Breast health

Looking after your breasts in these years means three things. Noticing changes. Screening at the ages the guidance gives. And, if you are weighing up HRT, understanding what it does and does not do to breast cancer risk.

Breast awareness is not a technique you have to get right. It is knowing how your breasts usually look and feel, so a change stands out.

Some changes are part of perimenopause. The Pakistan Menopause Society lists breast tenderness among its early symptoms, alongside the hot flushes, the bloating and the sleep trouble.

Other changes need a doctor to look. The same recommendations name a breast lump, nipple discharge and a skin change on the breast or nipple among the red flags for assessment (section 2.3).

• Screening in Pakistan. The Pakistan Menopause Society asks doctors to use midlife visits to promote health awareness and screening that fits a woman's age and risk. As for other women, it describes mammography every three years after the age of 50 (Table 4).
• Screening in England. The NHS invites women registered with a GP from 50 up to their 71st birthday. The first invitation comes between 50 and 53, then every three years.
• Examination. The Pakistan Menopause Society says a breast examination should be done when symptoms, risk factors or screening call for it, rather than routinely for every woman (Table 2).
• Family history. The same recommendations ask doctors to record breast screening status and family history of cancer, and to refer women at high familial risk for breast assessment (Tables 2 and 4).
• Screening on HRT. The European Menopause and Andropause Society (EMAS) says HRT is no reason for extra mammograms. The Menopause Society notes that some types of HRT can make breasts look denser on a mammogram, which can make it harder to read and lead to more call-backs.

If breast cancer is the first thing you think of when HRT comes up, this is what the British Menopause Society's fast-facts sheet sets out:

• For women at low underlying risk, which it says is most women, the symptom benefits of HRT for up to five years outweigh the potential harm.
• Estrogen-only HRT is linked with little or no change in risk. Combined HRT can carry an increased risk that grows with the length of use, which it describes as small.
• Vaginal estrogen does not increase the risk.
• Women with symptoms who are at high risk of breast cancer, or who have had it, should be referred to a menopause specialist for advice.

The Pakistan Menopause Society lists breast cancer among the reasons not to use MHT, its word for HRT (5.2). For women with menopause symptoms who have had breast cancer or are at high risk of it, NICE NG23 asks doctors to offer information on every option and referral to a professional with expertise in menopause (1.5.31). The numbers are in HRT risks and benefits, and what they mean for you is a conversation with your doctor.

See a doctor promptly if you find a lump, notice discharge from a nipple, or see a change in the skin of the breast or nipple. The Pakistan Menopause Society says suspicious symptoms should not wait for evaluation (Table 4).

The NHS website makes the same point about screening: if you are worried about symptoms, see a GP even if you have recently had a mammogram, and do not wait for your next screening appointment.

If your mother, sister or aunt had breast cancer, say so at any menopause appointment.

The British Menopause Society notes that the traditional and conservative nature of many Asian women's lives can be a barrier to seeking help. Modesty is a real concern, and it deserves a practical answer, not a lecture.

When you book, you can ask whether a female doctor is available, and asking is not making a fuss. In England, the NHS says breast screening is done by a female mammographer and that you undress and dress in private. The Pakistan Menopause Society asks doctors to raise sensitive symptoms respectfully and in private (2.2). Women also ask how an examination sits with their faith. That question belongs with a qualified scholar.

In families where cancer is spoken of in whispers, or not at all, the family history may be the hardest part to find out. Asking an older relative what an aunt actually died of can matter more than it seems.