Chapter 1

Breast Health and Anatomy

WHAT'S A NORMAL, HEALTHY BREAST?
A "normal, healthy breast" comes in many different shapes, sizes, and colors. In fact, I'm not a big fan of the word "normal," as there is such great variability in what's "normal," as well as what's healthy. Normal for you may be quite different from what it is for other women; and, for that matter, "normal" changes throughout your life cycle, as the breast goes through a wide variety of changes I'll discuss in this chapter. For instance, before you reach puberty and begin menstruating, your breasts tend to be quite smooth inside and out; afterward, with the dramatic shift in hormones within your body, the breasts begin to develop greater texture. With texture can come concerns—suspicious lumps and other nodules that may worry you—but that are most often perfectly harmless. (I'll talk about the kinds of breast changes to worry about later in this chapter.) The bottom line is that big breasts can be healthy and normal; tiny breasts can be healthy and normal; loose, sagging breasts can be healthy and normal; and firm, perky breasts can be healthy and normal. Breasts that are different in size can be healthy and normal (in fact, few women have breasts exactly the same size, and when I see a perfectly matched pair in my office, I always look for the implant scars!). We come in a wide variety of packages. The most important idea to cling to is that you must never fall prey to the billion-dollar advertising campaigns that try to tell you what "normal" breasts look like—usually hard-as-rocks and practically pointing to the ceiling—with lots of cleavage and a golden tan. Sure, the image is an attractive one—but attractive, healthy, and normal come in many other guises as well.

WHAT ARE SOME NORMAL VARIATIONS ON THE EXTERIOR OF THE BREAST?
Let's start with the breast skin.

Naturally, depending on what color your overall body skin is, the skin of your breasts will differ. However, no matter what your skin color, the breasts tend to be a little lighter than the rest of your skin—partly because of a relative lack of sun exposure. While some women have extremely smooth and almost hairless breasts, others have fine or even coarse hair on the breasts. The nipple of the breast is usually relatively dark—pinkish or brownish—and protrudes slightly (I'll talk about inverted nipples a bit later). The nipple is surrounded by the areola, a ring of slightly lighter-colored skin than the nipple itself. This area often darkens during pregnancy and breast-feeding (lactation). Often, there are little pimple-like bumps on the areola; these are known as "Montgomery gland tubercles," and they are a cross between sweat glands and breast glands. They sometimes secrete a watery substance around the time of breast-feeding and pregnancy. Some women worry about these glands—especially if they are increasing in number—and think they are early tumors. But they are perfectly normal, and if you have twice as many as your sister, there's nothing wrong with you—or with her.

The nipple can be very sensitive, as it contains many nerve endings.

SO WHAT SHOULD THE INSIDE OF MY BREASTS BE LIKE?
The picture that follows shows the inside of a healthy breast, which you'll see is a very busy workplace.

Let's go through the various parts of the breast and what they do. Starting right behind the nipple are the biggest tubes inside the breast, called ducts. These ducts are where the milk flows when you breast-feed. Behind the ducts, moving farther back into the breast, are the ductules—smaller tubes that feed into the larger ducts. (Believe it or not, there are twelve to fifteen major duct systems in the breast—it's a complex organ.) Behind the ductules are the lobules. The very smallest of the ducts, farthest away from the nipples and deep in the breast, are the so-called terminal duct lobular units, or TDLU. This happens to be the most susceptible part of the breast to cancer. You can think of the lobules as the factories that produce the breast milk before it is carried through the duct system. The lobules are surrounded by supporting or fibrous tissue, fatty tissue, blood vessels, lymphatic tissue, and nerves. At certain ages, you'll find more or less of this material in the breast. For instance, younger women have a higher ratio of breast cells and fibrous tissue—and less fat in the breasts. Older women tend to have the opposite, with more fat, fewer breast cells, and less fibrous tissue. This is one reason why younger women's breasts often appear firmer than older women's breasts, and why mammograms are sometimes tougher to read in younger women (the breast tissue shows up as very dense). Other reasons for the difference include the strength of the underlying chest muscle, and the tone of the skin of the breasts.

Throughout the breast you have many little lymph channels, which lead to the lymph nodes under the arm and along the breastbone. These channels drain the breast of fluid, including waste fluid. On the negative side, this is one of the means by which cancer cells can travel out of the breast and into the lymph nodes. The lymph nodes extend from under the arms into the neck area, and create a rich network with each other in several areas in the upper body. Later in this book, I'll talk about the importance of checking the lymph nodes for cancer spread in certain cases.

Underneath the breasts lie the chest muscles; and these muscles, in turn, rest on the ribs. Extremely thin women may feel what they believe to be hard lumps in the breast, which actually turn out to be rib bone—particularly between the two breasts, where there is the least overall tissue.

Just to give you an idea of where in the breast various common problems occur, I've created a picture of the internal anatomy of the breast—tagged for various disease processes.

It helps a great deal to become educated about the anatomy of your breasts and to be familiar with how different parts of your breasts look and feel. The more you know about your breasts when they are in a baseline "normal" state, the better able you will be to detect new abnormalities for you. But no matter what, as I'll discuss later in this chapter, if you're worried about something new or different you feel in your breast, don't try to diagnose it yourself, and don't doubt yourself. Tell your doctor.

SHOULD I WORRY ABOUT "INVERTED NIPPLES"?
Here is a guiding principle about what should not worry you: if it's a long-standing condition that has not changed, it is usually fine. As a breast surgeon, I often don't see women until they have reached midlife—so I haven't had the benefit of seeing their breasts develop over a lifetime. For this reason, I take women's reports about their own bodies very seriously. For instance, consider the case of inverted nipples. With inverted nipples, the tip of the nipple does not stick out—it goes inward, into the areolar area.

If a woman tells me that her nipples have been like this her whole life, then I generally don't worry—because inverted nipples are a perfectly normal and healthy variation. Or, if she tells me that her nipples have a tendency to move in and out—which is also common—I usually won't worry. On the other hand, if a woman comes to me and says that her nipple has recently become inverted, but used to stick out all of the time—this would raise a red flag. Why? Because a cancer may be pulling on the ligaments, which in turn may be pulling the nipple in. Also, breast surgery can cause benign nipple inversion. Or, perhaps there is another, separate benign condition (i.e., benign inflammation) tugging on the nipple. In any case, further examination may be necessary.

WHAT ARE SOME OTHER VARIATIONS ON "NORMAL" BREASTS THAT I SHOULD NOT WORRY ABOUT?
1. Extra nipples, also known as polythelia: About 1 out of every 100 people (men and women) has more than two nipples. They do not necessarily appear on the breast site—they can appear anywhere from the armpits to the groin. This condition is also called "accessory nipples"—although the extra nipples are sometimes much more than accessories, as some of them actually can function. For instance, women may be able to breast-feed from an extra nipple. In other cases, you might not even realize you have an extra nipple—you just assume all your life that you have a protruding mole. The nipple might be more noticeable if it is attached to extra breast tissue, as well—but this is not always the case.

2. Extra breast tissue, known as polymastia: This is another variation on normal breasts. Some women have extra breast tissue, or what appears to be a full extra breast, somewhere between the usual breast location and the armpit or as low down as the groin. Extra breast tissue can appear with or without an extra nipple, as described above. Extra breast tissue is subject to the same range of changes and problems as any other breast: it can become tender before menstruation, it can develop breast cancer, it can lactate (produce milk for breast-feeding), and so on. Some women find that their extra breast tissue appears for the first time after pregnancy, as a result of changing levels of estrogen. The extra breast tissue may then recede after delivery, only to recur with a subsequent pregnancy. Other women have an extra breast all the time. While this is usually a normal condition, it can be extremely upsetting to many women, who are bothered either by the unsightly appearance of an extra breast or by the constant worry that the lump is a tumor in and of itself, and not a separate breast. In other cases, if the extra breast tissue is especially firm or nodular, there may be a malignant process going on, so it's important to be checked by your doctor. In extreme cases, this can appear like a mound the size of a grapefruit under the arm. Even if the tissue is found to be normal, however, if you find an extra breast or mound of breast tissue especially upsetting, and it is hindering your lifestyle in some meaningful way—(e.g., stopping you from wearing sleeveless shirts or bathing suits, or otherwise making you dislike and hide your body from others), you might want to consider having it removed. A plastic surgeon would usually be the one to do the job.

3. Stretch marks: These are pink, white, or silvery lines on the breast, usually slightly indented. Not every woman has stretch marks on her breasts, but many do. They are associated with rapid growth of the breasts during adolescence, and also with dramatic weight gain or loss. They are normal and not an indication of any disease process.

4. Premature or delayed breast development: Girls who develop breasts before age eight and without other signs of puberty (such as underarm or pubic hair) are considered to have premature or early breast development. On the other side of the coin, young women who develop breasts after the age of fourteen are considered to have delayed or late breast development. Both cases are usually normal, but it's wise to have a doctor check it out. You may need to have certain hormone levels checked, to be sure that there is no underlying hormonal abnormality causing the atypical breast development.

5. Leaking breasts during pregnancy and/or breast-feeding: The breasts go through a great deal of change during pregnancy and lactation, and a milky discharge at this time is not uncommon. Mention it to your doctor to be on the safe side, but usually this is no cause for alarm. In fact, milky discharge can occur even up to two years after breast-feeding, as it takes your breasts quite some time to return to their prefeeding "resting state." See a later question for a discussion of when nipple discharge is worrisome.

There are many other variations on normal breasts—I could take up a whole book discussing them. The important thing is if anything about your breasts worries or frightens you, talk to your doctor about it. New changes, as I said before, are more worrisome than conditions or appearances that have been there for many years. But you shouldn't be the one to decide what's worrisome and what isn't. Always seek your doctor's input and trust your judgment if something seems awry.

WHAT CHANGES SHOULD I EXPECT IN MY BREASTS DURING PREGNANCY AND BREAST-FEEDING?
During pregnancy and breast-feeding, there is a proliferation of cells in the breasts. You will develop more ducts, more lobules, and your breasts will start to enlarge and become plump with fluid rich in protein. This is all in preparation for lactation or breast-feeding. The blood flow to your breasts at the end of pregnancy increases a startling 180 percent, and the breasts can double in weight at this time. Your nipples and areolar area may darken during pregnancy and breast-feeding, as well.

Later, after you stop breast-feeding, your breasts may take as long as two years to return to their "resting state"—that is, their condition before you became pregnant. Sometimes, there are permanent visible changes in the breast—such as stretch marks, or a bit of sagging or shape change to the breast. Remember, while the breasts become fully developed at about age twenty, they start to show changes associated with age at about age forty. So if you have children in your mid-to-late thirties or later, as is increasingly common, you may see changes in your breasts that are related both to age and to the biological shifts of pregnancy and lactation.

WHEN SHOULD I WORRY ABOUT NIPPLE DISCHARGE?
I tend to worry about nipple discharge when it is spontaneous. By "spontaneous" I mean that the discharge appears when you are not touching or squeezing your nipples—e.g., you might just wake up and find it on your nightgown, or discover it in your bra during the day. Many women can elicit some type of discharge from the nipples by squeezing them—but this is rarely an indication of a problem.

Nipple discharge comes in many different colors and consistencies. It may be milky and whitish; creamy; watery and clear; yellow (serous); pink; red (bloody); or it can be multicolored, or greenish. As a rule, green is good, as green discharge often indicates "normal" fibrocystic changes in the breast. In addition, very often you'll find that discharge is multicolored and comes from different openings in the nipple, and this is usually fine as well. A milky discharge during pregnancy or breast-feeding is not worrisome—and can also result from taking certain psychotropic medications, from thyroid disorders, or from oral contraceptive use. But if you have a milky discharge (called galactorrhea) without such an explanation, I recommend a workup to make sure there is no underlying hormonal problem or trouble with the pituitary gland—such as a prolactinoma (a tumor producing the hormone responsible for making milk).

A yellow, pink, red, or clear discharge requires a workup by your doctor. In addition, a discharge associated with a mass also requires medical attention.

Many doctors do a "guaiac" test of the fluid to see if it is bloody. A "smear" test of the cells (on a slide) may also be performed to see if they are benign or cancerous. This is not a definitive test, but if the results are positive—that is, if cancer shows up—it is usually accurate.

On examination, your doctor will try to ascertain the location of the duct from which the discharge is emerging. A test called a galactogram may be ordered, in which a needle is inserted into the duct to pinpoint the source of the discharge. In the past, I considered the galactogram somewhat barbaric—but with newer, tiny catheters, it is less invasive.

Remember that the results of these tests are often inconclusive, and should not deter surgical excision of the duct or ducts. In preparation for this, one trick I've been using for some time involves a product called collodion—a sealant that is normally used to close scars after some forms of pediatric surgery. When you use this sealant once a day for about five days to occlude the nipple, the discharge is trapped and builds up inside the duct(s), at which point it becomes easy for your doctor to locate.

A surgical procedure can cause both cosmetic and sensation problems in the nipple and rarely impedes future breast- feeding.

Certainly any unusual discharge (unusual for you, that is) should be brought to your doctor's attention. Sometimes, discharge is associated with benign breast conditions, most commonly papillomatosis or duct ectasia (more on these later). As a rule, the older you are with papilloma, or nipple discharge, the greater the chance that it is associated with cancer. However, even in older women, nipple discharge is usually benign.

I HAVE A GREAT DEAL OF BREAST PAIN BEFORE I GET MY PERIOD. WHAT'S THE CAUSE?
There are many causes of mastalgia or breast pain, but about two-thirds of the time, it's related to the menstrual cycle—and termed "cyclical pain." The fluctuation in hormones that takes place throughout the menstrual cycle can cause varying amounts of pain and sensitivity. The pain is usually related to the consistency of the breast at different points in the cycle—for instance, the increased nodularity and volume of the breast in the days just before your period begins can be associated with extreme tenderness. There are many theories as to why the breast is more tender at various points in the cycle—each relating to the relative amount of the hormones estrogen and progesterone that are present at that time. Usually the pain is in both breasts, and is poorly located—that is, it hurts all over the place. The pain often increases in severity from midcycle onward. Some women find that their breasts are so engorged and sensitive before menstruation that they can hardly be touched, and even putting on a bra is quite bothersome. Usually, the swelling and tenderness recede quickly within a day or so after menstruation starts.

WHAT CAUSES BREAST PAIN OTHER THAN MENSTRUAL OR HORMONAL CHANGES?
One-third of breast pain is "noncyclical"—that is, it has nothing to do with the menstrual or hormonal cycles in your body.

Breast pain should be evaluated initially to exclude benign lesions of the breast, such as cysts, fibroadenomas, and other such problems that require aspiration or surgery. The broad term for many unrelated types of benign, noncyclical breast pain is MDAIDS—for mammary duct associated inflammatory disease sequence. Duct ectasia is one common benign problem that falls under this umbrella. It involves inflammation of the breast ducts, which can lead to scarring, which can in turn cause bad, localized breast pain. Another name for this problem is plasma cell mastitis (and others use the term periductal mastitis as well). A terrible cycle can develop in which the ducts fill with fluid, which leads to inflammation around the ducts, which in turn leads to scarring, all causing pain and further fluid buildup. Sometimes, it looks like an infection, and antibiotics are given; other times, it mimics cancer, and a biopsy is done.

MDAIDS can be chronic, lasting a few years and causing supersensitivity in the breasts. It's comforting that it's benign—but it sure isn't fun to live with. It tends to worsen in cold weather; the pain comes on abruptly and usually in the same site in the breast. Some women report a burning sensation behind the nipple. Often there is an associated sticky, green nipple discharge (which may contain bacteria). Sometimes, the nipples invert, or there is an accompanying mass in the areolar area around the nipple. In other cases there is an abscess (pus) or a fistula (a connection between the outside breast skin and an infection inside the breast). Some believe that there is an association between MDAIDS and cigarette smoking, especially in younger women—but this is controversial. (My personal take on that subject is that no one should smoke anyway, so it can't hurt to quit and find out if your breast pain abates!)

HOW IS MDAIDS TREATED?
For starters, reassurance is critical—women with this problem are often frightened and miserable, and finding out that the condition is benign and will likely recede with time can help a great deal. If there is an associated infection, antibiotics are needed. If there is an associated mass, surgery may be required. As for symptomatic relief, the following will help relieve pain: (1) mild analgesics and nonsteroidal anti-inflammatory drugs; (2) firm, supportive bras; (3) warm showers; and (4) possibly smoking cessation.

ARE THERE OTHER CAUSES OF NONCYCLICAL BREAST PAIN THAT ARE NOT RELATED TO MDAIDS?
Yes. For example, a less common type of noncyclical breast pain is Tietze's syndrome, which involves an inflammation of the cartilage where the rib cage meets the breastbone. With this condition, you might experience pain between the breasts. Usually nonsteroidal anti-inflammatory drugs will relieve the pain and the problem will disappear with time.

Less than 1 percent of the time, breast pain is caused by trauma or by postbiopsy complications.

MY DOCTOR SAYS I HAVE FIBROCYSTIC BREAST DISEASE. WHAT DOES THIS MEAN?
You'd be amazed how many women are told that they have fibrocystic breast disease without any firm documentation of the fact. It's one of the most common "throwaway" diagnoses about the breast. Most women with working hormones have lumpy, bumpy, nodular breasts—and usually, this is normal. But it is not fibrocystic breast disease! In fact, the only accurate way to diagnose fibrocystic breasts—that is, the whole host of breast changes—is with a needle (or surgical) biopsy, or a sonogram test to reveal the cysts. While some forms of fibrocystic breast disease do raise the risk of breast cancer, common cysts do lumpy, granular, or nodular breasts and call them "fibrocystic" based only on their physical examination. Insurance may call this a "pre-existing condition" and can refuse to pay—and women understandably panic. But often, the diagnosis of fibrocystic breast disease is a fallacy. Always ask for the specific name of your condition, so that you can determine if it is in fact something to worry about.

"Fibrocystic breasts" encompasses many things, including cysts, fibroadenomas, radial scars, hyperplasia, duct ectasia, and other benign problems in the breast. Sonograms can diagnose cysts; sometimes mammograms can suggest—but not prove—that there is fibrocystic disease by demonstrating milk of calcium, when calcium is floating in cyst fluid, or diffusely scattered calcifications, which are commonly seen in a condition called sclerosing adenosis, also a form of fibrocystic disease. The bottom line: Fibrocystic breast disease cannot be diagnosed by your doctor's hands or imagination.

SO WHAT ARE BREAST CYSTS?
Cysts are fluid-filled, which distinguishes them from other solid masses. They are extremely common in young, menstruating women, and in postmenopausal women taking hormone replacement therapy. In fact, about a third of women who have one cyst turn out to have additional cysts elsewhere in the breast—and half of the time you'll find cysts in the opposite breast as well. When I aspirate fluid from a cyst, it may appear yellow, bluish-black, or murky green, which I liken to muddy river water. As long as the cyst is not bloody, collapses completely, and has not recurred on reexamination of the breast, there's nothing to worry about. On the flip side of that coin, if the mass does not collapse or if there is blood present in it, I will recommend further testing.

Simple cysts do not require aspiration—if we're sure that's what they are. Sometimes, we do have to aspirate cysts—for instance, I will aspirate a lump I feel in the office, or if on a sonogram the cyst appears to be a combination of fluid and solid material (called a "complex" cyst), I will request a biopsy under the guidance of the sonogram machine. If a cyst is extremely large and interferes with my physical exam, I will aspirate it.

Sometimes, cysts do cause pain. For instance, when they abut on neighboring tissue, they can cause pressure and pain. Also, cysts can rupture, creating inflammation, which in turn can cause pain. So sometimes, I'll aspirate them to make women comfortable. But keep in mind, they can recur.

CAN BREAST PAIN INDICATE CANCER?
Yes. I am troubled by the widespread myth that "if there's pain, there can't be cancer." It's always important to notify your doctor of any breast pain you may be having, so that he or she can do a complete workup and rule out the more common benign problems, as well as a potential cancer. Up to 15—20 percent of breast cancers may be associated with some degree of pain or discomfort.

Cyclical pain is less likely related to a serious problem than is constant pain. But there's no way to know just by guessing. Your doctor may recommend a mammogram (breast X ray) and will likely do a thorough physical examination of your breasts and take a detailed history of your discomfort to determine the underlying cause. Most cases of breast pain are not cancer. But that's no excuse to avoid a workup.

MY FAMILY AND EVEN MY DOCTOR THINK I'M NEUROTIC AND IMAGINING MY BREAST PAIN. THIS IS VERY FRUSTRATING. CAN IT BE TRUE?
It's not only likely untrue—it's terribly insulting and degrading to you and to women in general. You'd be surprised how common your complaint is. Usually, the accusation that women are imagining their breast pain is totally unfounded. Breast pain takes a terrible toll on your quality of life, making sex painful or impossible and seriously impairing your overall mood and ability to enjoy life. If you feel such pain, find a doctor who is willing to explore the many possible pathophysiologic causes—and one who respects you and takes your discomfort seriously. After a "pathologic" process is ruled out, and reassurance is given, 60—80 percent of women with breast pain require no further intervention.

I READ IN A WOMEN'S MAGAZINE THAT I SHOULD AVOID CAFFEINE IN ORDER TO AVOID BREAST PAIN AND LUMPS. IS THIS TRUE?
The scientific answer is "no"—studies have not substantiated a real connection between caffeine (methylxanthine) intake and breast pain or lumps. The anecdotal answer, however, is "yes"—there are lots of women out there who insist that caffeine promotes both breast discomfort and lumpiness. My advice is to see what works for you. If you have lumpy, painful breasts and you can live without your coffee, tea, caffeinated soda, or chocolate, for example, try giving them up. I know many women who find that their breasts feel better afterward, and I know many others who say the change made no difference whatsoever. Remember, there's always the placebo effect—that is, if your body thinks you have made a change for the better, you may in turn feel better. And there's nothing wrong with that! However, I confess that I enjoy the occasional cup (or more) of coffee, and haven't let breast sensations get in the way of it.

I DO LOTS OF AEROBIC EXERCISE AND MY BREASTS BECOME VERY IRRITATED AFTERWARD. WHAT CAN I DO ABOUT THIS?
Over-the-counter anti-inflammatory drugs, mild analgesics, warm showers, and well-fitting, supportive sports bras all can reduce discomfort. But certainly if you're relying even on mild pain medication more than once in a while, you should talk to your doctor about it. If you're doing high-impact aerobic exercise, you might consider switching to a lower-impact sport (e.g., walking or swimming instead of jogging, a stair-climbing machine instead of a treadmill, and so on). Your breasts will likely feel better as a result, and the joints throughout your body will also be grateful in the long run!

I HAVE A SORE ON MY NIPPLE. CAN IT BE CANCER?
Yes, it could be cancer—but it doesn't have to be. Cancer of the nipple is known as Paget's disease— which is often associated with DCIS (ductal carcinoma-in-situ). Paget's disease is another form of breast cancer that happens to appear on the nipple not the areola around the nipple, but on the nipple itself If your sore is on the areola only, it's not likely to be Paget's disease. Sometimes, however, it can spread, untreated, to the adjacent skin surrounding the nipple. Paget's disease can appear suddenly or gradually. Some women have associated cracking, ulceration, oozing, scaling, or crusting of the nipple as well. Years ago, more than half of women with Paget's disease presented with a nipple lesion and associated mass, but these days, thanks to earlier detection, Paget's disease is usually found when it is limited to the breast ducts. Of course, there are noncancerous, common, scaly disorders of the skin of the breast as well—including eczema, psoriasis, herpes, jogger's nipple (from rubbing on the bra or shirt), and dermatitis. Dermatitis, or skin irritation and inflammation, can be triggered by allergy to nickel alloy in bra straps and hooks; latex; laundry detergent; or perfumes, for example. But always be sure to tell your doctor of any unusual lesions or bumps on your nipple—or elsewhere on your breast, for that matter—without delay. Do not apply topical creams or ointments without consulting your doctor, as these may mask Paget's disease.

WHAT ARE THE TROUBLE SIGNS TO WATCH FOR IN MY OWN BREASTS?
You don't have to be a doctor to be a good guard dog for your own body. In fact, no one is better equipped than you to evaluate your body's changes, as you live inside it year in and year out. The more you know about your overall anatomy and the anatomy of your breasts, the greater your chance of catching a problem early—and of alerting your doctor to that problem. So consider yourself your doctor's best ally.

Here are some key trouble signs to watch for in your breasts. They certainly do not guarantee that there is a cancer or other serious problem, but they should catch your attention so you, in turn, can bring them to the immediate attention of your doctor:

1. RECENT ASYMMETRY OF YOUR BREASTS: Many women have asymmetrical (different-sized) breasts, and this is perfectly normal. And there are other normal causes of breast asymmetry, including having surgery on one breast and not the other, or long-term breast-feeding on one side and not the other. But when your breasts are normally close in size, and then become asymmetrical without some obvious explanation, this can be a trouble sign. Be sure to discuss any such change with your doctor, as a breast can become smaller if a cancer is pulling the skin in and shortening the ducts. This can also create puckering on the skin of the breast.

2. PUCKERING, INDENTATION, OR RETRACTION OF THE SKIN: Puckering of the breast can indicate the existence of a cancer—perhaps one growing in or involving the connective tissue surrounding the breast ducts. Cancers close to the surface of the skin can cause puckering as well.

3. DIMPLING OF BREAST SKIN: This condition, known as peau d'orange or orange peel, may indicate the presence of a tumor that is blocking the lymph system and causing fluid accumulation under the skin. Be sure to bring it to your doctor's attention.

4. REDNESS OF THE BREAST SUN: Redness does not necessarily indicate cancer—for instance, a woman who is breastfeeding and has redness, swelling, or warmth in a breast may have an infection or abscess. But if antibiotics fail to clear the problem, it's important to have your doctor confirm that no cancer or other underlying problem is present. A relatively rare form of breast cancer is called inflammatory breast cancer, and does involve redness and heat in the breast. When dimpling and redness appear together, this is more worrisome. Again, don't diagnose yourself—see your doctor.

5. ULCERATION OR ERODED SKIN ON THE BREAST: This is something I don't like to see on the surface of the breast, as it can indicate a cancer which is eroding the breast skin. Tell your doctor as soon as this sign appears.

6. RETRACTION OF THE NIPPLE: This must be differentiated from long-standing inverted nipples, which can be perfectly normal. But a sudden, pronounced retraction of the nipple can indicate a cancer pulling the nipple inward. So show it to your doctor.

Other problems to look for are discussed earlier in this chapter, such as certain kinds of nipple discharge, and a sore on the nipple.

In the next chapter we will discuss how to screen your breasts for cancer and other common problems. Read it carefully for information on three key breast screening tools: your doctor's physical examination of your breasts; the breast self-exam, a monthly examination of your breasts which you do yourself and which will help you to find suspicious lumps or other irregularities in your breasts; and the lifesaving annual mammogram or breast X ray.

© 1999 by Rosie O'Donnell and Deborah Axelrod
Excerpt posted with permission from http://www.twbookmark.com

Many thanks to Time Warner Bookmark (Little, Brown & Company, Warner Books, A Time Warner Company) at: www.twbookmark.com. We appreciate their cooperation with OfSpirit.com to share this chapter of their book with our visitors for education, entertainment and empowerment.