By the way, doctor

Q I dislike the side effects of progesterone and want to take unopposed estrogen for postmenopausal hormone replacement therapy. If I do so, will it really be necessary for me to have an endometrial biopsy regularly?

A Women who do not take progesterone -- which causes the endometrial cells to slough off monthly -- are at an increased risk for hyperplasia -- the build-up of endometrium -- and for endometrial cancer. Currently, the most accurate way to screen for endometrial cancer is to perform an endometrial biopsy -- an office procedure in which the doctor inserts a cannula through the cervix into the cavity of the uterus and takes small samples of endometrial tissue to be examined for evidence of cancer cells. Although the procedure is safe, it can be painful and can cause bleeding for a day or so. Like any test, it is also imperfect, and misses an estimated 7% of endometrial cancers.

Transvaginal ultrasound, which is performed by inserting a probe about the size of a tampon into the vagina, is a less invasive tool for evaluating the endometrium. It provides a more accurate view of the ovaries and endometrium than ultrasound performed from the abdomen, making it possible to reliably measure the thickness of the endometrium. Clinical studies of transvaginal ultrasound have indicated that it is rare to find endometrial cancer in women whose endometriums appeared to be less than 5mm thick. Many gynecologists believe that transvaginal ultrasound will become the procedure of choice for screening women for endometrial cancer as the technique is further honed and more studies are completed. Currently, however, it can provide information only about the thickness of the endometrium, not about the character of the cells it comprises.

For now, you should have an endometrial biopsy annually if you have your uterus and are taking estrogen without progesterone. Also, any postmenopausal woman who has abnormal vaginal bleeding, whether or not she is on hormone replacement, should undergo endometrial biopsy.

Q I have pain in my breast occasionally. it be a symptom of cancer?

A There are several types of breast pain, and they almost never indicate breast cancer.

Most women experience some degree of cyclic breast pain that begins at ovulation or just prior to menstruation and wanes after their periods begin. The pain can be merely troublesome or can make every hug an agonizing experience.

Cyclic pain is related to hormonal changes, but exactly how it is isn't understood. Studies indicate that the ratio of progesterone to estrogen or the regulation of pro-lactin, a hormone that stimulates lactation, may play a role. However, there must also be other factors to account for those situations in which one breast is much more tender than the other. Doctors suspect that something in the breast tissue reacts to the hormonal activity.

Breast pain that is not cyclic is less common and feels different. It does not vary with menstruation, and is usually in one specific area of the breast. It may be caused by trauma, such as a blow to the breast, or may occur after a breast biopsy, persisting for as long as two years. In this case, the cause is obvious because the pain is at the site of the biopsy scar, and although a source of discomfort, is nothing to worry about.

Structures outside the breast can also be a source of pain in the breast area. Most often, such pain is due a condition called costochondritis --an inflammation of the joint where ribs and breastbone connect. If you can elicit pain by pushing down on your breastbone near your ribs or by taking a deep breath, you are likely to have costochondritis.

Occasionally, arthritis in the neck can cause pain that radiates into a breast and lung infections, or pleuritis can contribute to pain in this area. Rarely, phlebitis of a vein in the breast can cause pain at the site and around the outer edge of the breast.

Because localized infection or cyst and, very rarely, cancer, can cause breast pain, the first approach to persistent breast pain is a breast exam and a mammogram.

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By Celeste Robb-Nicholson, M.D.

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