Navigating Breast Health

Breasts play a role in our sexual response, as I’ve described before. Our nipples are bundles of nerve endings that respond to touch. Some women (though not most) can reach orgasm through nipple stimulation alone. Others of us rely on breast and nipple fondling to put them “over the top” in experiencing orgasm during oral sex or vaginal intercourse. \

So while breast cancer isn’t central to my focus on women’s sexuality, it’s obviously connected—as the heel bone is to the ankle bone, the ankle bone to the shin bone. And because in my practice, I advise women on many aspects of their health, I pay attention to the discussion about mammograms and breast cancer diagnosis.

It’s complicated, and it’s controversial right now. An article in the New York Times last month previewed a study published in JAA Internal Medicine. Dr. H. Gilbert Welch, of the Dartmouth Institute, concludes that three to fourteen 50-year-old women in 1,000 (that range tells you something of the current controversy about data) will be overdiagnosed and overtreated as a result of mammograms. Zero to three women in that same 1,000 will avoid a breast-cancer death. Dr. Welch encourages more study, but also concludes that mammograms are over-used and ineffective.

That article prompted an almost immediate response from Dr. Elaine Schattner. Dr. Schattner takes issue with the notion that women are overly harmed by false positives. Mammogram technology is “more accurate and involves less radiation than ever before,” she says. Instead of doing more study, she suggests we focus on making high-quality screening facilities available to all women, get really good at accurately reading the images, and let women themselves decide how to manage the balance between risk and reward.

In my own practice, I use the guidance from the American Congress of Obstetricians and Gynecologists, which calls for annual mammograms for best early detection. I balance that with my own knowledge of each woman’s history and risk factors, but it’s still complicated. I might have a patient whose mammogram comes back entirely negative—which is positive!—but still receive a recommendation for further imaging because of family history. The family history might be for cancer detected in a woman in her 80s or 90s.

Cost factors in, too, both individually and collectively. As more of my patients have high-deductible health insurance, the decision about whether to have an MRI is more consequential. And, of course, tests that aren’t necessary or productive are part of what’s driving the cost of health care up for all of us.

And yet! Given where we are with treatment, early detection remains one of our best assets in combating breast cancer. I’m reminded of an earlier paper that concluded that of the study subjects—women from 40 to 49 with stage I, II, or III invasive breast cancer—77 percent who died hadn’t had regular screenings.

As a physician, I’m frustrated by the difficulty we have in sending consistent messages to women. I don’t want women to be afraid of breast cancer, but neither do I want them to be casual or skeptical about screening methods—like mammograms—that are relatively low risk and low cost.

What about you? Are you confused by what you read about mammograms? Do you know what’s recommended for you? Do you follow those recommendations? Are you confident your health care provider is taking you—individually—into account? Have you had to navigate insurance guidance as well as medical guidance?

The worst thing we can do is to throw up our hands and give in to the ambiguity. The best thing we can do is to encourage each other, speak up, demand common sense paths to follow, and work to make screening readily available.

“Each of Us Will Recover at Her Own Pace”

Without doubt, breast cancer is a game-changer, altering every area of life and relationships. At first, amid the flurry of medical decisions, surgery, chemo, and recovery, you don’t have the time or energy to think about sex. But then… how do you make your way when all the furniture is rearranged? When your body, your emotions, your self-image and feeling of security, and your relationship with your partner are so permanently changed?

For a while, sex is understandably the last thing on your mind. Your chest is a surgical site; chemotherapy and radiation may make you nauseous, bloated, and incredibly fatigued; it may induce menopause if you haven’t already made that passage. Cancer survivors frequently experience depression as well. It’s important to know that if you don’t feel like sex for a period of time, you don’t have to go there. Focus on getting well first, say the experts, without completely shutting the door to intimacy. You can still love and support each other in small ways—holding hands, taking a walk, reading in bed together—to keep the coals alive during this period of stress and anxiety.

Your partner is under a lot of pressure, too, and is probably struggling to find purchase on the slippery slope of this crisis, uncertain about how to support you, and how or when to approach the sticky wicket of sex. Your partner may be waiting for you to make the first move, or be afraid of hurting you.

It might be helpful for both of you (or just your partner) to talk with your doctor or a counselor. Forthright, open communication about sex (or any other issue) can make the difference between feeling your way in the dark alone or shining a light on a difficult path. The most challenging situations can be overcome with honest dialog and the willingness to seek help and information.

Over time, as you begin to heal, you face the inevitable hurdle: resuming your sexual life. How will your partner respond to the way you look; for that matter, how do you feel about your changed body? Your incision site may still be tender or you may be undergoing reconstructive surgery. Chemotherapy may have brought on menopausal symptoms. Maybe you’re not sure you feel like having sex at all, and you certainly don’t feel very sexy.

First, take it slow. You (and your partner) have been through a prolonged, life-threatening crisis. In addition, you’ve lost an important erogenous zone. Unless your doctors have been able to spare your nipples and their nerve endings, you probably can’t feel anything in an area that used to be erotic and arousing.

You and your partner need to become acquainted with your new body. You may have lost your breast(s), but other parts—neck, shoulders, ears—may become more sensitive. Your first foray into sex could be an exercise in gradually raising your awareness of sensation rather than worrying about intercourse.

Try simply touching each other. Leave the genitals out for now. Talk about what feels good. Or—don’t talk at all, just be together, touching each other. Slowly, in this session or the next, add genital exploration and move on to intercourse when it feels comfortable. Sex will be different—and not necessarily for the worse.

Experts say that you don’t have to “love your scars.” If you’re uncomfortable letting your partner see you naked, wear sexy lingerie. On the other hand, your partner may be able to reassure you that you are as loved as you ever were, and that’s incredibly affirming.

Second, assemble your tool kit. This should include lubricants to make penetration easier and sex more pleasurable. Maybe experiment with toys; try massage oils. Experiment with positions that are comfortable. Lying on the affected side may be painful, for example. You may prefer being on top or on your knees with your partner behind you. Since so much is different anyway, why not shake up the routine? Be sure to discuss any problems or questions about sex with your doctor. A solution may be easier than you think.

In a blog about sex after having had both breasts prophylactically removed, one young woman likens the experience of resuming sex with her husband to a second adolescence—shy, awkward, fumbling, uncertain. “But like adolescence, this is a phase I will grow out of. I will become more comfortable with my body and my husband will too.… But all of this is uncharted territory, and I'm trying to do what feels right to me. Each of us will recover our sexuality at her own pace, and this is the (frank) truth about mine.”

What Do Breasts Do for Us?

Recently I treated a patient who’d had elective breast reduction surgery. Nerve damage during the procedure had caused her to lose all sensation in her nipples. She found herself unable to have an orgasm without the extra stimulation those nerves had provided. That was a consequence she hadn't thought to ask about!

Changes in nipple sensation are possible side effects of any type of breast surgery, including elective surgery to increase or reduce breast size. Sometimes the effects are temporary, but they can be permanent. It’s important to understand these risks -- and the role your breasts play in sexual arousal and satisfaction -- when choosing breast surgery for cosmetic reasons. I don't know if my patient would have made a different choice, but she may have.

How do breasts contribute to orgasm? Some women (not most) can reach orgasm through nipple stimulation alone. Others rely on intense breast and nipple fondling to “put them over the top” during oral sex or vaginal penetration.

Like the clitoris, nipples are bundles of nerve endings that respond to touch by releasing certain hormones in the brain. One of these hormones, oxytocin, is sometimes referred to as the “cuddle hormone”: It makes us feel warm and open toward the person whose touch initiated its release in our bodies. Other hormones, including testosterone and endorphins, combine to create a surge of sexual arousal that increases blood flow to the clitoris and stimulates vaginal lubrication.

For most women, sexual foreplay is essential to getting us interested in and ready for intercourse or penetration. And for most women (82 percent in one study) breast and nipple stimulation are an essential ingredient of foreplay.  We talk a lot about clitoral stimulation and vaginal maintenance for maintaining our sexual satisfaction, but other parts of our bodies also play a part in arousal and orgasm, though.

For those of us fortunate enough to retain the pleasant sensations our breasts can provide, remembering these important sites of arousal during foreplay and intercourse (warming and massage oils can work wonders here) will enhance our readiness for and enjoyment of sex -- at any age. Let's not forget to raise our focus -- to our breasts.