so many options. If the first pill you select is not well tolerated, there are many alternatives.
One of these choices will almost certainly prove to be the correct one for you.
PREGNANCY
Baseline Mammogram
One matter of importance to women in their mid-thirties who are considering future pregnancies is deciding when to obtain a baseline mammogram. Since breast cancers are more difficult to detect during pregnancy, it is common sense that patient and doctor would want to know in advance if the patient is harboring a small cancer that cannot be detected on physical exam.
A PRE-PREGNANCY EXAM THAT SAVED A LIFE
The Giuliana Rancic story was an eye opener for me. Rancic, a television personality and anchor for E! News, has been very public about her personal problems with infertility. She explained to viewers that she had failed to get pregnant on two attempts at in-vitro fertilization (IVF). She subsequently announced that she had found a world-class expert on IVF and was going to give it one more try.
Even though she was only thirty-six at the time, Rancic’s infertility specialist advised her to have a baseline mammogram before beginning IVF. Despite having no breast symptoms and no family history of cancer, she nevertheless complied with the doctor’s order. All her fans know the rest of the story: A small cancer was detected. She cancelled her IVF, and her cancer was successfully treated. Subsequently, Rancic used a surrogate, and she is now the proud parent of a little boy named Edward Duke.
Had she not gotten the mammogram and instead proceeded with IVF, the story would not have had such a happy ending.
I now think it is appropriate to recommend a baseline mammogram for women in their mid-thirties or older who are thinking about getting pregnant. Women with dense breasts should also consider a screening ultrasound. In addition, those with a strong family history of breast or ovarian cancer should opt for a baseline MRI.
Detecting Breast Issues During Pregnancy
Breast cancers and other issues can be detected early in their evolution if pregnant women follow a short list of guidelines. Having confidence in what the normal breast feels like prior to the onset of pregnancy is the first step.
In general, as we’ve noted in other chapters, we advise non- pregnant women to do monthly self-exams five to ten days after the onset of their menstrual period, since this is the time when breasts are least lumpy. Learning what your normal breast feels like should be started months, if not years, before becoming pregnant. (Guidelines for doing breast self-exams with confidence are outlined in chapter thirteen.)
Just as a non-pregnant woman can learn the pattern of her normal breasts, it is also possible for a pregnant woman to have a clear mental image of evolving, normal changes as her pregnancy progresses.
One approach for a woman to keep track of changes is to review the breast exam with her caregiver at each prenatal checkup. This self-exam should be repeated on the same night as the office exam.
The breasts should also be examined between well-woman checkups. It is normal to see changes as the pregnancy follows its usual course. As long as the changes seem symmetrical on both sides, it is reasonable to assume all is well. If, during the self-exam, one area seems to stand out from the rest, it should be rechecked daily for a few days.
If the area of concern persists, an appointment should be made to review these findings with a medical provider. In most cases, the woman will be reassured that the questionable area can be safely observed. Still, it’s important to make a one-month follow-up appointment. This short interval is vital, because breast cancers can grow rapidly during pregnancy.
If, on the first visit, the caregiver agrees there is an area requiring further evaluation, the next logical step would be a diagnostic ultrasound. If the ultrasound appears abnormal, a referral should be made to a breast surgeon or a breast imager with expertise in dealing with complex breast problems.
For the majority of women, however, that one-month return office visit would be the next step. If the patient is still concerned about a particular area, again a directed ultrasound should be ordered, even if the physical exam seems normal to the clinician. Assuming the diagnostic ultrasound is negative, the patient can then return monthly for at least two more visits.
On the other hand, if symptoms persist and the exam and ultrasound remain negative, the next step is a diagnostic mammogram. Women can be reassured that the mammogram is perfectly safe as long as the abdomen is properly shielded with a lead blanket.
When the doctor notes a problem area on either the ultrasound or mammogram, tissue sampling is suggested, which is typically done with a large bore needle to get an adequate sample. Open surgical biopsy is rarely indicated.
Lactating Adenomas
Most breast biopsies done during pregnancy turn out to be benign. One example of a common benign solid lump is called a lactating adenoma. These lumps are actually more common in pregnancy than during lactation, thus the name is misleading.
Like most benign lumps that occur during this event, lactating adenomas can be safely observed once a needle biopsy has established the diagnosis. However, lactating adenomas may rapidly enlarge, and careful follow-up by an experienced surgeon is indicated. In some cases, rapidly growing benign solid lumps require removal, which is relatively safe if done during the second or third trimesters.
Breast Cancer Treatment During Pregnancy
In the rare case in which the core biopsy does reveal a breast cancer, the patient should be referred to a team of physicians and support personnel who are experienced in meeting the complex needs of a pregnant woman with breast cancer. A comprehensive treatment plan must take multiple factors into consideration, including the health of the mother and her unborn child. Issues regarding the timing of surgery and chemotherapy must be individualized to the patient’s personal needs, based on the stage and aggressiveness of the cancer, as well as to the time period of the pregnancy.
It should be noted that both surgery and chemotherapy are considered safe for the mother and her unborn child after completion of the first trimester. Breast irradiation, however, is not safe.
BREAST ISSUES DURING LACTATION
Soon after delivery, the breasts become engorged with milk. They are swollen, lumpy, and seemingly impossible to examine with confidence. Fortunately, breast cancers are rare in lactating women. However, they do occur, and diagnostic delays are common.
During the first few weeks of lactation, the breasts are so engorged that it is impractical to attempt self-examination. However, over time the breast exam is more easily performed. The best time to do it is after nursing or pumping.
In my own practice I am often surprised by how easy it is to do a clinical exam of a woman who has “emptied” her breasts within the hour of her office visit. This observation leads me to conclude that once the early changes associated with the onset of lactation are resolved, breast self-exam is feasible, and is still the most effective method a woman has to protect herself against a delay in breast cancer diagnosis.
While breast problems are common during lactation, the vast majority are not related to cancer. One of the most frequently seen issues is a plugged milk duct, which can
