Dr. Ada Ozoh

Hysterectomy is the second most common major operation performed in the Western world after cesarean section. About 30% of women over 50 in the US have had a hysterectomy. There is a lot of unreasonable fear surrounding this procedure. Some of these fears come from reports from other women who have had a hysterectomy.

These reports depend on their own expectations and preconceptions. When it is performed by an experienced gynecologist and for the right reasons, a hysterectomy can significantly improve your quality of life and even save it!

Reasons for having a hysterectomy

1. Fibroids – this is the most common reason for having a hysterectomy. It may be the only way to treat very large or multiple fibroids.
2. To control uterine bleeding – when it is very heavy, prolonged, irregular and does not respond to non-surgical treatment. In the absence of a tumor, ovarian cyst, infection, pregnancy or endometriosis, this is known as dysfunctional uterine bleeding (DUB). It is often caused by hormone imbalance.
3. Endometriosis – when it is widespread and painful.
4. To treat descent (prolapse) of the uterus – Hysterectomy is recommended when the symptoms are very severe and Kegel exercises or vaginal estrogen have been unable to provide relief.
5. To treat widespread and uncontrollable pelvic infection.
6. Ectopic pregnancy – e.g. in cervical pregnancy or pregnancy outside the uterus where the placenta is attached to the uterus and cannot be removed.
7. To remove cancer in the vagina, cervix, uterus, fallopian tubes or ovaries.
8. To treat some life-threatening conditions affecting organs close to the uterus where treatment is difficult without removing the uterus e.g. cancer of the rectum or bladder.

Types of Hysterectomy

1. Abdominal hysterectomy – this is carried out by making a cut (incision) in the abdomen and removing the uterus. This method is best for extensive painful endometriosis, very large uterine fibroids and cancer. It allows the surgeon to have a better look at the uterus and other pelvic organs. Abdominal hysterectomy recovery time is longer than for the other two types so a longer hospital stay is usual. It also has more complications during and after surgery.
2. Vaginal hysterectomy – the uterus is removed through the vagina. It is ideal for cases of uterine prolapse and for removal of a moderate-sized uterus. This usually has fewer complications than the other two methods.
3. Laparoscopic hysterectomy – here the uterus is removed with a laparoscope. This allows smaller incisions to be made.

Hysterectomies can also be divided into different types based on what tissues and the amount of these tissues that are removed:

1. Subtotal hysterectomy – here only a part of the uterus is removed. This type of hysterectomy is usually done if you want your cervix left behind, or where total removal would cause injury to nearby organs like the rectum orbladder.
2. Total abdominal hysterectomy (TAH) – here the whole of the uterus is removed completely.
3. Total abdominal hysterectomy + bilateral salpingo-oophorectomy (BSO) – here the whole uterus is removed along with both ovaries.

Should normal ovaries be removed during a hysterectomy performed for conditions that are non-cancerous?

Generally, bilateral salpingo-oophorectomy is recommended for postmenopausal women. By this time, the ovaries have stopped functioning and it removes the risk of ovarian cancer.

However, removal in premenopausal women has been more controversial. Ovaries of premenopausal women are still producing sex hormones. Their removal at this time leads to surgical menopause. Note that even if the ovaries are conserved during hysterectomy their function gradually diminish due to reduction of blood flow afterwards. So you will tend to experience menopause several years earlier than you would without a hysterectomy.

On the other hand, if you have a strong family history of breast cancer, your risk of developing breast cancer will be reduced by 50% if both ovaries are removed.

Before your doctor gets to the stage of recommending a hysterectomy for you, usually he/she will have done the following:

1. Taken a complete medical history from you including types of symptoms, their duration and severity.
2. Done a thorough physical examination which may include a vaginal exam.
3. Done some tests to confirm his/her diagnosis.

Your doctor should tell you clearly and in simple language:

1. Why he/she is recommending the operation.
2. The risks, benefits and side effects
3. How long the operation will last
4. Recovery time after a hysterectomy and when you can get back to your normal activities
5. Whether or not your ovaries will be left behind and why
6. Whether you will need hormone replacement
7. Which type of hysterectomy is suitable for your condition
8. Effects on your sex life
9. Any feasible alternatives to hysterectomy

Make sure your partner, a close friend or family member is involved in the discussion. They should ask questions and clear their own doubts. Ultimately, it is your decision. Never go through with a hysterectomy until you are satisfied that you have enough facts to make an informed decision.

If your doctor is impatient with, or cannot answer your questions convincingly, then you’ve got the wrong surgeon. Try and get a second opinion.

A hysterectomy done for the right reasons by a good surgeon can dramatically improve your quality of life. Think of it positively as a the solution for your troublesome symptoms. It doesn’t make you less of a woman, it doesn’t make you less attractive. You’re still exactly the same woman except that you don’t have a uterus anymore.

Hysterectomy side effects include

1. excessive bleeding
2. damage to nearby organs e.g. bladder, gut
3. infection
4. pulmonary embolism
5. vaginal dryness especially if your ovaries have been removed

You are more likely to develop side effects of a hysterectomy:

1. if you are obese
2. if you are having a hysterectomy because of cancer
3. if you have any medical condition e.g. diabetes
4. the older you are, the more likely you are to develop complications.

Death resulting from side effects of a hysterectomy are rare in most good centers in the US, about 1-2 per thousand surgeries, and none in some cases. Complications may occur in about 25% of women undergoing vaginal hysterectomy and 50% of women undergoing abdominal hysterectomy.

Some hysterectomy side effects are minor while others are life threatening.

There has been a lot of concern about decreased sex drive and difficulty in achieving orgasms even when the ovaries are intact. Studies have shown no difference in sexual or bladder function after a simple hysterectomy for non-cancerous disease.

Laparoscopic Hysterectomy

Traditional hysterectomy involves a large abdominal incision to locate the uterus and remove it or all of its parts. Depending on the need and severity of the condition, the ovaries and cervix may or may not be removed. Hysterectomy is a procedure that should serve as a last option when the patient has not responded to other treatment protocols.

With today’s advancements in medicine, a less invasive form of hysterectomy, called laparoscopic hysterectomy is now another option for surgery. This type of hysterectomy is done by creating 4-5 small abdominal incisions where tubes are inserted, guided by a lighted tube called laparoscope which serves as the camera for viewing the uterus from outside the body. Surgical tools and instruments are inserted through the openings, then the uterus is cut into pieces and removed through the tubes. The operation is performed under general anesthesia with an endotracheal tube in place.

Laparoscopic Hysterectomy Pros and Cons

A number of advantages have been found with laparoscopic hysterectomy over traditional abdominal hysterectomy:

• Less invasive than abdominal hysterectomy
• Faster healing and recovery time
• Shorter hospital stay
• Minimal pain and blood loss
• Best suited in cases where the cervix may be left intact
• Leaves smaller abdominal scars

On the other hand, there are drawbacks associated with a laparoscopic hysterectomy:

• Because the procedure is quite recent, it can be challenging to find an experienced surgeon
• Can be very costly compared to abdominal hysterectomy
• May not be an advisable method in removing a very large uterus
• Patients with cancer or bad pap smear histories are not good candidates for this type of hysterectomy
• The procedure is longer to perform than abdominal hysterectomy
• Risk for injury when done by an unskilled surgeon

Removing the uterus is a very tough decision to make, especially for a woman in her childbearing years. It may affect femininity, sexual function, and cause emotional disturbances. Before consenting for a hysterectomy, you should explore all possible alternatives with your gynecologist, and seek second opinion if needed. It is also vital to understand the extent of the uterine removal, as to whether the cervix, ovaries, and other parts should be removed as well. As with any other types of surgeries, you should find a highly competent surgeon to perform the task to avoid possible complications. In addition, although laparoscopic hysterectomy is something to consider as an alternative, you should realize that this procedure is not right for everyone. Ask your doctor for advice if you are a candidate for this type of operation.

Hysterectomy or uterine artery embolization?

Most women have heard of hysterectomy, being removal of the uterus, for treating uterine fibroids but many may not be familiar with uterine artery embolization (UAE). This is a procedure where arteries leading to the fibroids are blocked so that the fibroids effectively starve and shrink. This procedure can be used on its own to treat fibroids but can also be used to shrink very large fibroids before carrying out a hysterectomy.
UAE has advantages and disadvantages compared to conventional hysterectomy.

Advantages of uterine artery embolization

• it has fewer complications
• it takes less time to recover from the procedure compared to hysterectomy

Disadvantages of uterine artery embolization

• it was less effective at curing symptoms associated with fibroids
• women were more likely to require further treatment for their symptoms, including a hysterectomy in some cases

In spite of these disadvantages, women were more likely to recommend UAE to their friends than a hysterectomy. UAE will definitely be popular among working women considering the shorter recovery time compared to hysterectomy.

 

Of all the discomforts and inconvenience, both big and small, you may experience during menopause, one of the most important is osteoporosis.

What is osteoporosis?

Osteoporosis is a condition in which there is less normal bone than expected for a woman’s age, with an associated increase in the risk of fractures. Essentially, the bones develop lots of holes in them which makes them weaker even though they still look normal on the outside.

What causes osteoporosis?

Bone tissue is being destroyed and reformed continuously in your body. A balance has to be maintained between the osteoclasts (which break down bone) and the osteoblasts (which make new bone). Estrogen plays an important part in the production of new bone. In the absence of estrogen bone is broken down and not replaced. Calcium is the substance that gives bone its strength. Estrogen helps in transporting calcium from the blood and keeps it in the bone. In the absence of estrogen, calcium moves from the bone back ito the blood. The end result- weak bones that are full of holes!

What increases your risk of getting osteoporosis?

1. Low bone density – From the moment you are born, new bone is being deposited in your body. This continues until you are about 35 years old when laying down of bone stops. At this stage, you have achieved your peak bone density. If it is low, then you have a greater risk of developing osteoporosis.
2. Premature menopause If you experience menopause before the age of 35 years your bone loss will start earlier than in a woman who has menopause at 45.
3. Removal of the ovaries and uterus  If you have had your ovaries removed for any reason, within a few years, you may develop osteoporosis. Even if your uterus is removed without the ovaries, you still have an increased risk of developing osteoporosis compared to a woman who has both uterus and ovaries intact.
4. Smoking  Apart from the many health hazards associated with smoking, it does not allow the body to taken in as much oxygen as it needs, which makes bones weak. Also, if you’re a heavy smoker, you run the risk of reaching menopause up to 5 years before a non-smoker.
5. Drugs  Medication used for some health conditions such as asthma, can lead to osteoporosis if taken in large quantities for a long time.

What are the features that suggest you might have osteoporosis?

Fractures
If you fracture your hip, wrist or spine after a minor fall e.g. tripping over something in the house, you may have osteoporosis, especially if you are over 40. It is usually not suspected or diagnosed in the early stages. By the time you have a fracture, you may have lost 1/3 of your bone mass.

Backache
If you have constant severe backache this may be due to a spinal fracture. Many tiny fractures of the bone cause them to collapse. This causes pressure on the nerves and leads to pain. This is also the cause of “Dowager’s hump” which is common in post-menopausal women. Collapse of the bones of the spine causes the curvature of the upper spine which gives the appearance of hunching over and causes loss of height.

Tests used to detect Osteoporosis

1. bone density test – This is a simple test similar to an x-ray that can be carried out in a hospital x-ray department or a clinic and assessed by a radiologist. It measures the thickness and strength of the bones. Usually the spine and femur (thigh bone) are measured. This test can be used:
   • to detect osteoporosis for the first time and
   • to measure if the condition is worsening or improving, especially if you are receiving treatment.
   Bone density scans should be done around the time of menopause to help predict the likelihood of developing osteoporosis. This is important because up to 1/3 of your bone may have been lost by the time you develop symptoms. Bone loss is fastest immediately after menopause and gradually slows sown over the years, by which time the bones have undergone a lot of damage.
2. ultrasound – Ultrasound of the heel can give an idea of the health of other bones in the body.

Osteoporosis Treatment

Hormone replacement therapy (HRT)
This is the most potent medical treatment to stop bone loss and encourage new bone deposits. Estrogen with progesterone acts to slow calcium loss from the bones and increase it’s absorption from the intestines. In low doses, estrogen slows down bone loss but at higher doses can actually help increase bone mass.

Selective estrogen receptor modulators
These have the same benefits as estrogen by slowing down bone loss.

Complementary therapies
These include acupuncture and TENS ( transcutaneous electrical nerve stimulation).

Pain management

1. Physiotherapy in the form of exercises to increase muscle strength and tone also help to relieve pain. Exercising in a water pool is very helpful as it allows an increased range of bodymovement because the water supports your body and bears your weight. Physiotherapy may also involve the use of ultrasound and electrotherapy.
2. Medication used for pain relief ranges from paracetamol and codeine to the more potent morphine. It is recommended that you take the lowest dose of the least potent painkiller that gives you relief from pain. Paracetamol is safe at recommended doses and non-addictive (unlike codeine and morphine).

Preventing osteoporosis

Osteoporosis prevention starts well before the menopausal years, during your late teens, 20s and early 30s, when preventing osteoporosis is the last thing on your mind.

Peak bone mass

Peak bone mass (PBM) is the amount of tissue in your bones when they are at their most dense. The higher your peak bone mass, the less likely you are to develop osteoporosis.

What affects your peak bone mass?

• If you spend much of your 20s and 30s being a couch potato, you are more likely to develop osteoporosis. Exercise (especially the weight-bearing type like walking and climbing stairs), increases PBM.
• Early onset of menstruation and late menopause are associated with increased PBM.
• Having several pregnancies increases PBM.
• If you use oral contraceptives for a long time your PBM will be increased.
• Healthy diet – you need lots of vitamin D and calcium for strong healthy bones.

Measures for osteoporosis prevention and reduction

Diet

You need a diet high in calcium and Vitamin D which helps the calcium to be absorbed into the body. If you aren’t getting enough calcium in your diet, you may need supplements.

Exercise

At least 30 minutes of weight-bearing exercise e.g. walking up stairs 3 times a week markedly reduces your osteoporosis risk. Walking is good general exercise because it helps posture which helps to maintain balance. This is important to prevent falls which may lead to fractures.

Do you need HRT?

HRT is probably the most effective way or preventing osteoporosis by maintaining bone mass.
However, it is not efective in some women. You may be wary of taking HRT because of the much-publicized side effects. Some women abandon HRT after only a few months.

It is important to discuss all the options available to you with your doctor. Often, adjusting the dose or the way the hormones are taken can significantly improve the side-effects without canceling out the advantages.

As menopause approaches, many women begin to worry about osteoporosis and how to prevent it.
This is something to be concerned about because the drop in estrogen production which occur after menopause causes an increase in bone loss leading to fragile bones.

Factors which increase the risk of developing osteoporosis include:

1. low bone density (thickness of your bones) at the time of menopause
2. smoking
3. premature menopause
4. removal of the ovaries and uterus
5. drugs (e.g. some asthma medications)

After menopause, bone loss is almost inevitable, so at this point, you’re trying to reduce the rate at which it is lost, and if possible reverse the loss.
The WHI (Women’s Health Initiative) trials on the effects of hormone replacement therapy also included a trial on the effects of Calcium and Vitamin D supplementation on:

1. the risks of suffering hip fractures and other fractures which are strongly associated with osteoporosis,
2. bone density and
3. the risk of getting colorectal cancer.

The 36,252 women who chose to take part in the Calcium/Vitamin D (CaD) trial were randomly assigned to two groups:

• one group taking a pill containing 500mg of Calcium and 200IU (IU =international units) of Vitamin D twice a day (a total of 1000mg of Calcium and 400IU of Vitamin D daily)
• the other group receiving an inactive placebo.

Overall:

1. women taking CaD had 12% fewer hip fractures
2. they had slightly fewer fractures overall but the difference was not significant
3. women who took their pills regularly had 29% fewer fractures than the placebo group
4. women 60 years and over had a 21% decreased risk of hip fracture compared to women over 60 in the placebo group
5. women on CaD had slightly increased bone density
6. they also 17% more kidney stones
7. there was no difference in the occurrence of colorectal cancer between the two groups

It is important to note that many of the women enrolled in the CaD trial already had a lower risk of developing hip fractures than women in the general population because:

1. most were on hormone replacement therapy which reduces the risk of developing osteoporosis
2. many already had a high personal intake of Calcium and Vitamin D
3. most had higher than average weight which also tends to reduce risk

These observations may explain the fact that there wasn’t much difference overall between the two groups. It is possible that differences may be greater in women who are not on hormone replacement therapy.

What does this mean for women worried about osteoporosis

1. Women over 50 should take a total of 1000 – 1200mg of Calcium and 400 – 600IU of Vitamin D a day.
2. Calcium and vitamin D are more effective when they are taken regularly.
3. Lifestyle changes that can help include :
   • eating a low fat, high fibre diet
   • carrying out weight-bearing exercise (e.g. walking and climbing stairs). The benefits of exercise aren’t limited to helping to reduce bone loss. Women who exercise have better posture and balance and are less likely to fall in the first place and so tend to have fewer fractures.

Burning questions

• What is the most common cause of sore breasts and nipples?
• Why do my breasts (boobs) hurt?
• Are tender nipples a sign of PMS?
• Are sore breasts and nipples a sign of cancer?
• Why do I have sensitive nipples during my period?
• Why does one breast hurt and not the other?
• My breasts are sore – am I pregnant?
• Is it normal to have sore breasts with mood swings?
• Why are my breasts sore? I’m menopausal.
• Are sore breasts after ovulation a sign of low progesterone?
• Can HRT cream cause breast soreness?
• What are the causes of tender breasts and nipples apart from pregnancy?

These are just some of the questions I get asked about breasts when I talk to other women. I used to be completely baffled by this because I couldn’t understand why they didn’t ask their own doctors all these questions. When I asked them the answers I got usually went something like:

• I felt too embarrassed to bring it up.
• I felt silly asking him these questions.
• He is usually in a bit of a hurry so I didn’t bother asking.
• He said my mammogram was normal and prescribed some painkillers.
• He said there was nothing to worry about, but I’m still worried.
• I saw my doctor about the pain but it was a complete waste of time.

I hope what you’re about to read will give you some answers and help you to understand more about breast pain.

What is breast pain and what causes it?

Breast pain is the most common breast complaint affecting women of all ages. If you’re reading this, the chances are that you are among the 70 percent of women who will experience sore breasts to some degree, at some time in their lives. Breast pain is also known as mastalgia or mastodynia.

Structure of the breast

The female breast is also known as the mammary gland. Several different types of tissue make up the breast. They can be broadly divided into two groups:

• Tissues involved in milk production and transport – the lobes, ducts and alveoli; and
• Tissues which support and feed the breast – connective tissue, ligaments, fat, blood vessels, lymph vessels and nerves. The amount of fat in the breasts determines how large they are.

Types of breast pain

Pain in the breast can basically be divided into two groups:

• Cyclic breast pain; and
• Non-cyclic breast pain.

Cyclic breast pain

Cyclic breast pain may start up to two weeks before your period
Cyclic breast pain is the most common type of breast pain. About two-thirds of breast pain is cyclic, and it occurs in relation to your menstrual cycle. It can occur at any age once you start having periods, but it is most common between the ages of 30 and 50. For this reason, it doesn’t occur naturally in women who have gone through menopause and are no longer having periods. If you have gone through menopause and you are using hormone replacement therapy (HRT), you may also experience cyclic breast pain.

How will you feel if you have cyclic sore breasts?

• You may experience mild discomfort in both breasts as your period approaches. One in ten women has pain that is severe enough to interfere with their day-to-day activities. The pain may start up to two weeks before the onset of the period. The few days before the period are usually the worst, and the pain gradually subsides after your period starts. For some women, the pain may last throughout the cycle and then worsen as the period gets closer.
• The severity of the pain may be different from month to month. In some months you may experience mild discomfort, and in others you may have severe pain.
• The pain in your breast may be constant or on and off. Your breasts may feel very full or heavy, aching or sore, or you may feel as if you have a fever in your breast. The pain may extend into your armpits and down your arm. You may find it uncomfortable to sleep on your tummy, wear a bra, hug someone or have your breasts touched while you are making love.
• Your breasts may feel generally lumpy, but you may not be able to identify a single, specific, large lump. The texture of your breasts usually returns to normal after your period starts.
• Your nipples may feel very hard and sore and uncomfortable to touch.
• You may feel the pain in only one breast.
• Pain usually stops during pregnancy and after menopause. However, some women still have breast pain during pregnancy and menopause, but it is non-cyclic.

What causes and/or worsens cyclic breast and nipple pain?

Various theories have been suggested as to the cause of cyclic breast pain. The most popular ones are:

• Low progesterone levels compared to estrogen in the second half of the menstrual cycle: It has been suggested that there is an imbalance between the levels of progesterone and estrogen after ovulation, with the effects of the estrogen outweighing those of progesterone. This idea is known as estrogen dominance and was made popular by Dr. John Lee, a Harvard-trained medical doctor and strong advocate for the use of natural, bio-identical hormones. Apart from sore breasts, other symptoms of estrogen dominance are said to be:
  • irregular periods,
  • irritability,
  • mood swings,
  • bloating,
  • low sex drive,
  • memory loss,
  • migraine headaches,
  • hair loss,
  • weight gain,
  • tiredness and
  • sleeplessness
• Abnormalities in prolactin levels: Prolactin is a hormone that is produced in very large quantities in pregnant and nursing mothers. It stimulates the breasts to produce milk. Abnormalities in the prolactin levels in the body can lead to breast pain.
• Stress: Several hormones in the body are made from progesterone, including cortisol. When you are under a lot of stress, your body converts more progesterone into cortisol to help you handle the stress. This leaves your body lacking in progesterone. This is known as the “progesterone steal.” The more stress you’re under, the less progesterone you have to take care of your other body functions.
• Over-sensitivity: It is possible that the breasts of some women are more sensitive to hormonal changes than others. This may be due to an imbalance in the fatty acids in the breasts.
• Drugs: Breast pain may be worsened by hormones (birth-control pills and injections, hormone replacement therapy, drugs used for infertility), drugs used for hypertension and heart conditions (digoxin, spironolactone, and methyldopa) and antidepressants (chlorpromazine).

Cyclic breast pain and Premenstrual Syndrome

Cyclic breast pain is usually one of a group of symptoms collectively known as Premenstrual Syndrome or PMS. PMS can be grouped into several different types based on the group of symptoms you experience each month.

TABLE

If you have cyclic sore breasts then your symptoms may belong to the PMS H (hydration) group with breast tenderness, bloating, weight gain and excessive storage of water in the body. It is possible to have symptoms from more than one group in this classification e.g. groups H and C.

Non-cyclic breast pain

Non-cyclic breast pain is pain in the breast and/or nipple that is not related to your period and that doesn’t have any particular pattern. About a third of women who have breast pain have the non-cyclic kind.

How will you feel if you have non-cyclic sore breasts?

• The pain may be continuous or may come and go.
• The pain may be felt in both breasts, one breast or even a specific part of one breast.
• Pain may extend into the armpit and down the arm.
• The pain may be described as burning, aching, drawing or pulling, or as heaviness in the breast.

Causes of non-cyclic breast pain

The source of the pain may be from within the breast itself or from structures close to the breast.

Pain from the breast

• Puberty: During puberty, breast pain may occur in both boys and girls, due to hormonal changes.
• Pregnancy,
• Breast feeding,
• Menopause,
• Breast cysts: A cyst is a localized collection of fluid. Pressure from the cyst pressing on surrounding tissues and nerves may lead to pain.
• Infections of the breast (mastitis): Mastitis may occur during breast-feeding (breast-feeding mastitis), or at other times. If you have mastitis, you may experience the following symptoms:
  • Pain in the breast,
  • Redness of the skin,
  • Warmth in the breast,
  • Breast swelling,
  • Body aches,
  • Extreme tiredness, or
  • Fever and chills.
• Breast abscess: This is a collection of pus in the breast and is usually a result of infection. You may experience the following:
  • A painful, mobile lump in the breast (if the abscess is very deep within the breast, you may not be able to feel it),
  • Pus draining from the nipple, or
  • Fever and other symptoms that have not improved 72 hours after starting treatment for mastitis.
• Tumors of the breast: Non-cancerous growths in the breast may cause pain due to compression. The most common non-cancerous growth is fibroadenoma.
• Shingles may cause breast pain before the rash appears.
• Previous breast surgery: This may leave scar tissue that causes persistent pain

Pain from outside the breast

• Tietz’s syndrome: This causes inflammation of the joints where the ribs meet the breastbone (costochondral junction). Pain is felt deep within the breast.
• Gastro-esophageal reflux disease (GERD): Acid that is regurgitated back into the lower esophagus (food tube) from the stomach can cause pain that may be felt in the breast.
• Angina
• Arthritis of the spine
• Hiatus hernia
• Nerve entrapment syndromes, such as carpal tunnel or cervical rib, where the nerve is compressed against bone leading to persistent pain.
• Gallstones
• Chest infection

Sore breasts in pregnancy

Many women experience breast pain in pregnancy
Many women will complain of discomfort in the breasts when they are pregnant. It is possible to start feeling pain, tingling or swelling in the breasts even before you confirm that you are pregnant. When you are pregnant, a lot of hormonal changes take place in your body. You produce large amounts of estrogen and progesterone. This is similar to what happens between ovulation and your period. The difference is that in pregnancy the hormone levels are much, much higher. This helps to prepare the body for pregnancy and nursing.

Changes in the breasts during pregnancy

The breasts usually get bigger, increasing by several cup sizes for some women. The increase in size is due to:

• Fat being stored in the breast,
• Milk glands becoming larger and more developed, and
• Blood vessels increasing in number and becoming larger. This accounts for the blue or green lines (which are actually veins) that you may see just under the skin on your breasts.

Your nipples become larger and darker, and you may also notice small bumps on the areola or flat part of the nipple; these are called Montgomery’s tubercles. You may also notice a yellowish fluid leaking from your nipples towards the end of your pregnancy; this is called colostrum or the first milk. On the other hand, you may find that your breasts change very little during pregnancy.

This does not mean that you are abnormal or that you won’t be able to breastfeed your baby. Every woman’s body is unique and different. Breast and nipple soreness tend to be worse in the first three months (first trimester) of pregnancy, causing some women to avoid lovemaking at this time. For some women, the discomfort may appear on and off at the beginning of pregnancy, whereas for others, sore breasts may persist throughout pregnancy.

Sore breasts during breast-feeding

Sore breasts and nipples can be very alarming and may give rise to a lot of anxiety, even if you have nursed before. The commonest causes of sore breasts during breastfeeding include:

• Milk let-down reflex: In the first few days of breast feeding a new baby, you may feel pain deep inside the breast when your baby is feeding. This may be felt as a tingling, or a feeling of heaviness or pain. This is a result of the milk let-down reflex or milk ejaculation reflex. When your baby suckles, the hormone oxytocin is released. This makes the muscles lining the ducts of your breast squeeze out milk.
• Breast engorgement: In the first few days after your baby is born, your breasts may feel swollen, hot and painful. Large amounts of milk are produced to make sure the baby is well fed. Large amounts of blood flow to the breast, and the milk producing cells become enlarged. All this makes it difficult for the milk to leave the breasts. As the baby starts to nurse and the breast empties, milk production stabilizes and the engorgement subsides.
• Plugged milk ducts: Milk flows through passages in the breasts called ducts. Sometimes a duct becomes blocked and milk cannot flow freely. The skin over the affected area may or may not be red, and you may feel a lump where the milk has accumulated.
• Infection of the breast, or mastitis: This usually arises from a blocked milk duct that has not been treated. Symptoms include:
  • generally feeling unwell or feeling run down,
  • fever,
  • chills,
  • redness of the skin over the breast and
  • severe pain in the breast.

You should see your healthcare provider if pain and fever lasts for more than 24 hours.

Sore Breasts and Nipples after Menopause

Hot flashes and night sweats are common menopause symptoms but you may also experience sore breasts.Sore breasts and nipples are a very common complaint in women who have gone through menopause. With the prominence given to hot flushes and night sweats in particular, sore breasts don’t get much attention. To make things worse, you may not find much information on breast and nipple soreness after menopause.

What causes sore breasts after menopause?

The exact cause is unknown, but it is most likely linked to hormonal imbalance. A large part of the progesterone in your body is produced by the corpus luteum after ovulation. When there is no ovulation and you are no longer menstruating after menopause, your body no longer gets progesterone from that particular source; in fact, your progesterone levels may be as low as 1 percent of the pre-menopausal level.

In contrast, estrogen is produced in the ovaries, adrenal glands and fat cells. This means that even when you go through menopause, your estrogen levels may be as high as 50 percent of the levels before menopause. Even though both progesterone and estrogen are reduced after menopause, there is an imbalance because progesterone levels are so low. Without a corresponding level of progesterone to oppose its action, the body is set to be in a state of estrogen dominance.

Visiting your doctor or healthcare provider

If you have sore breasts make sure you see your doctor or healthcare provider
If you have any doubts whatsoever about your health, you should always see your healthcare provider. However, you should visit your healthcare provider as soon as possible if you experience any of the following symptoms:

• A suspicious lump in your breast,
• Abnormal discharge from the nipples,
• Redness,
• Swelling,
• Severe pain, or
• Changes in the skin over the breast.

To help your healthcare provider to make a diagnosis, it’s usually a good idea to keep a pain diary or a pain chart, on which you should mark the days when you experienced breast pain and the days when it was worse than others. You should also record anything else you notice about your health. This will help guide your healthcare provider in making a diagnosis.

Questions your doctor may ask you

• Which part of the breast you feel the pain in,
• How long you have had the pain,
• What the pain feels like,
• Times when the pain gets better or worse in relation to your period and in relation to anything else,
• Your menstrual history,
  • How often you see your period,
  • How many days it lasts,
  • Whether your flow is heavy or light,
  • Whether you have period pains and
  • Whether you have noticed any changes in your cycle recently.

These questions are usually asked to determine if your pain is cyclic or non-cyclic. The doctor will also ask you about:

• Any medication you are taking,
• History of illness in your family and
• Your personal habits (e.g., smoking, your alcohol consumption, etc.).

Other things your doctor may do

Always see your doctor for persistent breast pain
After doing a general examination, your doctor will examine your breasts. She will look for:

• Differences in size and shape, and abnormalities of the skin over the breast,
• Redness or pitting of the skin,
• Differences in the levels of the nipples,
• Warmth of the breast,
• Lumps in the breast,
• Discharge from the nipple, and
• Tenderness of underlying muscle or the surrounding ribs and breastbone.

If she cannot find any specific condition that is making your breasts sore, she will tend to reassure you. She might also prescribe some pain killers and orders some tests. These will usually include:

• a mammogram (an x-ray of the breast),
• an ultrasound scan, and possibly
• a pregnancy test