Identifying potential problems: annual exam called great time to discuss breast-feeding
Michele G. Sullivan
ASHEVILLE, N.C. -- Gynecologists can do much to support and encourage breast-feeding by educating women about their breasts and identifying potential lactational challenges during a regular gynecologic exam, Dr. Edward Newton said at the annual Southern Obstetric and Gynecologic Seminar.
"Your role here is underlined, because 50% of women already have decided how they're going to feed their infant before they even get pregnant," said Dr. Newton of East Carolina University, Greenville, N.C.
Family planning visits and annual gynecologic exams provide great opportunities for gynecologists to identify women who might be at high risk for lactation failure due to breast abnormalities and to counsel them about the effects elective breast surgery might have on lactation.
The breast exam is an ideal time to talk to young women about lactation--an often over-looked aspect of breast health, he said.
"The fear of getting breast cancer has forced us to focus on the breast exam as a cancer identification tool, even in 18-year-old," he said. "But less than 2.5% of breast cancer occurs in women under age 34, when 90% of pregnancies occur, and we know that lactation is associated with a decrease in the risk of later breast cancer. At these visits, we could also be teaching a woman what the breasts were actually put there for and [we could be] building self-confidence about her ability to breast-feed should she decide to become a mother."
Flat or inverted nipples and breast hypoplasia can be easily identified on the breast exam. Each of these conditions is associated with an increased risk of lactational failure.
Inverted nipples occur in about 3.3% of women; they are most often bilateral. This condition is associated with almost a tripling in the odds of lactational insufficiency.
"There are lots of ways to manage this, which only shows that we don't really know how to manage it," Dr. Newton said. "The Hoffman technique is uncomfortable and can cause contractions. Breast shells and pumps may be more effective in increasing lactation success in these women."
True breast hypoplasia--a nonpregnant breast that weighs around 200 grams--is very rare, occurring in a ratio of about 1:500 or more women. The breast will not grow as it should during pregnancy. Normally, each breast grows from 200 grams in the nonpregnant state to 600 grams in the third trimester and 800 grams during lactation.
"The degree of lactational insufficiency is hard to predict." Dr. Newton said. "With these women, anticipatory guidance is necessary, as well as close postpartum follow-up."
Anticipatory counseling is also very important for young women who are considering breast augmentation or reduction. Although women can successfully breast-feed after either of these surgeries, they are less likely to even attempt it, and they have higher failure rates than do women who have not had the procedures.
"The risks in terms of breast-feeding come mainly from the destruction of nerve tissue, which interferes with the let-down reflex and the production of prolactin. And, of course, any time you put a knife or a suture into the breast you are likely to injure a duct," he said.
Women who are considering augmentation and express a desire to breast-feed in the future should be aware of these risks and discuss with the surgeon incisions that have the least impact on nipple sensation. Circumareolar incisions are likely to be most harmful to the nerves.
In breast reduction, the removal of more than 500 grams of tissue is likely to decrease the ability to lactate. In a 2003 study, 58% of women who chose to breast-feed after reduction were able to do so at 1 month post partum, but only 16% were still exclusively breast-feeding at 6 months post partum, compared with 58% of controls. "Most women who have reductions decide not to breast-feed; only 12% even try."
These same anatomic changes--loss of breast and ductal tissue and nerve injury--can interfere with breast-feeding after breast biopsy. Again, a circumareolar incision, especially from the 6 to 9 o'clock position, poses the greatest risk for nerve injury and should be avoided, if possible, in the women who desire to lactate. "It's important to educate young women about this if they should ever have to face that situation," he said.
Breast-feeding is even possible after breast cancer, he stressed. "About 25% of women who are diagnosed with breast cancer are premenopausal, and up to 35% of them will get pregnant after their diagnosis of cancer--most within 5 years of it."
About 40% of breasts that have been irradiated will still produce milk. Although the volume is decreased, the quality of the milk is not affected in any way. The degree of volume reduction will vary according to other factors, including maternal age, preexisting glandular volume, and the dose of radiation. The nontreated breast will be unaffected.
"Fortunately, one breast is perfectly adequate for growing a baby," Dr. Newton said. "The untreated breast can definitely produce enough milk to successfully breast-feed."
A woman's attitude toward breast-feeding is probably the most crucial component of future success or failure, and should be assessed. Educating a woman and building her self-confidence about breast-feeding is crucial.
"I can't tell you how many successful, professional women come into my office and timidly say, 'I'd like to breast-feed ... if I can.'" Dr. Newton said. "Here are women who are used to succeeding and making decisions every day, and yet they are unsure of their ability to succeed at this most natural process."
Those telltale words, "If I can ..." are a strong signal that a woman lacks confidence about breast-feeding. "This is a great opportunity for you to dispel any myths she has and assure her that she has adequate lactational anatomy."
BY MICHELE G. SULLIVAN
COPYRIGHT 2004 International Medical News Group