Now we’re turning our attention to breast cancer screenings. While most people have likely heard the term “mammogram,” the details around this screening may be hazy. So we’ve tapped our clinical experts to answer frequently asked questions like…
- Does menopause affect mammograms?
- How often do I need a mammogram before, during & after menopause?
- Does everyone get the same type of mammogram?
- It’s my first time! What should I expect during my mammogram?
- Are there any other tests for breast cancer besides mammograms?
- What factors contribute to my breast cancer risk during the menopausal transition and how can I lower my risk?
And so. much. more.
Breast cancer, when detected in stage 1, has a 99% survival rate. 99%!!!! This is why understanding how to find it early, including how often to get mammograms and which type to get, is SO important.
So take your bra off, throw on a comfy sweatshirt, and keep reading. We’ve got you covered.
What IS a mammogram?
A mammogram is an X-ray of the breast that’s done using low doses of radiation.
(If you want to get technical with vocabulary, a mammography exam is called a mammogram.)
Does menopause affect mammograms?
In a way, yes. Why? Because pre-menopausal women younger than 50 are more likely to have dense breasts compared to postmenopausal women over 50 (about 2/3 for the former and 1/4 for the latter).
When we say “dense” breasts, all that refers to is the amount of glandular and fibrous tissue versus fatty tissue in the breast, which varies from person to person. Glandular and fibrous tissue appear white on mammograms, and make it harder to see abnormalities like cancer. There are four categories of density:
- Fatty (A in image below)
- Scattered areas of fibroglandular density (B)
- Heterogeneously dense (C)
- Extremely dense (D)
The latter two categories are considered dense, and having dense breasts is a risk factor for breast cancer…more on that below.
How does a mammogram change after menopause?
After menopause (and with age), our breast tissue generally becomes more fatty — in other words, less dense. This is a GOOD thing since this makes it easier for mammograms to detect cancer.
How often do I need a mammogram before, during & after menopause?
Here are the formal recommendations according to The American Cancer Society (ACS), U.S. Preventive Services Task Force (USPSTF), and the American Congress of Obstetrics and Gynecology (ACOG) — although how early you start and how frequently you’re screened may be different depending on your individual risk factors as well as the recommending organization.
- For women ages 40-44: you have the choice to begin annual or biennial (every other year) screenings if you’d like (based on your risk factors and/or risk tolerance)
- For women ages 45-54: you should receive an annual or biennial mammogram
- For women ages 55 and older: you can still continue receiving annual or biennial mammograms
- For women 75+: while both the USPSTF and ACOG cite age 75 as a potential consideration for stopping mammography screening, there is quite a debate here. Rather than just using this age as an absolute cut off, some organizations — ACS, for example — qualify that screenings can continue if someone is in good overall health and does not have shortened life expectancy.
Researchers are looking at ways to further personalize screening schedules based on individual risk. We know that a one-size-fits-all approach isn’t appropriate for all women, but we’re not sure what those appropriate schedules should be just yet. As always, more research is needed.
Is there just one type of mammogram?
Nope. Here are a few top-line differences:
2D vs 3D mammograms
Most women will receive a 2D mammogram. This is when two X-ray images of the breast are taken (from the top and from the side).
However, there’s also a 3D mammogram, which is when multiple images are taken from various angles in an arc over the breast. From there, the images are computer synthesized to create a three-dimensional reproduction of the breast, which the radiologist will assess one “slice” at a time. 3D mammograms are also known as 3D tomosynthesis (“tomo” for short), digital breast tomosynthesis, or 3D breast imaging.
A new study from the University of Pittsburgh looked at adding breast ultrasounds to 3D mammography for women with dense breasts. The results showed a modest increase (1 in 1,000) in cancer detection as well as 61% increase in a false-positive call-back and benign biopsy rates (from 7% with mammography alone to 11.5% with added ultrasound). The takeaway: adding ultrasounds may increase cancer detection rates, but it also comes at a price of more false positives and recalls.
In short, it’s a complicated issue. Awareness of the limitations of mammography with dense breasts has been lacking. To counter this, 30+ states have passed breast density notification laws to increase awareness, and starting next year, the FDA mandates that all women in the US will receive information about their breast density on their mammogram reports. If you have dense breasts, you’ll see this message:
“Breast tissue can be either dense or not dense. Dense tissue makes it harder to find breast cancer on a mammogram and also raises the risk of developing breast cancer. Your breast tissue is dense. In some people with dense tissue, other imaging tests in addition to a mammogram may help find cancers. Talk to your healthcare provider about breast density, risks for breast cancer, and your individual situation.”
As the message implies, additional screening is needed, but with the current state of research on the subject, “the value of additional, or supplemental, imaging tests such as ultrasound or MRI to screen for breast cancer in women with dense breasts is not yet clear.” Simply put, we need more research on this topic.
Screening vs diagnostic mammograms
We can also categorize mammograms and other breast imaging as screening or diagnostic.
Screening mammograms are the kind you get every 1-2 years to look and see if there is any possible disease in the breast. Typically, these mammograms will consist of two views, or pictures, of the breast.
Diagnostic mammograms are those done to investigate a clinical finding: a lump, pain, discharge, etc. A radiologist will review the mammogram in real time, so additional images or ultrasounds can be done if needed while the patient is still there.
While the technology is the same, there are some key differences: the reason for the imaging (as stated above), insurance coverage, and access. Screening mammography is a fully covered screening test, mandated by the ADA, which means for most women, there are no copays or deductibles. Diagnostic mammograms are not a screening, so your insurance deductible and copays will apply. You don’t need a provider’s order to get a screening mammogram; you can schedule one on your own. However, a diagnostic mammogram is always ordered by a provider.
What symptoms of breast cancer should I be on the lookout for?
Below are some potential signs of breast cancer, BUT…and this is important…keep in mind that these symptoms can often happen with other conditions that are not cancer.
- Lump in the breast or underarm (armpit area)
- Thickening or swelling in part of the breast
- Irritation of the breast skin
- Dimpling of the breast skin
- Redness or flaky skin around the nipple
- Nipple discharge (other than breast milk), including blood
- Change in the size or shape of the breast
- Unexplained pain in any area of the breast
If something seems off, it’s best to see your provider for a clinical exam and possible order for a diagnostic mammogram rather than scheduling yourself for a screening.
Source: Know Your Lemons
Are there any other tests for menopause besides mammograms?
Mammograms are THE gold standard when it comes to the detection of breast cancer, but there are other tests used as follow-ups to mammograms or to check breast health for non-cancerous reasons (cysts, etc).
- Breast MRIs
For women at an increased risk of breast cancer due to family history, for example, it’s recommended to get a breast MRI in addition to regular mammograms (although MRIs alone don’t classify as screenings since they may pick up on false positives…aka things that don’t turn out to be cancer).
- Breast ultrasounds
Ultrasounds use sound waves and echoes to generate computer images of the inside of the breast that help doctors identify breast changes (like fluid-filled cysts) that may be difficult to view via a screening mammogram.
- Breast thermography
Breast thermography is NOT the same thing as mammography. The former relies on detecting temperature differences in the breast tissue using an infrared camera to identify “hot spots” that may represent cancer, especially in more advanced stages. While thermography is sometimes promoted as an alternative to mammography, at this point the research is clear: mammography is THE test to get, especially when it comes to early detection.
There are also a slew of new tests currently in development for breast imaging, including fast breast MRIs, radionuclide imaging, positron emission mammography (PEM), contrast-enhanced mammography (CEM), elastography, optical imaging tests, and electrical impedance tomography (EIT).
What should I expect during my mammogram & how can I prepare for it?
The screening itself is fairly quick — it only takes about 10-20 minutes.
Here’s what happens: The technician will position your breasts one at a time between two plastic imaging plates. You’ll feel slight pressure as the plates take X-ray images (multiple images from multiple positions), and then you’re done!
The morning of your mammogram, remember to wear a two-piece outfit because you’ll have to undress above the waist (dresses or rompers aren’t ideal here!). Also, avoid applying any deodorant, lotion, or ointment in the chest area since products like these may appear as white spots on the screening mammography.
If you are still menstruating, the best time in your cycle to undergo mammography is right after your period, when your breasts may be least tender. Asking the mammography technician to do the compression more slowly can also help with the feeling of pressure.
What factors contribute to my breast cancer risk?
Regardless of your menopausal status – whether you’re perimenopausal or postmenopausal — there are certain risk factors to be aware of.
Factors that are in our control
Moderate alcohol consumption (1-2 drinks/day) is associated with a 30-50% higher risk of breast cancer.
Being overweight or obese
Obesity (BMI of 30+) is associated with a higher risk of developing breast cancer, particularly for postmenopausal women, and worse disease outcomes for all women.
Lack of physical activity
In a 2016 analysis of 13 studies, researchers found that physically active women had a 12-21% lower risk of breast cancer compared to those who were least physically active (this is the case for both perimenopusal and postmenopausal women).
How & when hormone therapy (HT) is used
Long-term use (10+ years) of combined hormone therapy (estrogen & progestin) may slightly increase our risk of breast cancer. However…and this is important…postmenopausal estrogen-only therapy (appropriate only in those with a history of hysterectomy) is actually associated with a lower risk of breast cancer.
An important study from 20 years ago, called WHI, tried to establish and quantify this risk. It was stopped prematurely when women using an estrogen+progestin combination were found to have a relative 24% increased risk for breast cancer. We need to put this in perspective, however. A 24% relative risk means that someone with a risk of 1% would go up to a 1.24% risk. Put another way: if 10 out of 1000 non-hormone takers had breast cancer, the risk would go up to 12 out of 1000 hormone users. This study has echoed to this day, despite its multiple limitations, including age of participants and the type of hormones used (oral premarin and progestin called MPA).
Today, we understand that the risk increase, if any, is minimal if hormone therapy is started around the age of menopause and no later than 10 years from the last menstrual period. What’s more, this risk may be further minimized through the use of micronized progesterone rather than a progestin (a synthetic progesterone analog).
This is a complicated issue, and the decision “to HT or not to HT” should be an individual one discussed with one’s provider while considering all its risks and benefits.
In a recent study published in the Journal of the National Cancer Institute, researchers investigated the association between air pollution exposure and breast cancer risk, finding that exposure to PM2.5 (which describes fine inhalable particles with diameters 2.5 micrometers or smaller) was associated with an increased risk of breast cancer. To decrease exposure when levels are considered “hazardous” on the Air Quality Index (AQI):
- Stay indoors with filtered air (Dyson and Molekule have great air filters)
- Keep your activity levels low
- Run an air conditioner (as long as it doesn’t draw air from outdoors and has a filter)
- Avoid using wood fireplaces
- Avoid vacuuming unless yours has a HEPA filter
The caveat here, however, is that we do not understand just how much of a direct or causative risk air pollution is versus other factors that may link those living in areas with high rates of pollution versus those who do not, so we should keep a conclusion like this in perspective.
For more tips, refer to airnow.gov.
Factors that are not in our control (aka “non-modifiable risk factors”)
As we get older, there are more opportunities for genetic “damage” (aka mutations) that our bodies are less capable of repairing. Studies show that 80% of all breast cancers occur in women over the age of 50. Here’s how the probability of developing invasive breast cancer changes over time:
- At age 40: less than 1.5%
- At age 50: 3%
- By age 70: 4%
BRCA is what’s known as the “breast cancer gene.” Compared to the general population, people who inherit BRCA1/BRCA2 mutations face a significantly increased lifetime risk of developing breast and/or ovarian cancer.
Family history of breast or ovarian cancer
Having a first-degree relative — mother, sister, daughter — with breast cancer almost doubles the risk of developing it, while having two first-degree relatives increases the risk by three-fold.
Previous treatment using radiation therapy
We may be at a slightly higher risk for breast cancer after radiation treatment in the chest area (either for previous breast cancer or something like Hodgkin’s lymphoma).
Exposure to the drug diethylstilbestrol (DES)
DES was given to some pregnant women in the United States between the years 1940 and 1971 to prevent miscarriage. Women who took this drug (as well as women whose mothers took it) may have a slightly higher risk of developing breast cancer.
Having dense breast tissue
Women with the highest density breasts are 4-6 times more likely to get breast cancer than those with the least dense breasts.
Race & ethnicity
While White women are slightly more likely to develop breast cancer than Black, Asian, and Hispanic women, Black women are more likely to develop more aggressive, advanced-stage cancer diagnosed at a younger age.