What do I need to know about breast cancer and how would a mammogram benefit me?

For the last several years October has been recognized as Breast Cancer Awareness Month. As a major health problem—the second leading cause of cancer in women with over 200,000 cases diagnosed each year—this attention is warranted. Many women, however, experience fear out of proportion to their actual risk and often avoid routine screenings. We would like to put the risk of breast cancer into perspective and to emphasize the benefits of screening and the effectiveness of treatment.

As already noted, the incidence of breast cancer is second only to lung cancer in this country. As a treatable disease, however, it ranks as one of the most favorable. For example, as a reflection of treatment, 5-year survival rates are often examined. In regard to lung cancer, this number is 15%; for breast cancer, 86%. And for the last decade or more this percentage has been improving. The reasons for this are found both in mammogram screenings and in advances in treatment.

Mammography has repeatedly been shown to decrease the mortality rate in breast cancer. Compared to women who don’t have regular mammograms, those that do, decrease their risk of dying from the disease by 25-30%. Indeed, in a recent study out of Sweden published in the journal Cancer, researchers found a 45% risk reduction. The reason is that mammography can find breast cancers that are much smaller than what a person can suspect by touch alone; some people estimate they are found 1-2 years before they will be identified by a woman or her healthcare provider. Smaller cancers are more curable as they are more likely to be localized to the breast and not to have spread elsewhere in the body.

Another benefit of screening mammography is that it finds precancerous lesions, most commonly what is called ductal carcinoma in situ or DCIS. Identification and treatment of these lesions probably prevents many cases of breast cancer.

It is estimated that approximately 2/3 of the recent reduction of breast cancer mortality is attributed to better screening; the other 1/3 is felt to be due to improved treatment. This emphasizes the need for all women to have regular screening. We added a state-of-the-art GE mammography unit to our practice as soon as we moved to our facility here at Griffin Road three and a half years ago. Our goal was to improve ease of access for women, hoping that more women would have it performed if they could have it done at the same time as their annual exam. We provide a quiet, private area; experienced sensitive mammography technicians; and a commitment to maintaining an accredited facility.

If you or anyone you know needs a mammogram, and all women over the age of 40 are advised to have regular screening, then please call us today. It truly can save your life.

HRT and Breast Cancer Risk

The week of July eighth saw headlines in all the news media advising women taking Prempro to stop immediately and consult their health care providers because of new evidence that this form of hormone replacement therapy (HRT) causes breast cancer. For the last several years there has been an ongoing debate in the medical literature as to whether HRT, in particular, estrogen therapy, increases a woman’s risk of developing breast cancer and, if so, to what degree. So why did this new evidence make the headlines and what are the researchers really saying?

Members of the research team running a study called the Women’s Health Initiative (WHI) released this information. The study began about five years ago and involves over 16,000 postmenopausal women. This is a randomized placebo-controlled drug study meaning the women were randomly assigned to receive either a form of hormone therapy or a placebo. Hormone therapy consisted of Prempro (an estrogen [Premarin] and a progesterone [Provera]) in women who had not undergone hysterectomy, and Premarin alone in those who had. The main goal of the study was to see if HRT decreased the risk of heart attacks and/or increased the risk of breast cancer. Other outcomes such as the risk of clotting and colon cancer were monitored as well.

Over the course of the study, the researchers periodically reviewed the data. At the beginning of the study they had set what they considered acceptable risk cut-off points for the adverse outcomes, that, if exceeded, would trigger termination of the study. For example, a slight increase in the risk of heart attacks had been noted earlier in the study, but at a level below the predetermined cut-off value, so the study continued. When the researchers looked at the results available as of April 2002, they noted an increase in the number of cases of breast cancer in the group taking Prempro that had not been previously seen. The number of cases in the treated group exceeded the limit so the decision was made to terminate the study. They claimed that the patients receiving the HRT had a 26% increased risk for developing breast cancer. News media reports covering this study included alarming quotes from various physicians such as “…long-term use of this therapy could be harmful…”;”…there is really no safe period…”; and “…this is a dangerous drug….” While the researchers were advising caution and asking women not to get alarmed, coverage of the study certainly had the opposite effect.

While this was clearly a well-designed, valuable study, several points need to be emphasized:

  • Other studies have looked at the same question (re: breast cancer risk) and have come to different conclusions. For example, another ongoing randomized study (HERS) that used the same drug could not demonstrate a statistically increased risk of breast cancer in the treated group over almost 7 years of follow up. The most recent update of this study was published in the same medical journal as the WHI study two weeks earlier (JAMA, 3 July 02) and it failed to make headlines.
  • The arm of the WHI study that involves 11,000 women taking Premarin alone is continuing, as there has been no increased risk of breast cancer noted in this group.
  • While the increased risk was quoted as 26%, this is misleading as this refers to what is called relative risk. The actual increased risk they noted was from 3.0 breast cancers per 1000 women in the placebo group to 3.8 in the Prempro group. According to the researchers, for an individual woman, this translates into an increased risk of approximately one-tenth of 1% per year of treatment.
  • There are several other forms of estrogen and progesterone used for HRT. None of these were evaluated in this study and the risk profile for these drugs could be quite different.
  • There remain well-established benefits of HRT including decreased risk for osteoporosis and bone fractures, decreased risk of colon cancer, and well-defined cognitive effects including possibly a lower risk of Alzheimer’s Disease. On the other hand, HRT seems less to be the fountain of youth it was once purported to be.

Harbour Women’s Health sponsored educational seminars three and four years ago addressing “Alternatives to Traditional Hormone Therapy.” We have never felt HRT was a cure all, but neither do we feel it has no place in the treatment of menopausal symptoms.

It has always been the policy of Harbour Women’s Health to discuss the use of HRT in the context of risks versus benefits. This is an individual decision that should be made with careful consideration of all the information available at the time. With the publication of the WHI results, this information has changed. However, it is our opinion that the issue remains complex, that the information will continue to evolve as more research is done, and that it is unlikely we have heard the last word on HRT.

I am planning on going back to work after having my baby and I want to continue breastfeeding. Can you tell me a little about preparing for such a decision?

Breastfeeding is often a satisfying and rewarding experience for you and your baby. It provides your baby with the many nutritional benefits only found in breast milk, protects your baby from colds and illnesses, and promotes weight loss in mothers. It is important to feel supported and positive in your endeavor to breastfeed your baby and women who return to work while still breastfeeding often face unexpected challenges.

Fortunately, women have wonderful options at hand and breastfeeding and returning to work no longer needs to be problematic. Not only is returning to work grounds for wondering how to continue breastfeeding, but the simple desire for wanting someone else to feed the baby at night, or going out to dinner are also reasons for women looking for an alternative. Breastpumps can be a wonderful way to incorporate breastfeeding into your busy schedule.

Several kinds of pumps are available and it’s important to select the pump that’s right for you and your unique situation. Handheld pumps are inexpensive but can be very time consuming, uncomfortable, and are often less effective than electric pumps. Battery-operated/mini-electric breastpumps allow you to pump one breast at a time. Many women find battery pumps noisy and uncomfortable to use which can lead to a decrease in the amount of milk expressed. High-grade electric breastpumps are very popular for they allow you to express both breasts at the same, are efficient, and easily portable. Although they are more expensive than manual or battery pumps, most women find them quick, easy, and comfortable to use. They are a great value for mothers who are returning to work part-time, or for mothers who wish to pump on a daily basis. Hospital grade electric breastpumps are the most efficient pumps available. They are particularly effective for women who are returning to work full-time, those who have low milk supply, or those who are exclusively expressing and giving their baby breast milk in a bottle. Renting a high quality, hospital grade breastpump allows you to express both breasts at once and saves you time and money.

In addition, breast milk is hardy, and once pumped needn’t be consumed immediately— another advantage for the busy mom. Breast milk can be kept at room temperature for 6 to 10 hours, placed in the refrigerator for 5 to 7 days, and stored in the freezer for 3 to 6 months. Frozen breast milk can be thawed in the refrigerator overnight or warmed under hot water. (Do not thaw or warm refrigerated milk in the microwave for it can destroy enzymes that protect your infant.) This storage benefit is helpful in that moms can pump an excess supply and keep it in the freezer for those unexpected occasions when she might need to have a bottle for her baby.

If you’re thinking about renting or purchasing a breastpump, our certified lactation consultant, Jan Archambault, is available to help you select a pump that will best meet your personal needs. A mother of three breastfed children, and with 15 years experience as a maternal/child nurse and lactation consultant, Jan provides practical solutions to breastfeeding problems. She is available to women to help them learn about the benefits of breastfeeding and how best to work this rewarding commitment into a busy lifestyle. She offers a monthly prenatal breastfeeding class, is available for private consultations in our office, offers Medela breastpump rentals, and sells breastfeeding supplies.

For further information, please call Harbour Women’s Health to speak to Jan or to one of our other providers at 603.431.6011.

“I feel very little interest in sex, and my partner has more desire than I have for sex. Why is this happening to me and is it normal?”

A woman’s desire for sex, or “libido” is multifactorial and complex, and can vary across the life cycle. The issue of low libido is a common and often disturbing concern, and is the most frequent sexual complaint in women (differentiated from, but not to exclude, problems in sexual arousal or orgasm). While there is no such thing as a “normal” libido, if you feel that your desire for sex is less than you would like it to be, or if your intimate relationship is strained by this issue, you are not alone. Most women experience diminished desire for sex at some point in her life. However, you may consider exploring the issue further. Very frequently, an underlying cause or causes may be identified, and then addressed to positively change a person’s sexual desire and satisfaction.

Basically, the cycle of sexual response includes desire, arousal, and orgasm. Many different factors can impact any of these areas of sexual response. Possible red flags may include the following: an underlying medical condition (such as hypertension, heart disease, diabetes, or thyroid disorder), side effects of medication (for instance, SSRIs which include Prozac, Zoloft, and Paxil), stress, relationship/intimacy struggles, a history of sexual abuse or trauma, painful or unpleasurable intercourse, poor body image or identity issues, dietary habits, smoking, alcohol use, caffeine use, hormonal fluctuations (such as occurring with PMS, pregnancy, postpartum, lactation, perimenopause, menopause, or hysterectomy) – just to name a few! What woman has not experienced at least a few of these factors at some point in her life?

Unfortunately, there is no simple or perfect solution to treat low sexual desire. The strategies to improve libido will reflect the underlying factors identified. In order to best understand what may be contributing to your concerns about libido, your health care provider will want to carefully review your overall health and sexual history. It may be recommended that you have a full physical to rule out any possible underlying medical conditions. If you take any medications, it is also important to review any potential sexual side effects related to their use. Your health care provider may also want to obtain bloodwork – again, to evaluate for particular medical conditions, and possibly to observe for any hormonal variations from normal.

Working toward increasing sexual desire (and/or arousal and orgasm) will usually involve a multi-faceted approach. For some women, identifying an underlying strain in a relationship can lead to an opportunity for changes and growth in the relationship, and a subsequent increase in sexual desire and pleasure. Other women find that simple (but sometimes difficult!) lifestyle changes will positively affect libido – more sleep and exercise, better nutritious intake, less alcohol or caffeine intake, smoking cessation, and improvements in stress management are all associated with increased libido. Women who have experienced sexual trauma or abuse will often do best in a safe, therapeutic environment in which they can begin to work through the complicated and negative associations with sex and work toward healthier, more pleasurable sexual experiences. Women experiencing depression or anxiety may also consider beginning to address their concerns with a therapist and with or without the use of medication, in order to lead a healthier life both overall and with regard to sexuality. As mentioned previously, any woman taking medication may be experiencing side effects which affect libido. Often, a change in dose or medication can help to reverse the sexual side effects. Not to be overlooked, hormonally based libido changes (whether related to menopause, pregnancy, post-partum, lactation, or even the use of oral contraceptives) can be addressed with your health care provider. Though the use of hormones is not always appropriate, supplemental hormonal therapy, or a change in a hormone regimen can, in some cases, positively affect libido. For women experiencing pain, discomfort, or a lack of physical pleasure with sex, it is important to be evaluated by your provider in order to discover the source of displeasure and thereby seek to improve sexual enjoyment and interest. Still for others, simply reserving more space in one’s life for intimacy will lead to more enjoyment and desire for sex.

Medications may be used to correct an underlying medical or emotional cause for low sexual desire – for instance, treating depression, diabetes, or hypothyroidism. However, the FDA has not as of yet approved the use of any medication for the specific treatment of low libido. Research trials are currently underway examining several possibilities for the future. A medication currently used to treat depression called buproprion hydrochloride SR may show promise in improving satisfaction with sexual desire, arousal, and orgasm. The use of androgens (i.e., testosterone) is presently being studied with particular regard to improving libido. There are also studies examining in women the use of medications which enhance blood flow to the genitals (i.e., Viagra, which is currently FDA approved for use in men with erectile dysfunction). However, medications that increase blood flow to the genitals will only address issues of arousal or orgasm, as opposed to actual desire for sex. Any of the above mentioned medications carry with them the potential for side effects, and should be discussed carefully with your health care provider. Additionally, there are many herbal remedies which have shown promising results in improving sexual desire and satisfaction. Seek more information from your health care provider or any clinician trained in the use of herbal medicines.

For further reading or information:

For Each Other: Sharing Sexual Intimacy by Lonnie Barbach
For Yourself: The Fulfillment of Female Sexuality by Lonnie Barbach
The Busy Couple’s Guide to Great Sex by Rallie McAllister, MD
www.AASECT – the American Association of Sex Educators, Counselors & Therapists

Trish Maginn Yauch MSN, ARNP
Harbour Women’s Health

What kind of insurance plan do I have?

There are many insurance plans that are on the market today.
Prior to 1997 most everyone in our local area had an indemnity insurance plan. This plan is a traditional fee-for-service coverage. With this plan a patient would pay their premiums. They could go to any healthcare provider for services and the insurance company would pay the full amount that the provider charged for the service. There are still some of these plans in the market today. Many of these plans have changed and added deductibles and coinsurance responsibility to the patients.

Things started changing in the healthcare market and insurers started to make a network of healthcare providers for their patients. Insurers approached healthcare providers to become an in-network provider with their organization. The insurance company would send patients to an in-network provider and the in-network provider agreed to bill the insurer and accept a discount for payment of services.

This arrangement supported the creation of our many healthcare plans of today. The following are the most common:

Preferred Provider Organization Plan(PPO): This plan gives a patient the flexibility of choosing services with any healthcare provider (similar to an indemnity plan) or the choice to see an in-network provider. There is a financial incentive to use an in-network provider. Some of these incentives are lower deductible, lower co-insurance or less out of pocket expenses. If you choose an out-of-network provider a patient may be required to pay the healthcare provider directly for services. The patient would then submit the bill to their insurance company and the insurance company would pay the patient less any deductibles, co-insurance, etc. (You should always call your healthcare provider’s office so you may be informed of their policies and procedures.)

Point of Service Plan (POS): This plan offers the flexibility of a PPO product with a managed care product. A patient has the option to go to any in-network provider for services (such as a PPO plan) or they may choose to utilize a primary care provider (PCP) and operate this plan as an (HMO). For this plan a patient will pick a PCP and then they can either go through their primary care for all services and be referred (referral) to another healthcare provider as an HMO product. Or a patient may self-refer and choose to see any healthcare provider in the insurance network. If a patient self-refers they will usually have a higher patient financial responsibility in their co-payment’s, deductible’s, etc. It is very important to understand with this type of plan if you choose a healthcare provider that is not in the insurance network, the insurance usually will not pay for your services unless you received prior authorization from your insurance company. If you wish to seek an out-of-network provider for your health services, always call your insurance company before any service is rendered to request an out-of-service authorization. Understand that if your insurance company does not authorize your service you will be responsible for all charges. NOTE: Some states have legislation, which will allow some services to be accessed without a referral process. For example, in the state of New Hampshire a patient can self-refer and does not need a referral for a gynecological yearly exam or for obstetrical (pregnancy) services. (Check on your state guidelines and your insurance company’s state affiliation.)

Health Maintenance Organization (HMO): For this benefit a patient has to pick a PCP. The PCP coordinates all the patient’s healthcare needs. If a patient is to see another provider such as a specialist, or if they were in need of special services such as physical therapy, it would have to be requested by the primary care provider. Your insurance company would have to approve the requested services for payment to be made by them. It is very important to understand with this plan all services need to be approved and referred by your PCP. A patient does not have the choice to self-refer with an in-network or out-of-network healthcare provider unless it falls under certain legislation. If a patient self-refers to either an in-network or out-of-network provider the service usually is the patient’s financial responsibility. NOTE: Some states have legislation, which will allow some services to be accessed without a referral process. For example, in the state of New Hampshire a patient can self-refer and does not need a referral for a gynecological yearly exam or for obstetrical (pregnancy) services. (Check on your state guidelines and your insurance company’s state affiliation.) You may also call your insurance company for a list of their self-referred authorized services.

Allowable Charge- The maximum fee that a third party will reimburse a provider for a given service

Co-Pay- A fee charged to members by their insurance company for certain services, such as office visits, drug prescriptions, etc.

Coinsurance- A percentage of the costs for services

Deductible- A fixed amount of money that a person must pay before the insurance pays for any health care

Indemnity Insurance- Traditional fee-for-service coverage in which providers are paid according to the service performed and charges that are submitted

HMO (Health Maintenance Organization)- A managed care product in which a patient must coordinate all health care services through their in-network primary care provider

Network – A defined group of providers, typically linked through contractual arrangements to an insurance company

Out of pocket expense- A dollar amount that a patient is expected to pay to share in the cost of her healthcare

PPO (Preferred Provider Organization)- A managed care organization that has a preferred provider network

POS (Point of Service) – A managed care product with the option to seek services with an in-network provider or to coordinate all healthcare services through their in-network primary care provider

PCP (Primary Care Provider)- Usually a family or internal doctor which is picked by a patient to coordinate her healthcare

Referral – A recommendation by a physician or managed care plan for a patient to be evaluated or treated by a different physician or specialist

Usual and Customary Fee – An amount of money determined by the insurance company that they will pay for services received by a patient

This information is not intended to give the specific detail of any insurance plan. This information is provided as a simplified overview of various common insurance plans. You should notify your employer or your healthcare insurance company to gather more detailed specifics regarding your individual insurance policy.