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Breast changes and breast care during menopause

Nicola West
RGN BN ENB All PGFETC(CertEd)
MACounselling
Senior Breast Nurse Specialist
Cardiff Breast Unit
University Hospital of Wales Cardiff

Very few organs in the body undergo as many changes as the breast. Not only is it important for its physical role in breastfeeding, but for many women the breast plays a major role in their psychological wellbeing, maintaining a high degree of femininity and having a large impact on sexuality.
The media also play a role in emphasising the importance of the breast, not merely by informing us of potential diseases, especially breast cancer, but also by emphasising sexual attractiveness, such as printing photos of young women baring their breasts in fashionable magazines. It is hardly surprising therefore that the breast is one of the most important organs in the body, at times causing as much anxiety as pleasure.

Breast development
The development of the breast starts prepuberty, continues through puberty, changes at pregnancy and again at menopause.(1,2)

Prepuberty
In the prepubertal breast there are a number of small ducts embedded in a collagenous stroma. The ducts develop in utero from a mammary ridge invading the epidermis at the 7th embryonic week and progressing to a budding stage at the 12th week. At 13-20 weeks the epithelial bud branches to form the 15-20 major ducts found in the adult breast.

Puberty
At the age of 10 the first changes occur. There is growth of the mammary tissue beneath the areolar which produces the breast bud or breast mound. At the age of 12 the nipple begins to grow outwards and breast elevation increases. By the age of 14 and 15 there is an increase in subareolar growth giving a "secondary mound". These changes at puberty all result from the secretion of various hormones in the body, namely FSH and LH (follicle-stimulating hormone and luteinising hormone). The secretion of these hormones in turn causes the secretion of oestrogen, which induces duct sprouting.
In addition, the monthly menstrual cycle and changes in hormone levels are responsible for the changes within the breast, including the discomfort and swelling often experienced before the period commences. It is at this time that breast lumps are often found.

Pregnancy
At pregnancy there are significant changes in the breast. These include ductal sprouting and lobular formation. The adult breast is made up of many ducts, and at the end of each duct is a lobule. The breast enlarges, there is vascular engorgement and the areolar pigment changes, giving it a darkened colour and appearance. The increase in mammary blood flow can be as much as 180%.

Menopause
The changes that take place in the breast at the menopause are due to regression of the glandular tissue which is seen in the younger breast and gradual replacement by fat, leading to a smaller, often pendulous breast. The changes seen at menopause occur as a result of changes in hormone levels. FSH levels rise progressively from the age of 30 upwards until the menopause, whereas the level of oestradiol and LH remain fairly constant after the menopause.

Changes to expect at menopause
It is very common at menopause for the breasts to become more pendulous and smaller due to the glandular tissue being replaced by fat. Breast tenderness can also occur, and benign breast lumps are common because of changes in hormone levels. It is also ­common for women taking hormone replacement therapy (HRT) to experience breast tenderness, and they should not be alarmed by this discomfort, as long as it is not accompanied by a lump.

The facts
The majority of lumps found in the breast are benign. For every 10 lumps presenting in a breast clinic only one will be cancerous. However, breast cancer sounds far more frightening than a benign lump, so the media tend to focus more on breast cancer and ignore the benign facts.
In the UK there are approximately 35,000 cancers diagnosed each year. This means that 1 in 10 women will contract breast cancer at some time in their life and being breast aware is therefore extremely important, especially around the menopause when breast lumps are more common.
Various benign conditions of the breast are common at certain ages: for example, fibroadenomas are common in women aged 15-30 years. Cysts are common in women aged 25-40 years, and breast cancer is more common in women aged 50-64 years. The incidence of breast cancer in the very young woman is rare. Many breast lumps are part of the normal pattern of cyclical changes within the breast. Often women present to a clinic with what they believe to be a discrete lump but is in fact part of their normal glandular tissue. However, if women do not self-examine or become breast aware it is very difficult to assess any changes in their breast.
Being breast aware is more than feeling for a breast lump. It is concerned with understanding an individual's normal breast and how it changes so that any differences can be identified and checked early.
Women should be encouraged to examine their breasts as part of their normal routine, as they would take care of their hair. It should not be a ritual undertaken or prescribed at a certain time of day and not carried out very often. Practice nurses can play a major role in educating women on how to be breast aware, although unless trained in breast self-examination and supported by a multidisciplinary team, practice nurses should be discouraged from undertaking this procedure. Women are the best judges of what is normal for them and whether any changes in the breast have occurred. The Breast Care Nursing Steering Committee on behalf of the Royal College of Nursing has produced guidelines on breast awareness and breast examination.(3)
At all stages of a woman's life any changes in the normal shape, colour and size of the breast should be reported, especially at menopause. It is important not to panic women or send out the wrong message, but at the same time it must be remembered that breast lumps are common and with early treatment the prognosis for breast cancer is more favourable.

What to look for and report

  • Changes in shape - any puckering or dimpling of the skin.
  • Changes in colour.
  • Nipple inversion.
  • Any discrete lump.
  • Any discrete lump with tenderness and pain.
  • Lumps in the armpit.
  • Swelling and redness of the breast.
  • Nipple discharge, especially blood.

Hormone replacement therapy
There has been much written in the news about the link between HRT and breast cancer (as well as chronic heart disease and stroke). Women who are considering taking HRT are generally older women who are approaching menopause. Women with a family history of osteoporosis or who are experiencing difficult menopausal ­symptoms are most likely to enquire about HRT.
HRT affects the breast by maintaining glandular tissue that would normally involute after the natural menopause. The stimulation of the breast by oestrogen can cause breast pain (mastalgia) and the development of benign lumps such as cysts that would normally disappear after the menopause. In maintaining the glandular tissue the breast density is increased, which in turn decreases the sensitivity of mammograms,(4) which is also one of the reasons why mammograms are not ­recommended for younger women.
The evidence to date on the safety of HRT concludes that the overall risks of breast cancer while taking HRT are very small. The collaborative group study of 1997 published in the Lancet and based on 160,000 women showed that after five years of HRT use there were an extra 2-3 breast cancers per 1,000 women.(5) Furthermore, it was found that as the duration of use increases so does the incidence, but again this is very small overall - there would be an extra 5-6 breast cancers per 1,000 women after 10 years of use. This study was supported by the Women's Health Initiative trial in 2002, which found eight more invasive cancers per 10,000 women.(6) It also concluded that this risk reduces rapidly after stopping HRT.
There is also some evidence that the cancers that do develop while on HRT have a better prognosis than those that develop without it.(7)
Unfortunately much anxiety was generated by this trial due to the finding that the incidence of cardiovascular disease and stroke increased with HRT?use, and therefore the study was stopped at 5.2 years instead of eight years.
The small incidence of breast cancer found in this trial is not a new finding, but nevertheless caused much concern. What must be remembered is that the risk and incidence of breast cancer at menopause are higher than at any other time of a woman's life.
Individual patient consideration is therefore recommended when deciding on whether to take HRT. For many women menopausal symptoms are very debilitating and quality of life is poor and so HRT is a good option. Also, women with a strong family history of osteoporosis have good reason to consider HRT. Assessment should be based on a woman's history of breast cancer, risk of osteoporosis and the individual reasons for taking it.
In some circumstances, for example after breast cancer treatment, especially for good prognostic cancers, HRT is still given, quality of life being of paramount importance.

Conclusion
Primary care nurses can be very influential in a woman's decision to take HRT because often they are the first person a woman will contact and discuss HRT with. It is important that the primary care nurse gives the most up-to-date, accurate information based on sound evidence without causing undue anxiety. Once provided with all the information, the woman can make an informed decision.
Primary care nurses can reassure women about taking HRT after careful assessment by dispelling any myths or negative perceptions generated by the media. Finally, primary care nurses can teach and promote breast awareness based on their up-to-date, sound knowledge. They can offer leaflets on breast awareness and HRT and inform women of the various resources available, not just on breast cancer, but also on benign disease and HRT.

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References

  1. Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast. Concepts and clinical ­management. London: Baillière Tindall; 1989.
  2. Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast. 2nd ed. London: WB Saunders; 2000.
  3. Royal College of Nursing. Breast palpation and breast awareness. The role of the nurse. London:?RCN; 2002.
  4. Kavanagh AM, Mitchell M, Giles G. Hormone replacement therapy and accuracy of mammographic screening. Lancet 2000;355:270-4.
  5. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormone replacement therapy: collaborative re-analysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet 1997;350:1047-59.
  6. Women's Health Initiative Randomised Control Trial. Risks and benefits of oestrogen plus progestin in healthy postmenopausal women: ­principal results. JAMA 2002;288;321-3.
  7. Harding C, Knox WF, Faragher EB, Baildon A, Bundred NJ. Hormone replacement therapy and tumour grade in breast cancer: a population study in a screening study. BMJ 1996;312:1646-7.

Resources
CancerBACUP
Information for healthcare ­professionals and patients. Links to relevant websites. Personal concerns addressed via individual web pages W:www.cancerbacup.org.uk
The National Cancer Institute and Cancernet
Information for healthcare ­professionals and patients, plus information on clinical trials
W:www.cancer.gov
The Breast Cancer Organisation Peer-reviewed educational ­journals, ­conferences, image library and links to other ­relevant sites, including a patient information link
W:www.bco.org
The British National Cancer Institute/Cancer Web Information for healthcare ­professionals and patients. Useful multimedia resources
W:www.graylab.ac.uk/cancernet