MiddlesexMD

I Will Observe Cervical Health Awareness Month

Resolution #2

The stars have aligned for our January resolutions series. Not only is January designated as Cervical Health Awareness Month, but I’d say that the cervix counts as an “often neglected body part” related to our sexual health or well-being, which was the criterion for this January resolutions series.

The good news about the cervix is that there really isn’t anything you have to do to improve its function—no exercise, no diet, no special creams or lotions. Basically, it’s four centimeters of tough muscle between the vagina and the uterus. It keeps a baby in safely tucked inside the uterus and then dilates when it’s time for the baby to be born. That dilation is what labor is all about, as though you could ever forget. It really has no sexual function, contrary to previous belief.

The deal with the cervix—and why we have this special month devoted to it—is that you can almost ignore it if it’s healthy, but if it acts up, as with cervical cancer, then you have a problem, Houston.

And that’s why you can’t completely ignore it. So let’s give the lowly cervix a little blog luv.

Times have changed with the sexual revolution and advent of cheap, easy, and effective birth control. There’s a whole lot more sex happening with more partners, for one thing. And with that has come a lot more sexually transmitted diseases. We talked about that at length, beginning here, but as it relates to the cervix, here’s the rub.

The precursor for cervical cancer is what we call SIL (squamous intraepithelial) change (or dysplasia in physicians’ lingo). That change is nearly always caused by human papillomavirus (HPV; there are rare occasions where cervical cancer isn’t HPV related), and HPV is pretty much ubiquitous among sexually active people (80 percent). Plus, it’s a virus, so once you have it, there’s no cure. Usually that’s no problem. In 70 to 90 percent of cases, a healthy immune system clears it up within two years—kind of like the common cold.

But as we know, viruses are wily, shape-shifting critters. There are about 100 strains of HPV, only a few of which are considered high risk for cervical cancer. About 12,000 women get cervical cancer every year in the US, and one-third of them die. This isn’t a huge number, but the tragic thing about cervical cancer is no one should die from it because cervical cancer is extremely easy to detect and treat. In women older than 65 with cervical cancer, 42 percent had never been screened.

Screening guidelines and testing procedures have changed in recent years, however, so it’s no wonder if you’re confused about what to do and how often to do it. There is now a test for HPV, which is recommended for any woman over 30. There is also the tried-and-true Pap test that tests the cervix for precancerous cellular change, or dysplasia. This test is recommended to start at age 21.

A woman with a history of negative results and no other complications only needs a Pap test every three years. Combined with a negative HPV test, the wait can be five years.

Obviously, if your cervix was removed during a hysterectomy (and you DO know whether or not it was removed, don’t you?), and if you don’t have a history of cancer or dysplasia, you are done with Pap tests forever. Even if your cervix is intact, until recently the guidelines advised that women over 65 with no history of positive Pap results no longer need screenings.

All that may be changing.

In a 2013 study of women between 35 and 60 found that some women who had been monogamous or celibate for decades began testing positive for HPV. The results suggested that these women had been carrying latent and undetectable levels of the HPV virus from sexual encounters in their youth that had spontaneously reactivated during menopause. This is akin to a childhood case of chicken pox returning later in life as shingles.

“As long as you are controlling these infections, your immediate risk of [cancer] is going to be low,” molecular biologist Dr. Patti Gravitt explains in this article from Johns Hopkins. “But if menopause, or just getting old, increases HPV reactivation, then we need to look at what this means for screening these older women who came of age during the sexual revolution and are much more likely to reach menopause with latent HPV than the postmenopausal women we have screened in the past.”

In the face of this surprising finding, the North America Menopause Society now recommends that “all women who have had multiple partners should not stray too far from their Pap smear or HPV test at menopause until we know more about the increased risk of HPV flare up at menopause.” 

Even women who have had their cervix removed should be aware that rarely HPV also causes vaginal and vulvar cancers. So more than ever it pays to be aware of your cervical health—and your HPV status. Being postmenopausal doesn’t give us a pass anymore.

 

 

Make Your Diet Cancer-Resistant

 According to the experts, the three most important things you can do to avoid cancer are to maintain a healthy weight, to exercise regularly, and to be smart about your diet. All three are interconnected, and none of them is easy, especially if achieving them requires confronting and changing lifelong habits.

Luckily, these happen to be the most important things you can do to avoid all kinds of disease and to enjoy a high quality of life as well. (Not to mention having the strength and stamina for better sex.)

Weight control has two parts: energy in and energy out—the number of calories (energy) that you ingest every day relative to the calories you burn in daily activity. But metabolism and calorie recommendations change with age and stage of life, so a moderately active 36-year-old mom needs about 200 calories per day more than a 65-year-old, post-menopausal woman.

So unfair.

I’m sure you’ve read the gospel of good nutrition: Eat a variety of fresh fruits and vegetables, whole grains, modest servings of fish, chicken, and some red meat, very limited amounts of salt, fats, sugars, and processed carbohydrates, such as those in white bread, pasta, and pastries.

Diet is complex and the interaction of many foods in the human system isn’t easy to study nor is it well-understood. Credible connections between cancer and a single food, vitamin, additive, or supplement require multiple studies over a period of time. So the correlations are rarely clear and straightforward, and lots of fad diets and “magic bullet” vitamins and supplements are debunked over time. For example, no research supports antioxidant supplements to reduce cancer risk.    

The best approach is to follow the general guidelines for good nutrition established by the ACS and other groups. People who prepare a variety of fresh foods at home and who limit empty calories in sweets and sugary drinks, fats in chips and fried foods, and excess calories and unpronounceable additives in heavily processed foods are more likely to maintain a healthy weight and to avoid illness and disease, including cancer.  

According to the American Cancer Society, “A dietary pattern that is rich in vegetables, fruits, poultry, fish, and low-fat dairy products has been associated with a reduced risk of breast cancer in observational studies.”

That said, a few causal links about specific dietary habits and cancer have been established:

• Alcohol consumption increases breast cancer risk. “Compared with nondrinkers, there is a 10 percent to 12 percent higher risk of female breast cancer associated with each drink per day,” according to the ACS. One alcoholic drink per day is the recommended limit for women. One. Any kind of alcohol.
• Processed meats are linked to “modest but significant” increases in various cancers. This includes bacon (ouch!), sausage, lunch meat, hot dogs. Red meats should also be limited.
• Fresh fruits and vegetables are beneficial for many reasons, but diets that contain a lot of fresh produce tend to carry a lower cancer risk. There is some indication that caretenoids, a substance found in dark, leafy greens and colorful vegetables, such as sweet potatoes and carrots, slightly reduces the risk of breast cancer. The ACS recommends 2.5 cups of fresh produce daily.

 Environmental pollution is embedded into our daily lives, and it is impossible to avoid. Some, such as radon or dioxin, are known carcinogens, while the cancer-causing status of many, many others hasn’t been determined.

 “Many pollutants in the environment have biological effects, so even in the absence of specific information linking these chemicals to diseases it is not safe to assume that they are benign,” said Dr. Larry Norton, deputy physician-in-chief for Breast Cancer Programs, Sloan Kettering Cancer Center.

 A few simple steps to reduce environmental exposure makes sense.

• Test your drinking water and consider a filter, if necessary. All filters aren’t created equal: some just filter chlorine while others eliminate heavy metals and specific chemicals. Here’s objective information from the gold standard of testing outfits (the NSF).
• Buy organic—sometimes. The ACS makes no recommendation for the safety of organic over non-organic foods. However, there is intuitive sense in buying organic options of specific foods that are known to be otherwise laced with pesticides and agricultural pollutants. Every year, the Environmental Working Group (EWG) publishes a list of the “Dirty Dozen”—products with the highest level of contaminants. (Sadly, strawberries top the list this year.) Consider buying organic in these categories—or grow your own!
• Avoid plastics labeled #3, #6, and #7, which are known to leach harmful chemicals like BPA into food and water. Don’t microwave food in plastic containers.
• Reduce the impact of stress and physical exhaustion. Modern stressors take their toll on our cells and make us less resistant to illness and disease. Take time to decompress, do yoga or some other exercise, meditate. Don’t overcommit or try to do everything perfectly. Listen to your body and respect its signals.

There’s no pill to keep you cancer-free. Personally, however, I find it very hopeful and motivating that I can make lifestyle choices that will not only improve my quality of life dramatically but will make me more resistant to disease and illness as well.

Exercising regularly and eating healthfully isn’t easy, but the effects are holistic and powerful. As Chris Crowley, co-author of the Younger Next Year series, says bluntly, “The most important thing you can do is work out—pretty hard—six days a week until the day you die. Got to quit eating garbage, too.” ‘Nuff said.

 

 

Lifestyle Choices to Beat Breast Cancer

In the last post, we talked about the major risk factors for breast cancer. Unfortunately, a whole lot of them, such as a family history of cancer, you can’t do anything about. But there are some really important things you can do to affect your chances of getting breast cancer—and other cancers as well.

Every five years, the American Cancer Society (ACS) brings together a panel of experts who review hundreds of the latest scientific studies and create detailed guidelines for healthy, cancer-resistant living that are based on sound science.

According to the latest guidelines from the ACS: “For the great majority of Americans who do not use tobacco, the most important modifiable determinants of cancer risk are weight control, dietary choices, and levels of physical activity.” Then the guidelines offer up the latest findings on what lifestyle habits, specifically, make a difference—and what don’t. (Tip: No evidence that garlic reduces cancer.)

The drumbeat from the ACS and most other sources is very consistent and very clear: diet and exercise are your best bets for reducing cancer risk. Even better, a healthy diet, regular exercise, and maintaining a good weight critically impacts your overall quality of life. You will be more flexible, have more energy, and a better sex life. You will preserve your joints; you are less likely to have heart problems, diabetes, and dementia. And…you’ll just feel better.

Such a deal!

So, let’s drill down into some of the details. Breast tissue is particularly susceptible to environmental insult because breast cells take longer to mature than those in other organs and because immature cells react more to environmental hormones. “The breast is a sponge for everything in the environment,” says Dr. Jose Russo, breast pathologist at Fox Chase Cancer Center. In fact, breast cells don’t completely mature until a woman has a full-term pregnancy. Then, breastfeeding completes that maturation cycle.

Additionally, the way we live and the environmental stresses that surround us are different from even a generation ago. We are more sedentary at our jobs and at home; more of us are carrying a lot more weight than is good for us; we are exposed to thousands of new and often untested chemicals in water, air, earth, and food; animals grown for food are routinely given antibiotics and hormones that we then ingest.

This could seem like a depressing list of uncontrollables, but we can do a lot to limit our exposure to carcinogens and to create a healthy, cancer-resistant life for ourselves.

The main focus of the ACS (and other) guidelines is to encourage us to maintain a healthy weight (“Be as lean as possible without being underweight”). According to the ACS, being overweight or obese accounts for 14 to 20 percent of all cancer deaths, and specifically breast cancer because fat cells release an estrogen-like hormone in postmenopausal women. The guidelines state: “Overweight and obesity are clearly associated with an increased risk of developing many cancers, including cancers of the breast in postmenopausal women.”

Determining your body mass index (BMI) is the most accurate way to determine where you fall on the skinny-to-fat continuum. Here’s an informative calculator that gives you a “smart” BMI range based on gender, age, height, and weight.

In order to lose weight, you have to both reduce the calories you take in as food and to burn more calories than you ingest—i.e. by being physically active. In fact, evidence suggests that physical activity all by itself is a protective factor against breast cancer. The ACS recommends 150 minutes (2.5 hours) of moderate activity per week, such as walking or yoga, or 75 minutes of vigorous activity per week, such as jogging, swimming, or cross-country skiing. “This level of physical activity has been shown to have clear health benefits, including reduced rates of premature death and reduced incidence of or mortality from various cancers,” according to the ACS guidelines.

Now, I completely understand how difficult changing lifelong habits can be. I also understand that exercise can be hard and even unpleasant. If you sit in front of the computer at work and flop in front of the TV at home because you’re mentally exhausted, it’s going to be very hard to begin a half-hour daily workout regimen.

Here’s the deal: a little is better than none, especially at first. So if you can only do fifteen minutes, or ten, or five, just start there. If you miss a day or two (or three), don’t make that an excuse for giving up. The trick is to persist. Yes, it’s hard to get started again, but the point is to just do it, not to do it perfectly.

Psychologically, you’ll tend to stick with a change if you make a commitment to a specific regimen (say, walking for a half-hour five days a week) and then tell someone about it. Choose an activity you like and do it with others. Join Curves or the local gym or just walk for a certain distance or period of time. Honestly, it’s a better way to chill after a stressful day at work than sitting in front of a screen.

I will tell you from personal experience that when regular physical activity becomes a habit, however haltingly, you will notice the change—in your mood, in your flexibility, in your strength, and, often, in how those nagging little aches and pains begin to fade. I’m a true believer because I’ve experienced the benefit. (And I will confess that it’s still hard to make myself get off the couch—but I always feel great after.)

Physical activity is one critical part of a healthy, cancer-resistant lifestyle. Diet is another, and both work together to keep weight at an appropriate level. There is no magic bullet for absolute protection from diseases like breast cancer, but the ACS guidelines offer “…a decreased likelihood that the disease will occur…” Plus, an increased likelihood of a higher quality of life.

Which is about the best promise anyone can get in life, don’t you think?

 

 

Breast Cancer Basics: Risk Factors

It’s October. That means, yes, Halloween and fall color, the harvest moon, pumpkins, and apples. Also breast cancer awareness. Not necessarily in that order.  

To recognize that dubious distinction, let’s review some breast cancer basics, beginning with the most important of the known risk factors that you may (or may not) be able to do anything about. In this case, knowledge is, if not power, at least awareness.

We’ve all lost friends and relatives to breast cancer. Maybe we’ve even had it ourselves. That’s because breast cancer remains the most common cancer for women. Fortunately, we’ve seen some advances in screening and treatment methods, but still one in eight of us (12 percent) will be diagnosed with breast cancer sometime in our lives, and one in thirty-six (3 percent) will die from it.

The good news is that breast cancer rates have been going down since 1989 (although they’ve stabilized lately). Still, every year almost 245,000 new cases are diagnosed and 40,890 women die from it.

We all carry risk factors for breast cancer, but there are very few absolutes when it comes to who actually gets the disease. Some high-risk women never get cancer while others with a very low risk profile do. The two most universal and unavoidable risk factors are being a woman and getting older. Although about 2,000 men are diagnosed with breast cancer every year, it’s overwhelmingly a female disease. It’s also largely a malady of older women. Two-thirds of invasive cancers are found in women over 55.

Genetics is, of course, a factor, but it may be less significant than we think. Most women (eight in ten) with some genetic predisposition to breast cancer never get it. However, the more genetic factors you have, the higher the risk. So, if you have several genetic risk factors, your chances of diagnosis increase. The most significant genetic factors are:

• Close relatives (mother, sister, daughter) with breast cancer
• Relatives with other cancers in your family
• Some genetic mutations, notably in the BRCA1 and BRCA2 gene.   

Other risks that we can’t control include:

• Early menstruation and/or late menopause increase our lifetime exposure to estrogen and progesterone, while having children and breastfeeding are protective factors.
• Dense breast tissue. This means that the breast has less fatty tissue and more glandular and fibrous tissue. Not only do extremely dense breasts have a slightly higher cancer risk, but screenings may be less effective and early cancer harder to detect. A discussion with your health care provider will help you understand which category includes you.
• Race and ethnicity are slightly significant: White women have higher rates of breast cancer, but African-American women are more likely to die from it. Asian, Hispanic, and Native American women are at lower risk for both.

Some risk factors for breast cancer have more to do with lifestyle and treatment choices—and these are factors we can control. These lifestyle choices impact our health and quality of life in a whole bunch of ways, so it’s important to pay attention to them.

• Obesity. Fat cells release estrone, a type of estrogen, which raises hormonal levels in post-menopausal women.
• Alcohol consumption. According to cancer.org, two to five alcoholic (any type of alcohol) drinks daily increases the risk of breast (and other) cancer by 1.5 percent compared to women who don’t drink. Cancer surgeon Dr. Jane Pettinga writes, “… alcohol reduction [is] the only dietary change that has science solidly behind it.”
• Sedentary lifestyle. Evidence is growing that regular physical exercise reduces risk. To reduce breast cancer risk, the American Cancer Society recommends at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week.
• Exposure to radiation. This doesn’t refer to the X-rays you get at the dentist’s office. Women who have had radiation treatment to the chest or face before age 30 for treatment of other cancer (like Hodgkins, which makes up the vast majority of young women who’ve had chest wall radiation), for example, are at higher risk.

Cancer is complex and multi-faceted. One risk factor doesn’t--or even several risk factors don’t inevitably equal cancer. There are gradations and mitigating factors and a whole lot of unknowns. Some things, such as exposure to certain chemicals, are considered “emerging risks,” which may or may not hold up under research, while others, such as wearing an underwire bra, have absolutely no supporting evidence.

I think the best approach is to understand your risk profile, but then live your life as richly and healthfully as you can. The most important thing you can do, bar none, is to maintain a healthy lifestyle (more on this in the next post). Then review your plan for screening every year--and follow through.

New Report: Localized Estrogen Safe for Breast Cancer Survivors

Before we begin, I just want to reiterate our long-held position here at MiddlesexMD: Natural is always better. By that I mean, if you can ease vaginal pain and enjoy sex comfortably using non-hormonal products like moisturizers and lubricants, that is always the first and best option.

That is also the position taken in a new report issued two weeks ago by the American College of Obstetricians and Gynecologists (ACOG). But when the non-hormonal route just doesn’t cut it, when the pain of vaginal dryness and atrophy is unpleasant enough to interfere with life and good things like sex, then the ACOG committee says that topical estrogen treatment is a good option even for breast cancer survivors. (Check out this link on our website for tons more information.)

Let’s dig into this.

For a long time, doctors focused on simply helping women with breast cancer to survive. Now, the good news is that women who have had breast cancer are indeed surviving for years longer. So the focus has shifted to quality of life—like making sure that sex is comfortable, for example.

This can be tricky, because we all know that estrogen is a bad thing for breast cancer survivors. In fact, a type of breast cancer, called “estrogen-receptor positive,” which unhappily is more common in postmenopausal women, has special receptors that are sensitive to estrogen. With this type of cancer, estrogen acts like fuel, making the cells grow more quickly. That’s why ongoing treatment for women who have had this type of cancer includes Tamoxifen or “aromatase inhibitors” that block estrogen activity.

Problem is, of course, estrogen is a good thing for our vagina, among other parts, and a lack of estrogen wreaks havoc on that sensitive system. Thus, drugs that block estrogen activity also cause urinary tract infections and painful vaginal dryness and atrophy. These side-effects can be so severe that 20 percent of women simply stop taking the drugs.

We know that oral estrogen replacement therapy—taking estrogen pills—increases systemic estrogen levels, but what about localized estrogen that’s used externally to treat vaginal dryness and atrophy? Does that increase estrogen levels in the body? Does it increase the risk of relapse?

While there hasn’t been a lot of research on the subject, ACOG released its committee report early in February stating: “Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.”

The ACOG guidelines recommend using the lowest effective dose for as little time as possible. And while the hormone comes in three forms: cream, ring, and a vaginal tablet, the lowest rates of absorption and the most accurate dosages occur with the ring and tablet.

For women whose symptoms are severe and who aren’t sufficiently relieved just by vaginal moisturizers and lubricants, it’s nice to know that there are other options. If you’re a breast cancer survivor who is suffering from vaginal dryness and painful sex, it’s time for a sit-down with your doctor to discuss treatment options. It’s time to start living well again.

To Squish or Not To Squish

The American Cancer Society has released new guidelines for Mammogram Screenings. We know you’ve likely read a lot about it. I thought I’d hand it over to our old friend and writer Julie, a longtime MiddlesexMD blogging pal, who has breasts of her own and some thoughts to share on what to do when new guidelines hit the airwaves.

Guideline Headlines!!! Okay girls! Grab them and run! But which way! When? Where? But wait!!! No!

No! These guidelines are saying to maybe squish less often? For some of us? Really? To not start so soon? Who are these people?

I’m confused.

With the latest release of Breast Cancer screening guidelines from the American Cancer Society, it’s easy to feel a little—entangled—in questions of when and whether to handle our screenings. And no wonder. The discussions are very much in the air, and the experts are agreeing to disagree. Very politely.

It wasn’t the intention of the committee to create this confusion, of course.

They truly wanted to offer up more leeway in guidelines, particularly for women with average risk of developing breast cancer—and that’s most of us. But leeway is very hard for most of us to interpret. Most of us just want very clear direction. We want safety and assurance. We want to avoid unnecessary exposure to radiation and unnecessary medical procedures. That’s not too much to ask, is it? 

Well, we can’t have absolute assurances from medical guidelines. It would be so nice if we could. We can only get the best advice from smart committees working from what data they have to keep the greatest number of us safe most of the time.

So the new guidelines ease up on the youngest women, aged 40-45, saying they don’t need to start screening if they have average to low risk of breast cancer. Of course we women in menopause are already screening our breasts, have already been at it for years by now. Now we are wondering what to tell our daughters. And we will be getting different advice from at least three of the six breast-cancer-guideline-writing organizations in the US alone. 

In fact all of those concurrent guidelines exist out there already, in our doctors’ heads. And online. And in our restless heads and hearts. So what do we do with all of this various information?

First… We breathe.

Then…  We remember, that we are each in charge of our own bodies. Guidelines are there just as a framework of reference. In practice, we each are working on our particular realities, which must be dealt with in the particular, with a plan that takes in all of the unique, unusual, specific aspects of our own bodies, or our daughter’s, their daughter’s.

So, I’ll take me, for example.

Those guidelines would suggest, since my breasts have been around for 55 years (well, one of them. The other seems much, much older), and in my family there is no history of breast cancer at all, and I have no current cancer markers, good and good. But… I’ve had so many surgeries and lung problems my chest as been radiated enough in my lifetime to light up Tokyo on a moonless night, which is not so good, and I’ve had to have a few lumps biopsied here and there, which have markers they like to peek at now and again, so….. Yeah I’m signed up for annual scans. Am I worried? Not really. But I’m committed. My sister, with the same family history, may logically choose to scan less often. Because she’s been much healthier throughout her life.  

A young relative in my family? Just turned 40. Did she need to go for her first exam? Not really, but she and her friends made a party of it at the local breast exam clinic. Wine and bites and breast squashing in paper robes. She could have put it off another 5 years, but she prefers to get this ball rolling. Preference plays a roll here. She is being cautious. 

You see how this rolls. Family history + conference with your physician over your own medical history + your own ideas and feelings about medical tests at this time in your life, taken together with a careful review of the recommendations = your best plan for screening. That plan for screening? It changes year over year as you age. That’s how you do this. Review your plan each year for you. Discuss it with the women in your family. And your friends. Like. Discuss it. Out loud. Over coffee or tea.  Like, “What’s your breast scan plan, Mom?” 

Like that.

It’s not rude. 

No. It’s not.

Happy deciding, everyone.

A Little Olive Oil with Your Workout?

So my medical journals are telling me, AGAIN, that I need I need to eat better and keep moving. Gee, folks, thanks for the news!

But I rarely receive such specific advice as I have these past few weeks. They have handed me very, very clear directions: 

• Eat a Mediterranean Diet including extra-virgin olive oil.
• Exercise 300 minutes a week.

Wait… Really?

Specifically….  for menopausal women… my medical journals are suggesting we do this to avoid breast cancer.

Well! That’s pretty specific! And pretty awesome when scientists are paying special attention to my favorite people!

So let’s look at these studies suggesting ways we just might, through diet and exercise, provide our bodies an optimal environment for fighting off breast cancer. 

The PREDIMED study, published in JAMA, September, 2015, was conducted in Spain from 2003 to 2009, wherein more than 4,000 women at high cardiovascular risk, aged 60 to 80, were randomly placed on three diets: the Mediterranean diet, supplemented with extra-virgin olive oil (first cold-pressed), The Mediterranean Diet supplemented with mixed nuts, or a Low-Fat diet.

The results of this study have been coming out for some time, and have been fascinating. This latest release shows that those on the olive-oil-supplemented diet had a 68-percent lower risk of developing breast cancer than the other participants in the study. It’s one study, of course, and needs to be repeated, but it’s rather fascinating. Earlier outcomes of the PREDIMED study suggested the same diet resulted in a delay in cognitive decline for the same population. There will be more news from this cohort. We will stay tuned. 

By the way, when shopping for olive oil, it is best to stick with first-cold-pressed, extra-virgin olive oil for your good health. It costs a little more, but that’s the healthy choice that this study is based upon. Cheaper oils have been heat-treated or chemically treated, and are no longer a healthy choice for your body. 

The exercise link is a the Breast Cancer and Exercise Trial in Alberta, Canada, published in JAMA Oncology in 2015. The study followed 400 women. Half of them worked out for a half an hour a day, 5 days a week. The other half worked out for an hour a day, 5 days a week. They worked out at 65 to 75 percent heart rate for at least half of their workouts. All without changing their usual diets. The women were overweight, disease-free non-smokers, and they were followed for three years. Subcutaneous and abdominal fat and waist-to-hip ratio decreased significantly more in the high-exercise-volume group.

Since body fat increases postmenopausal breast cancer risk, this suggests this higher dose is a better dose of exercise for us to keep the weight off, the body fat down. Lower body fat is a better environment for lower breast cancer risk. 

So I’m going to take a brisk walk to the grocery store, buy two big bottles of my favorite extra-virgin oil, and do biceps curls with them on the way home. Or maybe I'll just stay a little longer on my treadmill and have a nice salad with dinner. 

Q: As a breast cancer survivor, can I use localized estrogen?

You say you've completed five years of regular tamoxifen, and your doctor has suggested Vagifem 10 mcg to address symptoms of dryness and itchiness. Vagifem 10 mcg is a very, very tiny dose of bioidentical estrogen, delivered as a tablet to dissolve in the vagina. I have many, many breast cancer patients who use it or other "localized estrogen" or "vaginal estrogen" options. Like you, they've had significant issues without it; over the counter creams, lubricants, and moisturizers may have had some benefit, but over time they've not done enough.

From what we know, localized estrogen doesn't enter the blood stream and get disseminated throughout your system; it is absorbed only in the genital area where it's needed. I like Vagifem because the dose is very low and there appears to be consistent absorption. But it is still estrogen, and there is sometimes reluctance to add this to a woman's regimen, especially after breast cancer.

There is a new non-estrogen treatment option for this condition. Called Osphena, it is a SERM (Selective Estrogen Receptor Modulator), the same class of medication as tamoxifen. They both target tissue and affect estrogen activity: tamoxifen targets breasts to block; Osphena targets the vagina to activate. Osphena is oral, daily, and in my practice has been well tolerated and effective. While it's been on the market for two years or so, it has not specifically been trialed in breast cancer patients (and nor have other medications, a reality I hope will change—and soon). There's not yet data on safety for women like you, but other SERMs on the market are favorable for breast health, it makes sense to think this one may be, too.

We don't have all the answers yet, unfortunately! Ultimately, the decision comes down to quality of life for you, and I'm glad it sounds like you have a health care provider who is helping you consider your options.

A Sexy Toolkit for Breast Cancer Survivors

Recovery from a devastating disease like breast cancer is a long and challenging road that frequently involves making peace with lots of change—different bodily sensations, altered abilities, different goals and perspectives. Rather than a return to “business as usual,” recovery is often a process of accommodation.

All that adaptation and accommodation applies to sex as well. Sometimes, the goal is not so much to regain the “before” experience as to redefine, along with your partner, what sex means “after” cancer. To start from now with patience and hope, because whatever your starting point, you will improve. That’s the resounding message from other survivors who have faced the same journey: “Don’t give up,” and “You are not alone.”

As you reconstruct the contours of your life, of which sex is a critical part, here’s a toolkit that might help you get started and might also help sex to be more comfortable.

First, some ideas to consider as you begin to reclaim your sexuality:

Self-image is a huge hurdle for most women who’ve had breast cancer, even after reconstruction surgery. Everything feels different, and sometimes there’s no feeling at all. According to a 2011 study of 1,000 survivors of breast cancer, co-author Mary Panjari, of Australia’s Monash University, found that women with body-image issues (and who doesn’t have issues with body image?) were much more likely to report sexual function problems.

Perhaps it’s comforting to know that, while you struggle with the psychological and physical scars of your illness, for most partners, the way you look isn’t a problem. “In our study, we asked women if they thought their partner felt differently about their appearance and the majority said, ‘No different.’ But the women felt differently about themselves,” says Panjari. Again, you're not alone, and there are steps you can take:

• Consider finding a support group for cancer survivors, and not just for advice on sex. Some women like them; others don’t, but at least give it a try.
• Consider couples therapy. As a couple, you need to figure out a path forward, sexually speaking. He may worry about hurting you or pressuring you. You may be consumed by how you look or experiencing loss of desire and sensitivity, vaginal dryness, numbness. And your medications may exacerbate your condition. Finding a sex therapist who can walk you through these changes could be your best gift to yourself and your relationship.
• Exercise when you feel ready. A regular workout will help you tone muscles, lose weight, and feel stronger and more capable. It gets more blood to your brain and your bottom, and it releases endorphins, the feel-good neurotransmitters in your brain. Simply feeling confident and capable can help stimulate your sex drive.
• Masturbate. This primes the pump. You can get lubrication going and see what feels good where. “Masturbation is a normal form of sexual activity and release,” says Dr. Marisa Weiss, founder of Breastcancer.org. “I tell my patients it's a form of exercise and conditioning for the vagina—which has suffered considerable change and lack of use during breast cancer treatment.”
• Remember: Breasts are only one part of a whole-body experience. Don’t focus on the tree when you have an entire forest to explore.

Now for that toolkit. These are items every postmenopausal woman should have on hand—they’re just more important for breast cancer survivors.

• Vaginal moisturizer. This is for regular, daily use, not just for sex. It conditions the vagina and keeps the tissue healthy and moist
• Lubricant. Use this lavishly in your vagina for extra lubrication during sex.
• Pillows. Lots of pillows for soft support where you need it. If a position feels ouchy, try cushioning the area with a pillow.
• Erotic movies and other scene-setting paraphernalia—candles, incense, music.
• Sexy attire. If you need to start out—or stay—clothed for a while, get sexy lingerie that covers the strategic parts.
• Read the information about vaginal comfort and genital sensation on my website: middlesexmd.com and the very helpful blog posts about sex after cancer by our own medical advisor, Mary Jo Rapini.

   

Lifestyle Choices for Breast Health

You know that silly song about the thigh bone being connected to the hip bone—and so on?

Well, the kernel of truth in the ditty is that, when it comes to health and our bodies, things are indeed beautifully and intricately connected.

You can’t do healthy things for your thigh bone—or your heart or your sex life—and not have it affect other corporal systems as well. So, while we might focus on breast health in honor of Breast Cancer Awareness Month, rest assured that healthy, cancer-free breasts involve habits and choices that are good for the rest of your body as well.

There’s a lot to celebrate when it comes to breast cancer, like steadily decreasing rates since the year 2000. But we still have a long way to go. About 12 percent—1 in 8 women in the US—will develop invasive breast cancer sometime in her life. Our most significant risk factors are 1. being a woman and 2. being older.

Women over 55 account for two-thirds of invasive breast cancers diagnosed each year. This is because, over time, we tend to accrue genetic mutations, and with age we’re less adept at repairing them.

Those are the facts. But we don’t have to helplessly wait for the shoe to drop. We can make lifestyle adjustments that will lower our risk of getting this cancer and improve our overall quality of life, including our sex life. (And don’t forget that a healthy sex life is also good for our health.)

Because it’s all connected, right?

So here are lifestyle changes that you can make specifically targeted toward breast health:

Maintain a healthy weight. Being overweight or obese—those with a body mass index (BMI) over 25—increases one’s risk of developing breast cancer, especially in postmenopausal women. This could be because estrogen is stored in fatty tissue, and women who have more fat are also exposed to higher levels of estrogen, which has been undeniably linked to breast cancer. But other issues related to obesity may also be involved, such as insulin and glucose levels. Some estimates suggest that 17 percent of breast cancers in North America could be avoided simply by maintaining a healthy body weight. Check out this page for a solid, common-sense approach to weight loss.

Eat healthy food. Not only will a healthy diet help maintain a healthy weight, but it’s a critical component to avoiding cancer. Some foods contain properties that help repair the wear and tear to our bodies in the normal course of life. These “super foods” contain antioxidants that help protect our bodies from cancers.

The link between food and cancer isn’t always straightforward or well-understood, and dietary fads change with the season. Basically, though, the approach to healthy eating remains the same: eat a variety of foods with an emphasis on fruits, vegetables, and whole grains. Avoid processed foods. Avoid fats and sugars. Above all, avoid super-sugary beverages, which are directly linked not only with obesity but also with some forms of cancer.

Finally, eat fresh and eat at home. (You can’t control what goes into your food at a restaurant.) Eat organic foods to avoid exposure to synthetic chemicals.

While the voices touting various diets and food fads are myriad, confusing and contradictory, here are some basic food facts from breastcancer.org. The USDA also has a website with tons of food and diet information here.

Exercise. Weight, diet, and exercise. This is the trifecta of good health. Some well-regarded sources say that 30-40 percent of cancers could be avoided simply with these healthy lifestyle choices. That’s staggering. And when you add in quality of life factors that come with the trifecta, well, it’s overwhelmingly worth the difficulty of losing weight, eating well, and exercising regularly, wouldn’t you say?

Regular, moderate exercise can lower your risk of breast cancer. Not to mention all the other good things you get with exercise, such as better mood, cardiovascular and joint health, greater stamina and flexibility, better sleep, better bones, and more regular bowel movements. What are we waiting for?

Even women who have already been diagnosed with breast cancer may improve survival rates or prevent recurrence with moderate exercise, like walking only 4-5 hours per week, according to the American Cancer Institute.

Don’t have time? As the trainers in my exercise video say, “Make time.” It doesn’t matter what your physical ability is right now—just start slow and keep on going.

Don’t drink. Sorry to be a killjoy, but the more you drink, the greater your risk. A woman who has three alcoholic drinks per week is 15 percent more likely to get breast cancer than a woman who doesn’t drink at all. If you’re on hormone replacement therapy or if you’ve already been diagnosed with breast cancer, you should be one of those non-drinking women.

What about that healthy glass of red wine? Sorry, it all counts. The benefit of red wine doesn’t outweigh the risk. If you’ve never had breast cancer, just don’t drink every day, but if you have risk factors, switch to non-alcoholic options.

Don’t smoke. This almost goes without saying. Yes, the major risk is lung cancer, but actively smoking as well as exposure to second-hand smoke increases the risk of breast cancer in premenopausal smokers. Plus, women who smoke have greater difficulty recovering from breast cancer treatment.

Avoid chemical exposure. This is like trying to dodge raindrops, given the chemical soup we live in every day. And most of the chemicals in our environment and in the things we use have never been tested for toxicity or carcinogenic properties. Some types of chemicals are known to be hormone-disrupting, which alter the way our natural hormones function. Research is ongoing about the way these substances work and their link to possible cancers, but the connection isn’t well understood.

In the meantime, how do we negotiate the reality of the world we inhabit without neurotic overreaction but also without putting our heads in the sand? Of greatest concern with regard to breast cancer are those chemical with hormone-disrupting properties, including those in pesticides, growth hormone residues in meat and dairy products, and certain plastics.

In general, some precautionary practices would be to

• Buy organic food. Here’s a list of the “dirty dozen”—the foods that have the highest levels of pesticide residue.
• Plant a garden. Put up your own food.
• Use fewer and simpler cleaning and personal care products. Look for certified “green” cleaning products (with GREENGUARD or EcoLogo insignias, for example) or make your own.
• Don’t use pesticides on your lawn or garden.
• Use BPA-free plastics or glass or stainless steel jars and bottles. Avoid #3 (PVC), #6 (polystyrene) and #7 (polycarbonate) plastics, which are linked to breast cancer.

You may not be able to tackle everything on this admittedly intimidating list, but it’s better to make a few changes than not to do anything at all. And the foundation you lay now will become even more important in maintaining health and functionality as you age.