely occur in the penis, armpit or chest wall. There is a sudden onset of pain and swelling of the skin over the affected area and a tender lump forms under the skin that is the blood clot in the vein. It may be caused by an injury or infection to the area, but often no cause is identified. The diagnosis is confirmed by an ultrasound scan. Other more serious causes of a breast lump must be excluded. Treatment involves indomethacin or other nonsteroidal anti-inflammatory medications, hot packs and pain relievers. The problem settles spontaneously over a week or two. See also BREAST LUMP MONTGOMERY GLANDS The Montgomery glands are the sebaceous (oil) glands in the areola (pigmented ring) around the nipple of the breast. The number varies from about six to 25 glands on each breast. They secrete the oil that keeps the nipple moist and supple. The glands open onto the skin surface through ducts that end on a small tubercle (protrusion) that cause the multiple small lumps (Morgagni tubercles) in the areola. See also AREOLA; MORGAGNIS TUBERCLES; NIPPLE MUCOCOELE A mucocoele is a cyst filled with mucous. They may occur in the lining of the mouth, nose, throat, anus or vagina. They also occur in the ducts of the breast where they may be mistaken for a cancer. MYELOFIBROBLASTIC TUMOUR Only identified as a separate entity since about 1990, myelofibroblastic tumours are a very rare form of slow growing cancer that can affect many structures within the body including the breast, skin, muscle, blood vessels and the intestine. They act as a mild form of sarcoma. Management is difficult as they spread insidiously through surrounding tissues, do not respond to chemotherapy and must be repeatedly surgically removed. NANDROLONE Nandrolone decanoate is an anabolic steroid used as an injection to treat kidney failure, inoperable breast cancer, severe osteoporosis, aplastic anaemia, suppression of white cells, and to prevent side effects in patients using corticosteroids long term. It is also used dangerously, and in an unapproved manner, by body builders and athletes. Nandrolone must not be used in pregnancy, or breastfeeding, if suffering from prostate and testicular cancer, male breast cancer, heart failure, or liver and kidney disease. Use it with caution in children as growth suppression may occur, and in adults with heart disease, enlarged prostate gland and diabetes. Common side effects include increased hairiness and decreased breast size in women, voice deepening in women, acne, frequent unwanted erections and infertility. Unusual side effects may include anaemia, enlargement of the clitoris in women, cessation of menstrual periods, decrease in testicular size, impotence, breast enlargement in males, baldness in females, reduced libido, unusual bruising or bleeding, calcium deposits (lumps) in tissue and jaundice (yellow skin). It interacts with insulin, warfarin, hypoglycaemics (used for diabetes) and echinacea. Although increasing muscle bulk, there is no evidence that this medication enhances athletic ability. Short term gains in muscle bulk when used inappropriately by body builders, may result in long term permanent body damage that may lead to early heart attacks, infertility, bone weakness, liver disease and premature death. Bottom line is dont use it except under strict medical supervision when indicated for specific diseases.

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NEEDLE BIOPSY It may be necessary to take a sample (biopsy) from an organ or tissue that is not easily accessible (eg. liver, breast lump). In order to avoid major surgery, the biopsy may be taken using a specially designed needle with a solid thin rod (trocar) down the centre of the needle (cannula). The biopsy needle is inserted through the skin and into the target organ or tissue. Ultrasound guidance may be used to accurately locate the required tissue. Once near the target tissue the trocar is withdrawn from the biopsy needle and the needle is advanced and rotated to cut out a tiny segment of the tissue. This can then be sucked back into the needle by an attached syringe. The needle is withdrawn, and the sample expelled and examined under a microscope after staining. NIPPLE The nipple is located at the apex of the breast and over the space between the fourth and fifth ribs in men. In both sexes it is an erogenous area in that stimulation of the nipple is sexually stimulating, but in men it serves no other purpose. The nipple contains numerous small muscles that contract to make the nipple erect when stimulated by suckling, plucking, cold or anxiety. These muscles are more numerous in women as the nipple is considerably larger. In women, 15 to 20 ducts from the milk glands in the breast open through the nipple. The nipple is surrounded by pigmented skin called the areola, which enlarges at puberty, and may darken further (chloasma) after pregnancy or hormonal medication use (eg. contraceptive pill). The areola contains sebaceous (oil) glands (Montgomery glands) that give it a bumpy appearance, particularly around its edge. Cancer of the breast (Pagets disease of the nipple) can develop solely in the nipple. See also AREOLA; MONTGOMERY GLANDS; MORGAGNIS TUBERCLES; NIPPLE, ACCESSORY; NIPPLE CRACKED; NIPPLE DISCHARGE; NIPPLE INVERTED; NIPPLE PIGMENTATION; PAGETS DISEASE OF THE NIPPLE NIPPLE, ACCESSORY An accessory, or supernumerary, nipple, is curiosity of foetal development.! Many mammals (eg. dogs, cats, pigs) have a line of nipples along each side of their chest and abdomen from which they can feed milk to their young. In humans there is normally only one nipple on each side of the chest. Nipples in all mammals can actually develop at any point along a nipple (or milk) line that in humans extends along the trunk from just below the centre of the collar-bone (clavicle) to the top of the pelvis. They occur in about one in every twenty people of both sexes. Accessory nipples are harmless and are often mistaken as moles, and only after excision is the correct diagnosis made. They can vary in size from merely an abnormal patch of hair to a fully functioning (but usually smaller) breast (pseudomamma). In medieval times a significant accessory nipple was considered to be the sign of a witch as the devil could be fed from it. See also NIPPLE NIPPLE CANCER See PAGETS DISEASE OF THE NIPPLE NIPPLE CRACKED A common complaint, especially in breastfeeding first-time mothers, is a cracked nipple. It usually starts a few days after the baby starts feeding and can be excruciatingly painful. Preparing the nipples for breastfeeding should lessen the likelihood of this problem. If a crack does appear, soothing creams are available from chemists or doctors to settle the problem, and often the baby will have to be fed from the other breast for a few days or with the aid of a nipple shield until the worst of the discomfort passes. See also BREASTFEEDING; NIPPLE SHIELD NIPPLE DISCHARGE The nipple of the breast will obviously discharge milk in a woman who is breastfeeding, and will often leak milk between feeds, particularly when the breast is engorged with milk some hours after a feed. At other times a discharge will indicate some medical problem. Sex hormone imbalances are the most common cause of abnormal nipple discharges. At almost any time during pregnancy, but particularly late in pregnancy, the higher levels of hormones in the body may stimulate premature breast milk production. Hormones in the oral contraceptive pill, or hormone replacement therapy after the menopause, may over 29 !

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stimulate breast tissue to cause a discharge if the dose is too high. The pituitary gland under the brain sends signals to the ovaries to increase or decrease sex hormone (oestrogen) production. A tumour or cancer of the pituitary gland or ovaries may result in excessive hormone levels and breast milk production. Newborn infants of both sexes sometimes produce witchs milk, which is a discharge from the nipples in the first few days of life due to high levels of sex hormone passing over to the child from the mother through the placenta during birth. It is a harmless condition that settles quickly. Other causes of an abnormal nipple discharge include breast cancer that involves the milk ducts (brown or blood stained discharge), kidney failure (may prevent the excretion of the normal amount of oestrogen and the levels of hormone increase), under or over active thyroid gland (hypothyroidism and hyperthyroidism), Cushing syndrome (over production of steroids, or taking large doses of cortisone) and excessive stimulation of a womans nipples for a prolonged period of time may result in a reflex which increases oestrogen levels and results in milk production. Some non-hormonal medications may increase sex hormone production as a side effect. Examples include methyldopa and reserpine (used for serious high blood pressure) and tricyclic antidepressants. See also BREASTFEEDING; NIPPLE NIPPLE INVERTED Some women have flat or inverted nipples. The nipple is also inverted if it retreats when the woman tries to express milk by hand. If a woman intends to breastfeed, the doctor will examine the breasts during an antenatal visit, and if the nipples are flat or inverted, a nipple shield may be worn to correct the problem. The shield fits over the nipple drawing it out gently, making it protrude enough for the baby to feed. Stimulating the nipple by rolling it between finger and thumb, and exposing the breasts to fresh air (but not direct sunlight) may also help. See also BREASTFEEDING; NIPPLE NIPPLE ITCH Itchy nipples are a relatively common problem. Women with small breasts may go without a bra and their nipples are irritated by clothing moving across them, or a loose fitting bra may constantly move across the nipple irritating it. Other causes include synthetic materials in a bra, allergies to soaps, perfumes and washing powders, and fungal infections such as thrush (common in breastfeeding mothers).

;'&($2&1$.!*1-30+&!3(1,3*1!(1+!,$%&'!.<*1!2,*.$0'*.&'.4!(1$*:*$-%!-'&(2.4!(1$*/018(3!-'&(2.!*/! $%'0.%!)'&.&1$4!,'!)'&.-'*"&+!2*3+!.$eroid creams. Padding a bra may help small-breasted women, and an
adhesive dressing over the nipple can give quick relief. See also NIPPLE NIPPLE PAIN A painful nipple may be caused by injury to the nipple while breastfeeding, repetitive rubbing of the nipple on a loose bra (particularly in small breasted women), and a bacterial or fungal infection of the nipple. Less commonly it may be due to dermatitis involving the nipple or Pagets disease of the nipple (the nipple becomes firm and hard). Rarely, Raynauds phenomenon of nipple (the nipple changes colour from red to white and blue) or Zuska disease (a nipple abscess) may be responsible. See also BREAST PAIN; PAGETS DISEASE OF THE NIPPLE; ZUSKA DISEASE NIPPLE PIGMENTATION Increased pigmentation of the areola (dark area around the nipple) is a form of chloasma (facial skin pigmentation) and is a sign of past or present pregnancy or hormone therapy (eg. contraceptive pill). It may also be an inherited or racial characteristic. Girls often have some degree of darkening of the areola at puberty. See also CHLOASMA; NIPPLE NIPPLE SHIELD A nipple shield is made from soft moulded latex. It is a shallow dish shape, has a tab handle on one edge and a hole in the centre through which the nipple partly protrudes. It allows a baby to continue feeding from a cracked or sore nipple. See also BREASTFEEDING; NIPPLE CRACKED

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NIPPLE, SUPERNUMERARY See NIPPLE, ACCESSORY OESTROGEN Oestrogen is a class of female sex hormone that is produced in the ovaries and to some extent the testes. Oestrogen is divided into several different types - oestrone, oestradiol and oestriol. Together they stimulate ovulation (the release of an egg from an ovary once a month) and the development of breasts, pubic hair and other sexual characteristics at puberty in women. The amount present in urine can be measured in the investigation of female infertility, determination of menopause state and even sex determination, but blood measurements of a specific form of oestrogen, oestradiol, are more accurate. In urine the normal results in g/24 hours are: Oestrogen Oestrone Oestradiol Oestriol Male 0 to 5 0 to 5 0 to 10 Menstruating woman 5 to 20 2 to 10 5 to 30 After menopause 0.3 to 2.4 0 to 1.4 2.2 to 7.5

A high level in females usually indicates sex hormone therapy, while in males it may be due to feminisation from taking female hormones or abnormal hormone production within body. A low level in women indicates infertility or menopause. As a medication oestrogen has the common trade name Premarin, which is derived from the original rather unsavoury source of oestrogen, pregnant mares urine. It is used as a tablet, vaginal cream or injection for hormone replacement therapy in the menopause. It should not be used in pregnancy, breastfeeding, children or males, but accidental usage in these situations is unlikely to be harmful. Use oestriol with caution in epilepsy, migraine, heart failure, high blood pressure, kidney disease, diabetes, porphyria or uterine disease, and not at all if suffering from liver disease, breast or genital cancer, blood clots, undiagnosed vaginal bleeding, endometriosis, porphyria or otosclerosis. Side effects may include abnormal uterine bleeding, vaginal thrush, nausea, fluid retention, weight gain, breast tenderness. Unusual effects may include a rash, blurred vision, vomiting, bloating, intestinal cramps, pigmentation of skin on face. Severe but rare reactions may be blood clots, calf or chest pain and yellow skin (jaundice). Smoking increases the risk of serious side effects. It may interact with other sex hormones, rifampicin and the herbs saw palmetto, alfalfa, dong quai, ginseng, liquorice, red clover. Vomiting and abnormal vaginal bleeding are the only likely effects of an overdose. See also SEX HORMONES ONCOTYPE DX BREAST CANCER ASSAY This very expensive test analyses 21 different genes tom determine the risk of cancer recurrence in women with breast cancer, and whether they would benefit from chemotherapy. The test is performed on a biopsy or sample of tissue from a breast cancer, and is normally performed on women with newly diagnosed breast cancer that is at an early stage and in whom there is some doubt as to the benefit of chemotherapy. The result is given as a score between 0 and 100, with results below indicating that there is a very low risk of breast cancer recurrence and minimal benefit from chemotherapy. A score of 19 to 30 is a grey area where there may be limited benefit from chemotherapy in a woman who has only a small chance of cancer recurrence, while a score above 30 indicates a higher risk of recurrence and greater benefit from chemotherapy. See also BREAST CANCER ORGASM The female orgasm is a reflex, in the same way as a tap on the knee causes a reflex. Some people have a vigorous response to a knee tap, while others have little. Thus it is difficult to determine what is a normal and abnormal reflex or orgasm. An orgasm is the female equivalent of the male ejaculation. The woman feels an intense sensation of pleasure sweeping over her associated with contractions of the muscles in the vagina and uterus and tingling of the nipples. This may last for a few seconds or half a minute. Different women require different degrees and types of stimulation to have an orgasm. Some can only orgasm by stimulation of the clitoris, while others require prolonged intercourse, while others may orgasm frequently and easily with merely breast stimulation or thinking about sex. A woman may find that one particular sex position causes orgasm more easily than other positions. OVARY The two ovaries are the main female reproductive organs. Shaped like an almond, each ovary is about 3 cm long, 1.5 cm wide and 1 cm thick. They lie in the pelvis, one on either side of the uterus. The ovaries have two 31 !

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functions - the development and release of eggs, and the production of hormones. All the eggs (ova) a woman will ever have - and considerably more than she will ever need - are contained in her ovaries when she is born. At birth, there are about two million immature eggs in each ovary. By puberty these are reduced to about 300,000, and only about 400 will be released during the childbearing years. The number of ova in the ovaries steadily decreases during middle life, and at by the time menopause starts only 25,000 are left. The ovum (egg) is the largest single cell in the body, but still needs a powerful microscope to be seen.

Each egg (ovum) is surrounded by a small sac called a follicle. When puberty is reached, a cycle is established in which a few of the egg cells develop each month, with one reaching full maturity. When this happens the follicle bursts and releases the egg in the process called ovulation. A woman is fertile and can become pregnant a day or two either side of ovulation - and not at other times. When an egg is released, it is swept into the adjacent Fallopian tube, the other end of which connects with the uterus. The ovaries also produce the hormones oestrogen and progesterone. Oestrogen predominates during the ripening of the egg, which takes about two weeks. It is this hormone that causes the lining of the uterus to thicken and the body to prepare for pregnancy. When the egg is released, the production of the second hormone, progesterone, increases, preparing the lining (endometrium) still further and bringing it to total readiness for a fertilised egg. If there is no conception, the oestrogen and progesterone levels fall suddenly and the uterine lining is shed during menstruation. The whole process then begins again. The monthly cycle continues throughout a woman's childbearing years from puberty to the menopause. It is the female hormones that also give a woman her secondary sexual characteristics, for instance her broader hips than the male, her breasts, pubic and armpit hair, and her rounder, more feminine shape. See also SEX HORMONES OXYTOCIN Oxytocin (OXT) is a hormone produced in the neurohypophysis, which is part of the pituitary gland under the brain. It acts to start labour in pregnancy, stop excessive bleeding after delivery by contracting the uterus and stimulates milk production by the breasts. A synthetic form can be given as an injection to increase the intensity of labour, and immediately after delivery to reduce bleeding. PACLITAXEL Paclitaxel (Taxol) is an antineoplastic medication used as an injection to treat cancer of the breast and ovaries.

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It must not be used in pregnancy or children, and only with caution in breastfeeding and neuropathy (nerve disease). Regular blood tests are necessary to check the function of blood cells. Common side effects include flushes, rash, shortness of breath, chest pain, fainting, joint and muscle pain. Less common effects may include low blood pressure, slow heart rate, damage to nerves Pins and needles sensation, numbness), damage to liver and jaundice (yellow skin). The active ingredients were originally derived from the bark of the Pacific yew tree. See also BREAST CANCER PAGETS DISEASE OF THE NIPPLE Pagets disease of the nipple (nipple cancer) is an uncommon type of cancer that starts in the milk ducts of the nipple, and may spread rapidly along these ducts, deep into the breast. The cause is unknown, but it is uncommon, occurring in only one in every one hundred breast cancers. There are often very few symptoms until the cancer is well advanced, and no lump is felt. Symptoms include itching and irritation of the nipple, a thickening of the nipple and in advanced cases an ulcer may form. The cancer may spread to breast tissue and nearby lymph nodes. The diagnosed is confirmed by biopsy of the nipple. Surgery to remove the nipple and the affected part of the breast is performed, followed by radiotherapy and chemotherapy when necessary. The more advanced the cancer when first treated, the poorer the survival rate. See also BREAST CANCER PEAU DORANGE In some forms of advanced breast cancer, the skin over the cancer takes on a dimpled appearance similar to that of an orange skin, and is known as peau dorange (orange peel in French). See also BREAST CANCER PHYTOESTROGENS Phytoestrogens are a hormone found in some plants, particularly soy beans, beans, sprouts, cabbage, linseed oil and corn. Even in concentrated form when used as a medication, they have only a minimal effect on human oestrogen levels and conditions such as the menopause and breast cancer that are generally affected by human oestrogen. POLYCYSTIC OVARIAN SYNDROME In the polycystic ovarian syndrome (PCOS) or Stein-Leventhal syndrome, multiple small cysts form in one or both ovaries. It occurs in about 7% of women and tends to run in families. The cause is unknown, but is probably a combination of genetic and environmental factors. The cysts interfere with the production of sex hormones (eg. oestrogens) by the ovaries and the patient develops facial hairs, develops adult acne, gains weight, stops her menstrual periods, is infertile and losses breast firmness. These patients have an increased risk of developing type two diabetes mellitus and often have raised cholesterol levels. Abnormal levels of hormones can be measured in the bloodstream, but the syndrome is often discovered on an ultrasound scan while investigating infertility. The presence of cysts in an ovary on ultrasound is not PCOS unless accompanied by the other symptoms of the syndrome associated with hormonal abnormalities. Treatment involves encouraging the patient to lose weight, using hormones to stimulate the ovary to restart its correct function, and sometimes surgically cutting away part of the affected ovarian tissue. Specific medications (eg. spironolactone or progestogens) are used for excessive hair growth. The diabetes medication metformin may be used to assist in weight loss. Rarely, some women find the discomfort of the condition and the side effects of medication unacceptable and decide to have a total hysterectomy. See also OVARY PREGNANCY The first sign that a woman may be pregnant is that she fails to have a menstrual period when one is normally due. At about the same time as the period is missed, the woman may feel unwell, unduly tired, and her breasts may become swollen and uncomfortable. A pregnant woman should not smoke because smoking adversely affects the baby's growth, and smaller babies have more problems in the early months of life. The chemicals inhaled from cigarette smoke are absorbed into the bloodstream and pass through the placenta into the baby's bloodstream, so that when the mother has a smoke, so does the baby. Alcohol should be avoided especially during the first three months of pregnancy when the vital organs of the 33 !

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foetus are developing. Later in pregnancy it is advisable to have no more than one drink every day with a meal. Early in the pregnancy the breasts start to prepare for the task of feeding the baby, and one of the first things the woman notices is enlarged tender breasts and a tingling in the nipples. With a first pregnancy, the skin around the nipple (the areola) will darken, and the small lubricating glands may become more prominent to create small bumps. This darkening may also occur with the oral contraceptive pill. Most women are advised to take tablets containing iron and folic acid throughout pregnancy and breastfeeding, in order to prevent both the mild anaemia that often accompanies pregnancy, and nerve developmental abnormalities in the foetus. As the skin of the belly stretches to accommodate the growing baby, and in other areas where fat may be found in the skin (such as breasts and buttocks), stretch marks in the form of reddish/purple streaks may develop. These will fade to a white/silver colour after the baby is born, but unfortunately they will not normally disappear completely. PREMATURE OVARIAN FAILURE One in every one hundred women suffers from premature ovarian failure, a condition in which the ovary ceases to function normally at a far earlier age than expected. It is really an onset of the menopause at an early age, usually defined as before 40 years of age. One in very thousand women has premature ovarian failure before the age of 30 years. Because many women are now delaying pregnancy until their career is established, premature ovarian failure is becoming a steadily more significant problem in the community. Affected women cease their periods and are unable to fall pregnant. They may start to lose some of their feminine characteristics as the breasts sag and pubic hair becomes sparse. There are usually no warning signs of a premature menopause, and the first a woman knows about it is when her periods cease. The most common time for the problem to occur is actually after a pregnancy, abortion or miscarriage when the menstrual periods fail to restart. There is a family tendency though, so it may be able to judge the risks of premature ovarian failure by the experience of older sisters or the womans mother. To refer to premature ovarian failure as premature menopause is not strictly correct, as more than half of these women still have eggs (ova) in their ovaries at the time the condition is diagnosed, but the mechanism for the maturation and release of these eggs is faulty. There is no specific cause for the condition in most cases although in some cases there is an obvious cause such as chemotherapy or irradiation for pelvic cancer, and surgery or injury to the pelvis that damages the ovaries. Rare causes of premature ovarian failure include the disease galactosaemia, severe pelvic infections, some autoimmune diseases (eg. Addison disease, myasthenia gravis), severe diabetes, thyroid disease and a number of rare syndromes. Abnormalities of the X chromosome that are passed from one generation to the next are the most likely cause of the problem in families who experience the condition across the generations. Screening techniques can now detect these abnormalities in an individual if necessary. There is no evidence that premature ovarian failure is becoming more common, it is merely that it appears so because so many women are starting their families at an older age. The diagnosis can be confirmed by tests on blood sex hormone levels, ultrasound scans of the ovaries and finally an ovarian biopsy using a laparoscope. Unfortunately the treatment of premature ovarian failure is unsatisfactory as the medications used to stimulate ovulation may not work. The solution may be to use donor eggs in a GIFT procedure. Women who know that they are due to have pelvic irradiation or chemotherapy may decide to preserve some eggs in liquid nitrogen for use at a later date. Premature ovarian failure may not be permanent, and years after the diagnosis is made the woman may suddenly start menstruating and ovulating again for no known reason. Up to one in ten women with premature ovarian failure becomes pregnant without further treatment. See also OVARY PREMENSTRUAL TENSION Premenstrual tension (PMT, premenstrual dysphoric disorder or premenstrual syndrome) may vary from a slight discomfort for a couple of hours before the onset of a woman's menstrual period to a severely distressing condition. During the two weeks leading up to a menstrual period, the body retains fluid. If the balance between the sex hormones oestrogen and progestogen is not quite right, an excessive amount of fluid may be retained in the pelvis, brain, breasts, hands and feet to cause gradually increasing discomfort in the pelvis and breasts, with swelling of the hands and feet, pounding headaches and depression. The worst sufferers will experience abdominal pain, swollen tender breasts, anxiety, irritability and clumsiness, and may be unable to concentrate, work or exercise effectively. The most severe form is known as premenstrual dysphoric disorder when symptoms seriously interfere with a womans lifestyle, mental and physical functioning, and relationships. Depression, very rarely severe enough to lead to suicide, and a psychosis that has been used in court as a defence for murder, can be extreme complications. The symptoms usually disappear within a few hours when the period starts. 34 !

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The oral contraceptive pill or similar hormones can be used to regulate the hormonal balance and prevent excess fluid retention, and diuretics (tablets that remove fluid from the body) may be used alone or in combination with the contraceptive pill. Other medications that may be beneficial include antidepressants (eg: citalopram), vitamin B6, mefenamic acid, naproxen, indomethacin and evening primrose oil. Other approaches include a sensible balanced diet, and avoiding coffee, chocolate and rich foods in the two weeks before the period. The majority of women can be helped adequately by good treatment. See also CONTRACEPTIVE PILL PROLACTIN Prolactin is a hormone produced in the anterior lobe of the pituitary gland that helps control the menstrual cycle and lactation (breastfeeding). High levels cause sterility, amenorrhoea (no menstrual periods) and galactorrhoea (abnormal breast milk production). The normal levels in a blood sample are:Female 3 to 25 g/L (less than 600 mU/L) Male 2 to 15 g/L (less than 450 mU/L) High blood levels are found in tumours or enlargement of the pituitary gland under the brain, tumours of the brain that put pressure on the pituitary gland, brain injury, hypothyroidism (under active thyroid gland), kidney failure, sarcoidosis, pregnancy, Stein-Leventhal syndrome, severe premenstrual tension, stress, with some drugs (eg. phenothiazines, antidepressants, antihistamines) and with excess caffeine. PSEUDOANGIOMATOUS STROMAL HYPERPLASIA Pseudoangiomatous stromal hyperplasia is the presence of excess breast support (stromal) tissue in an area that forms a lump or may involve large parts of the breast to make it firm and lumpy. These benign growths can increase in size quite quickly and may be mistaken for a fibroadenoma of breast cancer. They can be surgically removed if only a small area is involved. See also BREAST LUMP; FIBROADENOMA OF THE BREAST PUBERTY The trigger for puberty is the production of sex hormone releasing factors from the pituitary gland at the base of the brain, which cause sex hormones to be manufactured in the gonads - oestrogen from the ovaries of females, and testosterone from the testes of males. Both sexes show a marked increase in weight and height, while boys develop more muscle and girls acquire the fatty deposits, which give their rounded feminine shape. There are also gender-based differences in the way the skeleton grows - boys develop wider shoulders leading to greater physical strength, and girls develop wider hips to facilitate childbearing. As a general rule, the bones stop growing in girls by the age of about 16 and in boys by the age of about 18, although sometimes growth continues until the early twenties. Some parts of the body are affected by the adolescent growth spurt more than others. The hands and feet mature first, then the legs, then the trunk, so children stop growing out of their jeans a year or so before they stop growing out of their jumpers. On average puberty starts in girls a year or two earlier than in boys - usually about 10 or 11 years of age in girls, 35 !

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and 12 or 13 in boys. Girls have been known to reach puberty as early as 8 and as late as 15 or 16. Boys vary similarly. Heredity is an important factor in the age of maturity. A girl whose mother started her periods late is likely also to be somewhat later than average in developing. Puberty is also affected by general health. A child who has been undernourished or experienced a lot of illness may have the onset of maturity delayed. Children who are much smaller than the norm also may not mature as early as usual. Generally speaking there is no cause for concern unless a child shows no signs of development by the age of about 15 or 16. The physical changes of puberty are accompanied by psychological and emotional changes, also due to the production of sex hormones. In both boys and girls, there is an increased interest in sexuality as well as greater natural assertiveness, which helps to explain why teenagers are rebellious and often seen by their despairing parents as turning life into a never-ending argument. Rising levels of the male hormone testosterone are thought to be the reason adolescent boys are so often adventurous and aggressive. In girls the physical changes include the development of the breasts, including an increase in the size of the nipples and possibly a darkening of the pigmentation. As well as the widening of the hips, the vagina and uterus develop further. Glands that will supply lubrication during sexual intercourse develop in and around the vagina. Hair grows in the armpits and the pubic region. In girls the pubic hair triangle has the base of the triangle closest to the navel and the apex points to the genitals. Fine hair may develop on the forearms, parts of the legs and the upper lip. The major change in any girl's life is the start of menstruation or the onset of her periods (the menarche). From this time on, every month the uterus prepares itself for a possible pregnancy by increasing the thickness of its lining so as to nourish a fertilised egg. If a fertilised egg does not arrive, the thickened lining is not needed and breaks down to be discarded from the body. It is this lining, together with some blood, that flows out through the vagina as the monthly menstrual flow. The first time a girl has a period, it shows that her body has started releasing its eggs (all of which are present from birth) and is capable of becoming pregnant. An entire cycle normally takes 28 days, with menstruation lasting four or five days. A girl's periods are usually irregular for the first few months, since it takes a while for a pattern to be established. Some women continue to have irregular periods for their entire reproductive lives, while other women are as regular as clockwork In boys the main physical signs of maturity are an enlargement of the penis and testicles and the ability to produce sperm and so fertilise a female egg. Most boys will experience wet dreams or the involuntary emission of semen (the fluid in which sperm is contained) while they are asleep. These are completely normal, and no reason for concern. The boy will also grow a triangular patch of body hair in the pubic region and under the arms. In boys, the pubic hair triangle is widest near the genitals and has its apex pointing towards the navel. Hair also appears on the face, and he will need to shave. Generally the hair is soft and downy to start with and becomes thicker and coarser as the maturing process progresses. Finally a boy's voice breaks and the pitch becomes lower due to the thickening of the vocal cords. See also MALE BREASTS; OVARY; SECONDARY SEXUAL CHARACTERISTICS; SEX HORMONES; QUINAGOLIDE Quinagolide is a medication used for the treatment of hyperprolactinaemia (an overactive pituitary gland producing excess breast milk). Non-hormonal contraception must be used while taking this medication as it must not be used in pregnancy, nor if suffering from kidney or liver disease. Use with caution with a history of psychotic disorders. Patients must check their blood pressure regularly. Side effects may include nausea, diarrhoea, headache, dizziness, tiredness, loss of appetite, sleeplessness, swelling of tissue, nasal congestion, low blood pressure and psychotic reactions. RADICAL The adjective radical is used to indicate a major procedure or drastic form of treatment, usually the removal of a part of the body. Radical surgery could be the removal of an arm or leg. A radical mastectomy is the removal of a breast while a radical dissection is the removal of a large amount of material that may be infected or cancerous. See also MASTECTOMY ROOTING REFLEX If an infants cheek is gently touched, it will turn towards the touched cheek and start to suck. This very primitive rooting reflex is present in all mammals and assists the infant in finding the mothers nipple as the breast brushes against its cheek. SECONDARY SEXUAL CHARACTERISTICS The primary sexual characteristics are the genitals (penis and testes in males, vagina and ovaries in females) and their direct connections that are responsible for the sexual act and reproduction. The secondary sexual characteristics are all the other features that are peculiar to one sex or the other and that develop only after 36 !

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puberty. In the male examples include a beard and body hair, and in the female breasts and the characteristic hourglass figure. The pubic hair also differs in its distribution between the sexes, being diamond shaped in males and triangular in females. See also PUBERTY SEX HORMONES Sex hormones are produced by the ovaries in the woman and the testes in the man, to give each sex its characteristic appearance. In men, they are responsible for the enlargement of the penis and scrotum at puberty, the development of facial hair and the ability to produce sperm and ejaculate. In women, the sex hormones that are produced for the first time at puberty cause breast enlargement, hair growth in the armpit and groin, ovulation, the start of menstrual periods, and later act to maintain a pregnancy. If the sex hormones are reduced or lacking, these characteristics disappear. This happens naturally during the female menopause and the male andropause. During the transition from normal sex hormone production to no production in the menopause, there may be some irregular or inappropriate release of these hormones, causing the symptoms commonly associated with menopause such as irregular periods, irritability and hot flushes. After the menopause, the breasts sag, pubic and armpit hair becomes scanty, and the periods cease due to the lack of sex hormones. Men also go through a form of menopause, the andropause, but more gradually and at a later age, so the effects are far less obvious than in the female. Sex hormones, and many synthesised drugs that act artificially as sex hormones, are used in medicine in two main areas - to correct natural deficiencies in sex hormone production; and to alter the balance between the two female hormones (oestrogen and progestogen) that cause ovulation, to prevent ovulation, and therefore act as a contraceptive. It is now well recognised that hormone replacement therapy (HRT) in middle-aged women who have entered the menopause significantly improves their quality of life by not only controlling the symptoms of the menopause itself, but by preventing osteoporosis (bone weakening), reducing the apparent rate of ageing, reducing the risk of dementia, and possibly reducing the risk of cardiovascular disease (ie. heart attacks and strokes) after the menopause. Women who have both their ovaries removed surgically at a time before their natural menopause, will also require sex hormones to be given regularly by mouth, patch or implant. Female sex hormones can also be used to control some forms of recurrent miscarriage and prolong a pregnancy until a baby is mature enough to deliver, to control a disease called endometriosis, and to treat certain types of cancer. The female sex hormone oestrogen can be given as a tablet, patch, vaginal or skin cream, implantable capsule that is placed under the skin or as an injection. If the woman has not had a hysterectomy, she will need to take progestogen as a pill or patch in a cyclical manner every month or two. This may result in a bleed similar to that of a natural menstrual period (but usually much lighter), but gives the added benefit of protecting the woman against uterine cancer. The common sex hormones fall into the categories of oestrogens, progestogens and androgens (male sex hormones). OESTROGENS Oestrogens include dienoestrol, ethinyloestradiol (Estigyn), oestradiol, oestriol (Ovestin), etonogestrel (active ingredient in the implantable contraceptive Implanon), conjugated oestrogen (Premarin), stilboestrol and piperazine oestrone (Ogen). They are used in contraceptive pills, for hormone replacement therapy during and after the menopause, and are usually combined with a progestogen unless the woman has had a hysterectomy. Side effects may include abnormal menstrual bleeding, vaginal thrush, nausea, fluid retention, breast tenderness, bloating and skin pigmentation. These side effects can usually be overcome by adjusting the dosage. They should not be used in pregnancy, breastfeeding, children, and patients with liver diseases or a bad history of blood clots. Care must be used in patients with breast cancer, epilepsy and hypertension. PROGESTOGENS Progestogens include dydrogesterone (Duphaston), medroxyprogesterone (Provera), progesterone, gestrinone, norelgestren and norethisterone (Primolut-N, Micronor, Noriday). They are used to control abnormal menstrual bleeds, endometriosis, for preventive contraception, morning-after contraception, hormone replacement therapy and premenstrual tension. Medroxyprogesterone is an injectable progesterone that may be used for contraception, to treat certain types of cancer and endometriosis. As a contraceptive it is given every three months. Side effects include the cessation of menstrual periods, breakthrough vaginal bleeding, headaches, and possibly a prolonged contraceptive action (up to 15 months). The other progestogens usually have minimal side effects, but they may include headache, abnormal vaginal bleeding, insomnia, breast tenderness, nausea and sweats. They should not be used in pregnancy, liver disease, and patients with blood clots or breast lumps. Care must be used in patients with hypertension and diabetes. Danazol (Danocrine) is a special type of sex hormone that acts against oestrogen and is used to treat endometriosis, severe menstrual period pain and severe breast pain. Side effects are common and may include 37 !

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acne, weight gain, excess body hair, retained fluid, dry vagina, sweats and the development of a deep voice. It must never be used in pregnancy, or in patients with pelvic infection, liver disease, blood clots or heart failure. ANDROGENS The androgen (male sex hormone), testosterone, is available in synthetic form as a tablets, as an injection (Sustanon), and as implants. They are used to treat conditions such as failure of puberty to occur, pituitary gland dysfunction, impotence, decreased libido (in both sexes), and male osteoporosis. Side effects are unusual, but the prostate gland must be checked regularly for enlargement. They are used in women to treat breast cancer and in both sexes for severe anaemia. Natural lack of the male sex hormone testosterone will cause the man to be impotent and sterile. Synthetic testosterones include fluoxymestrone (Halotestin), mesterolone (Proviron), and oxandrolone (Lonavar). Fluoxymestrone is used to treat breast cancer, osteoporosis and aplastic anaemia. Mesterolone and testosterone are used for male infertility and impotence. Oxandrolone aids short stature, male puberty failure and aplastic anaemia. Side effects may include penis enlargement, infertility, fluid retention, increased body hair and nausea in men, and if used in women irregular periods, deep voice and an enlarged clitoris may develop. They must not be used in pregnancy, heart, liver or prostate disease. Antiandrogens counteract the action of testosterone. The only common hormone in this group is androcur. It is used to treat excess body hair, severe acne and loss of scalp hair in women, and prostate cancer in men. Side effects may include reduced libido, tiredness, nausea, weight increase and irregular menstrual periods. They must not be used in pregnancy, and patients with blood clots or liver disease. See also CONTRACEPTIVE PILL; OVARY; PUBERTY SHEEHAN SYNDROME Also known as post partum pituitary necrosis, Sheehan syndrome is damage to the pituitary gland under the brain due to a sudden drop in blood pressure with massive blood loss after childbirth. It causes a failure of breastfeeding and many varied other hormonal disorders. It is named after the British pathologist Harold Sheehan (1900-1988). SILICONE Silicone is an inert polymer that is stable at a wide range of temperatures and resists water. It is used in medicine as prostheses (eg. breast), lubricants, sealants and adhesives. It is also used to coat the inside of some blood collecting tubes to prevent the blood from adhering to the tube. There is no scientific evidence that silicone is harmful to the body. SKIN TAG A skin tag (cutaneous papilloma or fibroepithelial polyp are the technical names) is a protuberant lump on the skin that has a narrow attachment to the body. They are more common in women and obese people, and appear more frequently after middle age. The cause is friction to the skin from skin folds (eg. in armpits, under breasts, between buttocks) or rubbing of clothing (eg. around waist or neck). They are a small soft, rounded lump of fat surrounded by skin and connected to the body by a narrow stalk. They may be skin or brown in colour. Occasionally they are irritated, injured and bleed, or become inflamed and infected. These harmless growths persist long term but may be surgically removed, diathermied (burnt away) or tied off at their base by a thin thread. STEWART-TREVES SYNDROME The Stewart-Treves syndrome is a sarcoma (form of cancer) of an arm affected by lymphoedema (hard swelling) in the elderly. The lymphoedema usually follows mastectomy (breast removal) for cancer. A purplish red growth (angiosarcoma) develops on the lymphoedematous limb. The diagnosis is confirmed after surgical removal of the tumour and examination under a microscope. These are relentlessly aggressive tumours with a poor prognosis. See also BREAST CANCER; LYMPHOEDEMA STRETCH MARKS Stretch marks (striae or stria gravidarum) are the curse of pregnant women, when they develop on their belly and breasts, and overweight people whose stretch marks persist after they have lost weight. The

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tendency to develop striae is one that may be inherited. They are caused by a break down and stretching of the elastic fibres in the skin by changes in the bodys hormone levels as well as direct stretching of the skin. Once they form they usually remain permanently unless removed by plastic surgery or reduced by creams containing retinoic acids. Cushing syndrome is caused by an over production of steroids such as cortisone in the body, or taking large doses of cortisone. Headache, obesity, thirst, easy bruising, impotence, menstrual period irregularities, stretch marks, acne, high blood pressure, bone pain and muscle weakness are common symptoms of this syndrome. TAMOXIFEN Tamoxifen is an antioestrogen (blocks the action of oestrogen) medication used as a tablet to treat and prevent breast cancer. It must not be used in pregnancy unless the mothers life is at risk. Adequate contraception must be used by all fertile women who use tamoxifen. Breastfeeding must be ceased before use and it is not for use in children. Use tamoxifen with caution if suffering from bleeding disorders and blood cell abnormalities. Regular gynaecological checks are essential. Common side effects include hot flushes, abnormal vaginal bleeding, itchy vulva, fluid retention, lightheadedness, nausea, vomiting and diarrhoea. less commonly a vaginal discharge, headache, blood clots (thrombosis), bone pain and vision changes may occur. Rarely there may be damage to the uterus and ovary, and blood cell changes. Tamoxifen interacts with anticoagulants (eg. warfarin) and the herb dong quai. This medication has saved the lives of thousands of women with breast cancer, and has prevented recurrences in thousands more. It was introduced in the late 1980s. See also BREAST CANCER THELARCHE The thelarche is the medical term for the process of breast development in girls during puberty. It starts with the development of a firm nub of breast tissue behind the nipple from which the breast steadily grows. See also GYNAECOMASTIA; PUBERTY THIAZIDE DIURETICS Thiazide diuretics are a type of fluid tablet that has been widely used for fluid problems since the 1950s. They increase the rate at which the kidney produces urine, and therefore the frequency with which a person has to visit the toilet to pass urine. They include medications such as hydrochlorothiazide, bendrofluazide, bendrothiazide, benzthiazide, chlorthiazide, chlorthalidone, clopamide, cyclopenthiazide, diazoxide, hydroflumethiazide, metolazone, triamterene and xipamide, and are used to treat conditions such as high blood pressure, tissue swelling and excess fluid in the body. They should not be used in pregnancy unless medically essential, and may reduce the volume of milk in breastfeeding. They are sometimes used for this purpose in women who wish to stop breastfeeding. Use thiazides with caution in gout, kidney disease, liver disease, diabetes, SLE and asthma, and not at all if suffering from complete kidney failure. Common side effects include increased urinary frequency, while unusual ones may include nausea, vomiting, gut cramps, diarrhoea, dizziness, headache and a rash. Uncommonly, photodermatitis (excessively sun sensitive skin) may develop. They may interact with lithium, barbiturates, digoxin, insulin, steroids, lithium, NSAIDs and tablets for controlling maturity onset diabetes. There is a beneficial interaction with most medications that lower blood pressure. The herbs guarana, liquorice, celery, dandelion and uva ursi may also interact with thiazides. They are not permitted in high-level competitive sports as they act as masking agents for other illegal drugs. An overdose may cause confusion, dizziness and gut spasms due to chemical (electrolyte) imbalances. Administer activated charcoal or induce vomiting if tablets taken recently, give extra fluids and seek medical assistance. THIOTEPA Thiotepa is an antineoplastic medication used as an injection to treat some forms of breast, ovarian and bladder cancer. There are almost invariably some minor to moderate side effects (eg. fever, dizziness, headache, blurred vision) but it must be used with great care as it may have serious side effects including low blood pressure (hypotension), brain effects and bone marrow damage. See also BREAST CANCER TOREMIFENE Toremifene (Fareston) is an antineoplastic medication used since 1998 as a tablet to treat some types of breast cancer in postmenopausal women. It is not to be used in breastfeeding, children or pregnancy unless essential for the health of the mother. Use toremifene with caution in patients with angina, heart disease, diabetes, liver disease or history of recent blood 39 !

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clots. Do not take it if the cancer of breast is oestrogen receptor negative, if suffering severe liver disease or some conditions affecting the lining of the uterus. Common side effects include excess calcium in the blood, hot flushes, sweating, dizziness, diarrhoea, nausea and a vaginal discharge. Less commonly vomiting, unusual bleeding from the vagina, swelling of tissue, muscle pain and blood clots may occur. Toremifene mat interact with phenytoin, carbamazepine, phenobarbitone, thiazide diuretics, warfarin, ketoconazole and macrolide antibiotics. See also BREAST CANCER; TAMOXIFEN TRASTUZUMAB Better known by its trade name of Herceptin, trastuzumab is a synthetic monoclonal antibody that was introduced in 1998 and targets breast cancer cells that are HER2 (human epidermal growth factor receptor 2/neu) positive. Herceptin attaches itself to the HER2 protein receptors on the surface of cancer cells and slows the growth and spread of the tumour and its secondaries. It is given intravenously (injected into a vein) but does not require hospitalisation but is only appropriate in those women whose cancer is HER2 positive. HER2 positive breast cancer is a more aggressive disease with a greater likelihood of recurrence and a decreased chance of survival compared with HER2 negative breast cancer. It may be given in combination with other medications such as paclitaxel. The side effects may include congestive heart failure, low blood pressure, shortness of breath, lung damage and severe allergy reactions. Herceptin increases patient survival time and significantly reduces the number of deaths from breast cancer. See also BREAST CANCER; HUMAN EPIDERMAL RECEPTOR 2/neu TRILOSTANE Trilostane is an unusual medication that is used to treat two very different conditions - breast cancer and excess activity of the adrenal gland (hyperaldosteronism or Conn syndrome). It must not to be used in pregnancy, breastfeeding, children or if suffering from severe kidney or liver disease. Use trilostane with caution with physical stress, or any kidney or liver disease. Non-hormonal contraception must be used by women. Side effects may include flushing, nausea, a runny nose and diarrhoea. Interactions are possible with potassium, amiloride, triamterene and high potassium foods (eg. bananas, apricots). See also BREAST CANCER TROPHIC HORMONES Trophic hormones are given as injections to aid infertility, prevent miscarriages, stimulate sperm production in men, control breast pain due to hormone imbalances, to start puberty in cases where it has been delayed, and to control some patients with asthma and arthritis. There are a number of rarer diseases in which they are also useful. Commonly used trophic hormones include gonadotrophins (Humegon), human menopausal gonadotrophin and tetrocosactrin (Synacthen). Adverse reactions are uncommon but severe when they do occur. They include nausea, headaches, peptic ulcers, fluid retention, high blood pressure, inappropriate sexual development and skin markings. TURNER SYNDROME The Turner syndrome (XO syndrome) is a rare defect in sex chromosomes. The person is born with only one X chromosome (XO), and no matching X or Y sex chromosome. The sex chromosomes are named X and Y. Normally two X chromosomes (XX) occur in a female, and one of each (XY) in a male. Patients look female, but are really asexual, as they do not develop testes or ovaries and are infertile. At puberty, the breasts and pubic hair fail to develop, the genitals remain childlike in appearance, and menstrual periods do not start. Other signs are short stature and a web of skin that runs from the base of the skull down the neck and onto the top of the shoulder. Complications may include eye disorders (eg. keratoconus), heart valve defects, narrowing of the aorta (main body artery), a stocky chest, the early development of diabetes and thin frail bones (osteoporosis). The diagnosis can be confirmed by blood and cell tests that show the abnormal chromosome structure. Female hormones (oestrogens) are given in a cyclical manner from the time of expected puberty to encourage the development of female characteristics, growth hormone can be used to improve height, and surgery can correct the heart defects and neck webbing. Patients can function as females in every way except fertility, and can lead a normal life. ULTRASOUND Ultrasound is based on the fact that high-frequency sound waves bounce off tissues of different density at different rates. For example, bone reflects back nearly all sound waves that hit it, whereas fluids allow the waves to pass through. Sound waves are bounced off the organ being investigated, and the reflected waves are translated 40 !

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into a picture so the doctor can see what they mean. Ultrasound scanners operate at the high frequency of 20 kilohertz (kHz) or 20,000 vibrations a second (Hertz). The maximum vibration a human can hear is about 6000 Hertz. Ultrasound machines produce a moving image from which selected still photographs are taken. Part of the patient's body is coated with oil, and a small pen-like probe that contains the sound recorder and microphone is placed on the skin. Once the area has been scanned, the instrument is moved a few centimetres and another scan is taken, and so on, until the entire area under investigation has been covered. INVESTIGATIONS Almost any part of the body can be examined by ultrasound, with the exception of the head because the sound waves cannot penetrate bone. Because of the ribs, it is also difficult to see into the chest. The most useful aspect of ultrasound is its ability to examine the foetus of a pregnant woman without the risks associated with X-rays. The size, position and sometimes sex of the baby can all be seen, and some of the internal organs of the baby, particularly the heart, can be checked. Abnormalities such as spina bifida, hydrocephalus and certain other congenital disorders can be identified. A routine scan may be performed between the sixteenth and eighteenth week of pregnancy when the foetus can easily be seen and transformed into an image. Another scan is sometimes performed later in the pregnancy, after about 32 weeks. The breasts can be carefully checked for cysts, fibrous lumps or cancer by ultrasound, as the cancer cells reflect sound in a different way from normal cells. The gall bladder and liver can be checked for damage and stones, the kidneys and pancreas for cysts and stones, the thyroid gland and spleen for enlargement, tumours and cysts, among many other uses. Ultrasound can also be used to study the flow of the blood. Among other interesting pieces of information to emerge is that the blood flow in the carotid artery (the main artery carrying blood to the brain) is strongly influenced by external stimuli, such as the phone ringing or someone coming into the room. Ultrasound is frequently used to guide a needle towards its destination in a biopsy. Unlike X-rays, sound waves have no effect on the tissues exposed to them, so ultrasound is completely safe. It can be repeated as often as required without concern. VINCA ALKALOIDS The vinca alkaloids are a class of medications that are used as injections or infusions to treat leukaemia, some lung cancers, advanced breast cancer (vinorelbine), blood disorders, Hodgkins disease and some other forms of cancer. They include vindesine, vinorelbine, vincristine and vinblastine. The active ingredients were originally derived from the Madagascan rosy periwinkle plant. They must not be used in pregnancy unless the mothers life is at risk as the foetus may be damaged. Adequate contraception must be used by all women during treatment. Breastfeeding must be ceased before use, but they may be used with caution in children. Vinca alkaloids must be used with caution in nerve, muscle and lung disease, and not at all if suffering from a serious infection, nerve damage or thrombocytopenia (bleeding disorder due to low blood platelet count). Regular blood and marrow tests to check blood and marrow cells and liver function are essential. Side effects are common and include the loss of all body hair, pins and needles sensation, nerve pain, muscle weakness, nausea and vomiting. Unusual effects include paralysis of some muscles, convulsions, constipation or diarrhoea, depression, headache, rash, fever and rarely unusual bleeding or bruising and yellow skin (jaundice) may occur. Interactions are possible between vinca alkaloids and phenytoin, mitomycin, cisplatin and live virus vaccines (eg. Sabin polio). Alcohol should be avoided during treatment. An overdose is frequently fatal. Despite significant side effects, these drugs may save the life of patients with leukaemia and other cancers. See also BREAST CANCER VIRILISATION Virilisation occurs when a woman develops male characteristics such as facial hair, body hair (hirsutism) and loses female characteristics such as menstruation and develops poor breast tone. The usual cause is a tumour of the adrenal gland or congenital adrenal hyperplasia. 41 !

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See also CONGENITAL ADRENAL HYPERPLASIA WEANING When weaning is desired, it is best done gradually over several weeks, with one breastfeed at a time being stopped in favour of solids, formula or cow's milk. The milk supply will gradually reduce, and the breasts will return to their original size. If a mother desires not to feed her baby at all, cannot feed because of disease or drug treatment, or the baby cannot be breastfed because of prematurity or other disease, it may be necessary to suppress milk production. A firm bra should be worn and nipple stimulation should be avoided. Fluid tablets can assist reducing engorgement, and occasionally oestrogens (as in the contraceptive pill) may be prescribed. The best medication to stop the production of breast milk is bromocriptine (Parlodel), which will dry up most women's milk in three or four days, but it must be taken for at least ten days to stop it from recurring. It may cause some nausea in the first few days, but this settles with time. The traditional method of using cabbage leaves inside the bra probably works because the leaves are cold and reduce the blood supply to the breast, and the cabbage taste on the nipples will discourage the baby from suckling. See also BREASTFEEDING; BROMOCRIPTINE WET NURSE A wet nurse is a woman who breastfeeds another womans baby. See also BREASTFEEDING WITCHS BREAST See NIPPLE, ACCESSORY WITCHS MILK Babies of both sexes sometimes produce milk from their nipples in the first few weeks of their life. Witchs milk is the rather off-putting term used for this rather common problem. Babies can be influenced by the hormones in their mother's milk, or may be affected immediately before birth by these same hormones. It is in no way detrimental to their health. No treatment is needed and the milk production is usually very slight and disappears in a few weeks. Interestingly, any woman or man can be made to produce breast milk if they are given the correct hormone cocktail at almost any time in their lives. XEROGRAM Xerograms are produced using xerography, a now rarely used form of x-ray in which a dry powder is used to create the x-ray image rather than a wet film or even more recently digital images. They were widely used in the 1970s for breast mammograms to reduce the radiation dose, but modern high speed films and computerised digital imaging techniques have rendered the technique obsolete. ZUSKA DISEASE Women who develop a painful and tender lump under the nipple, with an associated purulent discharge may be suffering from Zuska disease, which is a discharging abscess under the nipple. It is a rare complication of breastfeeding or nipple injury. The abscess may discharge through the nipple or an adjacent fistula. See also FISTULA; NIPPLE PAIN

Warwick Carter www.medwords.com.au

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