WomensHealth - Wellcast

Dense Breast Tissue

October 29, 2023 By Deborah

Dense breast tissue is normal and very common. About 40% of women 40 and older have dense breast tissue. It tends to run in families. The density of the breast is based on the proportion of stromal and epithelial tissue compared to fibrofatty tissue. For these women it makes it harder to interpret mammograms. Women with dense breasts are up to twice as likely to develop breast cancer as women with average density breasts. Possibly because dense tissue has more cells that can become abnormal, or women with dense breasts may have higher levels of estrogen.

Now there is an add-on cancer check for dense breast tissue known as a 3D whole-breast ultrasound tomography system. It sends sound waves to create a 360-degree image of the breast that offers a more comprehensive look at the tissue and details of any changes.

The Automated Breast Ultrasound (ABUS) is a newer approach to finding up to 30% more cancers in women who have dense breasts. With 3-D ultrasound volume and U-Systems software, radiologists can review hundreds of breast tissue image “slices”: to look at layers of breast tissue to find cancers which may have been missed by mammogram. There is no radiation with ultrasounds. The scan takes about 60 seconds and the technologist follows the display monitor in real time to make sure the entire breasts are covered. Usually 3 scans are performed on each breast.

Traditional ultrasounds are still done by ultrasound technicians and physicians. The limitations are that it is dependent on the skill of the operator and type of device used. There is also a shortage of ultrasound technicians. Sensitivity and specificity have been a problem. Whereas, the ABUS technique is a dedicated method that scans the breast in an automated, standardized manner with a transducer that is larger than that used in conventional ultrasound. Also, it does not need to be performed by a physician. Radiology technicians perform the procedure which allows physicians time to interpret their images.

Limitations related to the ABUS are that lesions behind the nipple and peripheral lesions may be missed (on the outside of the breast and under the arm), especially in women with large breasts. There can be artifacts due to poor positioning. There is a lack of studies evaluating ABUS use in women with breast implants as well as women who experience post operative changes such as scarring. If something looks “suspicious” a hand held ultrasound is used for further evaluation. In a 2020 study, the system measured breast tumor changes early in chemotherapy -which makes this potentially useful for evaluating if treatment is useful or not.

ABUS has a detection rate for invasive breast cancers that is equivalent to hand-held ultrasound when they are both used as a supplement tool to mammogram. Health plans are now required to cover regular screening mammograms without charging anything out of pocket. But that is not the case with supplemental screening for women with dense breasts. And theses tests can be pricey with on average breast ultrasound costing $250 out of pocket and a Breast MRI costing $1084 according to the Brem Foundation to Defeat Breast Cancer.

If you have extremely dense breast tissue, the detection rate of your screening mammogram is 70-75%. So there is a 25% chance that a cancer could be missed with just a mammogram.

Only 38 states require breast imaging centers to inform women of their breast density. Breast density is classified based on the Breast Imaging-Reporting and Data System (BI-RADS) of the American College of Radiologists. Density is classified into 4 categories:

A: All fatty Tissue, B: Mixture of scattered glandular and fatty tissue, C: Heterogeneously Dense Tissue, D: Extremely Dense Tissue. If you have heterogeneously dense breast tissue, the detection rate of your screening mammogram is around 80-85%. So there is a 15% chance that a breast cancer could be missed by mammogram along. By adding a diagnostic bilateral breast ultrasound to your mammogram, you increase your detection rate by 95%.

If you have extremely dense breast tissue, the detection rate of your screening mammogram is 70-75%. So there is a 25% chance that a cancer could be missed with just a mammogram. By adding a diagnostic bilateral breast ultrasound, you increase your cancer detection rate to 95%. Your breast density type is determined by your radiologist.

One key harm that researchers are concerned about, besides the possible extra cost, is the chance of a false-positive result. This could lead to follow-up testing such as breast biopsies that are invasive and raise cancer fears.

If 1000 women with dense breasts get an ultrasound after a negative mammogram, the ultrasound will identify 2-3 cancers, studies show. But the extra imaging will also identify up to 117 potential problems that leads to recall visits and testing that ultimately are a false positive. This can lead to lots of cost and emotional stress. This is why it is worth having a conversation with your practitioner on whether additional testing is worth it, especially for the 8% of women who have extremely dense breasts.

Studies have shown that mammograms reduce breast cancer mortality. But research has found that women that do more testing such as ultrasound or MRI are not less likely to die of breast cancer after a negative mammogram result. It’s best to discuss screening strategies with your practitioner. Options include 3D X-ray mammography, Ultrasound and an MRI along with a standard mammogram.

Reference: The George Washington University Hospital. Automated Breast Ultrasound System (ABUS). gwhospital.com

Andrews, M. Despite Katie Couric’s Advice, Doctors Say Ultrasound Breast Exams May Not Be Needed. KFF Health News, 10/2022.

Palmer, W. The Advantage of ABUS vs. Hand-Held Ultrasound with Dense Breasts. Diagnostic Imaging. Jan 29, 2020.

AARP The magazine: Medical Breakthroughs in Women’s health: 3D Ultrasound for better Mammograms. Oct/Nov 2023, p. 48-49.

So If It’s Not Alzheimer’s, Then What Is It?

April 11, 2023 By Deborah

Many older Americans expect to lose brain function but most don’t ask their doctors about preventing dementia. Walking into a room and then forgetting why you are there. Or unable to recall names of old TV shows or long-lost friends or classmates. Even though these instances can be a normal sign of aging, if they become more frequent or escalate, then it’s time to evaluate other causes. In reality, research suggests that less than 20% of people who have reached age 65 will go on to lose cognitive ability from Alzheimer’s disease, vascular dementia or other conditions. So if it’s not Alzheimer’s, then what is it? It could be something known as mild cognitive impairment. Mild cognitive impairment (MCI) is an early stage of memory loss in people who are still independent.

For people diagnosed with MCI, there are some screening tests worth doing. Screening includes: Checking thyroid and other hormone levels and B12 as well as other markers of inflammation. Ruling out sleep apnea and ADHD are important screening tests but are commonly forgotten. ADHD is a conditon which a person may have had all their lives but is more pronounced since entering menopause. Also, screening for depression and looking for side effects of certain medications are essential in looking for answers.

If symptoms are more related to feeling overwhelmed, forgetful, lack of concentration and difficulty prioritizing, then consider getting screened for ADHD (attention deficit hyperactivity disorder). It is a neuropsychiatric disorder that starts in childhood and and continues throughout life. Three quarters of adults 18 to 44 who are diagnosed with ADHD were never diagnosed as children. For adults 60 and older, that’s 100% according to Dr. David Goodman, assistant professor of psychiatry and behavior sciences at the Johns Hopkins University School of Medicine. The reason is that half a century ago, practitioners simply didn’t know how to screen for it in children.

When a woman reaches menopause or the stretch of time before her last menstrual period (peri-menopause), the symptoms of ADHD can be significantly worse. The drop in estrogen (which is very protective for the brain) can make hyperactivity, distractibility, executive function challenges, including time management and impulse control more difficult. This means coping methods that you may have relied on no longer work. Lowered estrogen levels affect short-term memory and the ability to focus. Many women complain of “brain fog”. These lowered estrogen levels in women may also not allow ADHD stimulants to work effectively. This is more of a problem for women than men since testosterone seems to have no effect on either the impairments of ADHD or the effects of ADHD medications in men.

Only 1 in 5 memory disorder clinics actively screen for ADHD. People can have ADHD all their lives and now they are developing dementia. Now you have 2 processes contributing to cognitive difficulty.

Menopausal women experiencing cognitive decline should be screened for ADHD. If ADHD is positive, then behavior strategies, counseling and medication should be considered. Stimulants such as Ritalin, Adderall, and Vyvanse are typically used to treat ADHD in young people. Many doctors have been trained to avoid these meds due to their risk of high blood pressure and other cardiovascular problems. The studies are mixed and a 2020 review in the Journal of the American College of Cardiology found a link between stimulant use and modest elevation of heart rate and blood pressure. But according to Dr. Bill Dodson, a Denver psychiatrist who specializes in adults with ADHD, “the effects observed were minuscule and of no clinical significance”.

Clinical trials from the 2002 Women’s Health initiative have cast a shadow on the safety of hormone replacement therapy. Subsequent evaluations have found the dangers of HRT to be overstated, while the health risks of low estrogen are well established. For more, check out What you need to know about hormone replacement therapy

There are ways to manage your symptoms. See a practitioner and express your concerns so biological markers can be ruled out and screening tests can be performed. Not all slowing cognition at middle age is due to a medical reason. Stress management and good support can make a significant difference in our lives. People with ADHD have a tendency to overcommit. When you feel overwhelmed, that is a sign you need to simplify. There are ADHD coaches and support groups that can help. CHADD.org is an educational and advocacy nonprofit that offers a network of regional support groups.

References: Macmillan, C. Mild Cognitive Impairment: It’s Not “Normal” Aging. Yalemedicine.org. Doctors & Advice, Family Medicine. June 6,2022.

Barger, T. Attention, Please! If memory and focus problems are placing you at midlife, it could be undiagnosed ADHD. Here’s how to tell. AARP Bulletin Dec 2022. pp. 20-21

What You Need To Know About Hormone Replacement Therapy

February 12, 2023 By Deborah

More than 1 million women in the United States experience menopause each year. Yet we are still in the dark about what to do about the troublesome symptoms that embrace this phase of life. Those symptoms can vary for each woman but primarily consist of intrusive hot flushes and night sweats with many hours of lost sleep. Low energy and mood changes that can disrupt work and relationships. Brain fog and difficulty grasping words which cause anxiety around the question of whether you are entering the beginning stages of Alzheimer’s disease. Then there’s the weight gain (especially in the mid-section) along with hair loss, dry skin, dry nails and eyes. The worst part is the fact that these symptoms begin 6 months to 12 years leading up to a woman’s last period, known as peri-menopause. This starts when women reach their late 40’s due to hormonal spikes and dips of estrogen and progesterone as the last eggs of the ovaries start to plummet in number. Irregular menstrual bleeding can also accompany these other symptoms making this time in a women’s life unpredictable. This presents confusion about where to turn for answers and options to get their lives back. Here is what you need to know about hormone replacement therapy (HRT).

Hormone replacement therapy has been around for many years (since 1942) until it took a dramatic turn. The prescriptions for hormone therapy, which was once the most commonly prescribed treatment in the United States suddenly dropped due to a 2002 poorly designed study finding links between hormone therapy and elevated health risks for women of all ages. This single study did women a disservice in how it generalized the use of HRT as opposed to what the study really was about- the unsafe and one-size-fits-all synthetic oral hormone, Prempro. The reasonable thing to do for women who were taking Prempro was to contact their gynecologist and yes, stop that form of HRT but to then discuss other hormone options. But instead, women flushed their pills down the toilet and never looked back. The message was “Hormones are Dangerous”.

It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort.

Hormone therapy can carry risks as do many other medications that people take to relieve serious symptoms. But dozens of studies since 2002 have provided reassurance for healthy women under the age of 60 or within 10 years of the onset of menopause who are free of contraindications. And the message is that the use of hormone therapy is safe and appropriate. The treatment’s reputation, however has never fully recovered and the consequences have been wide-reaching. It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort. Instead women are offered a pill for their insomnia, a pill for their depression, a pill for their newly diagnosed osteoporosis, a pill or injection for their diabetes, a pill for their high blood pressure, a pill for achy joints, a pill for their high cholesterol and plaque (caused by endothelial damage). Is it possible that there is a treatment for all these symptoms but has been overlooked by doctors? Yup! And it’s hormone replacement therapy. I am not saying that women would be immune to these conditions if they were on HRT, but it would be significantly less, if at all. This is just another example that reflects the medical culture’s challenges in keeping up with science as well as a representation of a lost opportunity to improve women’s lives.

Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes menopausal women have been underserved- an oversight that she considers one of the great blind spots of medicine. She states “it suggests that we have a high cultural tolerance for women’s suffering. It’s not regarded as important”.

So what does this mean now? Guidelines on hormone therapy from The North American Menopause Society has recently updated their 2022 position statement from 2017. It states that treatment should be individualized using the best available evidence to maximize benefits and minimize risks. Timing is important and the type of hormones are important. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation and whether a progestogen is used. The benefit-risk ratio appears favorable in lowering the risk of coronary heart disease, stroke, venous thromboembolism osteoporosis, depression and dementia for those that initiate treatment younger than 60 years or who are within 10 years of menopause and have no contraindications. Most women start HRT due to bothersome vasomotor symptoms (hot flushes) and genitourinary symptoms. Longer durations of therapy beyond the age of 65 are for persistent symptoms and women should be a part of the decision-making as periodic evaluation continues.

I still have patients tell me that their doctors insist they go off their HRT because they have been “on it for too long”. Do we say the same thing about a man’s testosterone or Viagra prescriptions?! Both women and their providers became very fearful after the 2002 WHI study. It is time to clarify and reassure women that hormone therapy can be given safely and effectively to relieve women’s symptoms and improve their quality of life as long as they are being monitored and the benefits continue to outweigh the risks. We also know that these hormones can delay or prevent many long-term degenerative diseases that are caused by aging. If women are expected to live on average another 30 years after menopause, let’s at least offer them the best quality of life for the years ahead.

We have come a long way…but we’re still not there. Let’s open up the discussion and allow women to voice their concerns and complaints without shame or guilt on whether their discomforts are “significant” enough. They deserve to ask questions and get reliable answers based on current studies with sound guidelines that we currently have, and not a study that was over 20 years old! More research is always needed to help navigate this topic not only for menopausal women now but for our younger generation of women moving forward.

References: Faubion, S, et al. NAMS Position Statement: The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of the North American Menopause Society, Vol 29. N0. 7, pp 767-794.

Dominus, S. Women have been misled about menopause. The New York Times magazine. February 1 2023. pp 1-19.

Kaunitz, A. Guidelines on HT have been updated by The North American Menopause Society. OBG Management. June 2017, Vol. 29, N0. 6. pp 18-23.

https://www.nia.nih.gov. Research explores the impact of menopause on women’s health and aging. May 6, 2022.

Breast Cancer Overdiagnosis

June 10, 2022 By Deborah

A recent study was done at Breast Cancer Surveillance Consortium (BCSC) facilities where researchers looked at the rate of breast cancer diagnosis in contemporary mammogram practice for the detection of nonprogressive cancer. Individual screening and diagnosis records were used to predict the rate of overdiagnosis among screen detected-cancer under biennial screening (every 23-26 months).

Participants were women between the ages of 50-74 at first mammography screen between 2000-2018. The cohort included 35,986 women, over 82,000 mammograms and 718 breast cancer diagnoses. The conclusion was that among biennially screened women aged 50-74, about 1 in 7 cases of screen detected breast cancer is over diagnosed. This included detecting indolent (benign) preclinical cancer and detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis.

Mammogram screening can lead to breast cancer over diagnosis. This should be a personalized decision between you and you’re practitioner as to the frequency of screening mammograms so an informed decision can be made including the risks and benefits.

References: Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort

Ann. Intern. Med 2022 Mar 01;[EPub Ahead of Print], MD Ryser, J Lange, LYT Inoue, ES O’Meara, C Gard, DL Miglioretti, JL Bulliard, AF Brouwer, ES Hwang, RB Etzioni

Carlos, C., Margarita, P et al. Benefits and harms of annual, biennial, or triennial breast cancer mammography screening for women average risk of breast cancer: a systematic review for the European Commission Initiative on Breast Cancer (ECIBC). British Journal of Cancer, 126, 673-688 (2022). Published 11/26/2021.

Breast Cancer Prevention – Reducing Your Risk

October 12, 2021 By Deborah

Breast Cancer Prevention

There have been plenty of new medications and treatments for breast cancer. That is astounding news. Today, a woman’s overall 5-year relative survival rate for breast cancer is 90%. This means 90 out of 100 women are alive 5 years after they’ve been diagnosed with breast cancer. The 10-year breast cancer relative survival rate is 84% (84 out of 100 women are alive after 10 years). These survival rates are based on many things, most importantly the time of diagnosis. We have heard that the earlier the diagnosis, the better the prognosis. Early detection involves screening tests, most commonly a mammogram. Technological advances in imaging have created new opportunities for improvements in both screening and early detection. The problem: Breast cancer prevention has not been talked about enough.

I want to discuss prevention. What are the potential modifiable risk factors that we have control over? One thing we need to understand is that the 2 main risk factors for breast cancer is age and gender. Clearly things we have no control over. But what can we do to be pro-active in reducing our risk as much as possible?

Approximately 67-80% of breast cancers in women are estrogen receptor (ER) positive. Also, about 90% of breast cancers in men are ER positive. So perhaps we should start there. Excess estrogen exposure can come from endogenous (what we synthesize in the body) and exogenous (environmental exposure) sources. Improving estrogen metabolism can be of benefit in reducing the risk of breast cancer. I have often said, “its not how much estrogen you have, but where is it gong…how is it being broken down?”

This brings us to the liver where the metabolism of estrogen takes place. It is complex but very important in that these metabolites vary greatly in biological activity. There is testing that can give us answers to this question of metabolites. Estrogen metabolite tests are completed through a 24-hour urine test which can personalize what your body needs to beneficially modulate estrogen metabolism. Another test that can give us insight into risks is a comprehensive stool analysis. It can identify a certain enzyme that can be modified as well as make sure you are digesting adequate fiber and nutrients that are important in affecting gene expression in the biological effects of estrogen.

Here are 10 things you can do right now to reduce breast cancer risk:

Get a screening test. Talk to your provider about a breast mammogram, ultrasound or possibly a thermogram (a risk assessment tool). As I tell women…it’s important to just do something!
Manage your weight and reduce your insulin level if it is high. Both estrogen and insulin are growth factors. Growth factors stimulate tumor growth and increase inflammation. Fat tissue also secretes estrogen. There are supplements that can help.
Consider time restricted eating. Studies show that fasting daily for 14 hours can reduce breast cancer risk by 40%. Fasting also decreases the incidence of Type 2 diabetes, non-alcoholic liver disease and esophageal reflux. Limit or avoid alcohol.
Eat plenty of fiber, especially lignin (found in flaxseeds, bran, beans and seeds). It binds to free estrogen in circulation in the digestive tract which then gets excreted in the feces.
Take the supplement Bioresponse DIM. A naturally occurring compound derived from cruciferous vegetables such as broccoli, brussel sprouts and cabbage that is protective to estrogen sensitive tissues.
Consume isoflavones such as soy or kudzu. Soy has gotten a “bad rap” with it’s association with breast cancer. They are phytoestrogens (plant compounds) that have the capacity to bind to estrogen receptors and appear to have both estrogenic and anti-estrogenic properties. The average daily intake of Japanese women is 20-80 mg and are associated with low rates of hormone-dependent cancers. American women consume 1-3 mg daily.
Exercise everyday to reduce excess fat deposition where the enzyme aromatase converts adrenal hormones, like testosterone, into more estrogen and allows it to be more freely available.
Reduce Environmental Estrogen (Xenoestrogen) Load. This includes avoiding foods and products with pesticides, herbicides, and fungicides, as well as non-organic cosmetics and soaps (which contain petrochemicals). Do not use plastic containers, especially when heating food in a microwave. For more information, check out Xenoestrogens
Minimize stress: I know that is hard to do with the current state of the world. But find ways of calming the mind, such as meditation, yoga, therapy, reading books that inspire you and STOP listening/watching the news! Chronic stress raises Cortisol and depletes Progesterone leading to estrogen dominance and excess inflammation.
Get good sleep. At least 7 hours/night is needed to clear toxic residue, repair damage from the brain and reduce cancer risk.

There are many other natural compounds and hormone-modulating herbs that have a significant benefit in promoting healthy estrogen balance. The percentage of inherited genetic mutations that cause breast cancer is less than 25%, whereas 65% -75% of breast cancers are traced to modifiable lifestyle factors. Talk to your practitioner about individual testing to identify what your risks might be in preventing breast cancer.

Reference: Cancer.gov. national cancer institute. “Hormone Therapy for Breast Cancer.

Hall, D. Applied Nutritional Science Reports. “Nutritional Influences on estrogen metabolism”. MET451, 2001.

Lam, M. Estrogen Dominance. Preventative and Ant-Aging Medicine. www.designsforhealth.com.