Medicine and Sex

Ovarian Cancer

2011-03-11T03:07:00.000-08:00

Ovarian cancer may not cause symptoms until it is large or has spread.
If doctors suspect ovarian cancer, ultrasonography, magnetic resonance imaging, or computed tomography is done.
Usually, both ovaries, both fallopian tubes, and the uterus are removed.
Chemotherapy is often needed after surgery.

Cancer of the ovaries (ovarian carcinoma) develops most often in women aged 50 to 70. This cancer eventually develops in about 1 of 70 women. In the United States, it is the second most common gynecologic cancer. However, more women die of ovarian cancer than of any other gynecologic cancer. It is the fifth most common cause of cancer deaths in women.

Factors that increase the risk of ovarian cancer include the following:

Being older (the most important)
Not having any children
Having a first child late in life
Starting menstruating early
Having menopause late
Having had or having a family member who had cancer of the uterus, breast, or large intestine (colon)

The risk of ovarian cancer is higher in developed countries because the diet tends to be high in fat. Use of oral contraceptives significantly decreases risk.

About 5 to 10% of cases are related to the BRCA gene, which is also involved in some breast cancers. In these cases, ovarian and breast cancer tends to run in families. This abnormal gene is most common among Ashkenazi Jewish women.

There are many types of ovarian cancer. They develop from the many different types of cells in the ovaries. Cancers that start on the surface of the ovaries (epithelial carcinomas) account for at least 80%. Most other ovarian cancers start from the cells that produce eggs (called germ cell tumors) or in connective tissue (called stromal cell tumors). Germ cell tumors are much more common among women younger than 30. Sometimes cancers from other parts of the body spread to the ovaries.

Ovarian cancer can spread directly to the surrounding area and through the lymphatic system to other parts of the pelvis and abdomen. It can also spread through the bloodstream, eventually appearing in distant parts of the body, mainly the liver and lungs.

Symptoms

Ovarian cancer causes the affected ovary to enlarge. In young women, enlargement of an ovary is likely to be caused by a noncancerous fluid-filled sac (cyst). However, after menopause, an enlarged ovary can be a sign of ovarian cancer.

Many women have no symptoms until the cancer is advanced. The first symptom may be vague discomfort in the lower abdomen, similar to indigestion. Other symptoms may include bloating, loss of appetite (because the stomach is compressed), gas pains, and backache. Ovarian cancer rarely causes vaginal bleeding.

Eventually, the abdomen may swell because the ovary enlarges or fluid accumulates in the abdomen. At this stage, pain in the pelvic area, anemia, and weight loss are common. Rarely, germ cell or stromal cell tumors produce estrogens, which can cause tissue in the uterine lining to grow excessively and breasts to enlarge. Or these tumors may produce male hormones (androgens), which can cause body hair to grow excessively, or hormones that resemble thyroid hormones, which can cause hyperthyroidism.

Diagnosis

Diagnosing ovarian cancer in its early stages is difficult because symptoms usually do not appear until the cancer is quite large or has spread beyond the ovaries and because many less serious disorders cause similar symptoms.

If doctors detect an enlarged ovary during a physical examination, ultrasonography is done first. Sometimes computed tomography (CT) or magnetic resonance imaging (MRI) is used to help distinguish an ovarian cyst from a cancerous mass. If advanced cancer is suspected, CT or MRI is usually done before surgery to determine extent of the cancer.

If cancer seems unlikely, doctors reexamine the woman periodically.

If doctors suspect cancer or test results are unclear, the ovaries are examined using a thin, flexible viewing tube (laparoscope) inserted through a small incision just below the navel. Also, tissue samples are removed using instruments threaded through the laparoscope and examined (biopsied). In addition, blood tests are usually done to measure levels of substances that may indicate the presence of cancer (tumor markers), such as cancer antigen 125 (CA 125). Abnormal marker levels alone do not confirm the diagnosis of cancer, but when combined with other information, they can help confirm it.

If fluid has accumulated in the abdomen, it can be drawn out (aspirated) through a needle and tested to determine whether cancer cells are present.

If doctors suspect advanced cancer or cancer is confirmed, they make an incision in the abdomen to obtain a tissue sample. At the same time, they remove as much of the cancer as possible and determine how far the cancer has spread (its stage).

Prognosis

The prognosis is based on the stage (see Cancers of the Female Reproductive System: Staging Cancers of the Female Reproductive System*). The percentages of women who are alive 5 years after diagnosis and treatment are

Stage I: 70 to 100%
Stage II: 50 to 70%
Stage III: 20 to 50%
Stage IV: 10 to 20%

The prognosis is worse when the cancer is more aggressive or when surgery cannot remove all visibly abnormal tissue. Cancer recurs in 70% of women who have had stage III or IV cancer.

Prevention

Some experts believe that if ovarian or breast cancer runs in the family, women should be tested for genetic abnormalities. If first- or second-degree relatives have such cancers, particularly among Ashkenazi Jewish families, women should discuss genetic testing for BRCA abnormalities with their doctors. Women with certain BRCA gene mutations may be offered the option of having both ovaries and tubes removed after they no longer wish to bear children, even when no cancer is present. This approach eliminates the risk of ovarian cancer and reduces the risk of breast cancer. These women should be evaluated by a gynecologist who specializes in cancer (gynecologic oncologist). More information is available from the National Cancer Institute Cancer Information Service (1-800-4-CANCER) and the Women's Cancer Network (WCN) web site (www.wcn.org).

Treatment

The extent of surgery depends on the type of ovarian cancer and the stage. For most cancers, the ovaries, fallopian tubes, and uterus are removed. When cancer has spread beyond the ovary, nearby lymph nodes and surrounding structures that the cancer typically spreads to are also removed. If a woman has stage I cancer that affects only one ovary and she wishes to become pregnant, doctors may remove only the affected ovary and fallopian tube. For more advanced cancers that have spread to other parts of the body, removing as much of the cancer as possible prolongs survival.

After surgery, most women with stage I epithelial carcinomas usually require no further treatment. For other stage I cancers or for more advanced cancers, chemotherapy may be used to destroy any small areas of cancer that may remain. Typically, chemotherapy consists of paclitaxel Some Trade Names
ABRAXANETAXOL
combined with carboplatin Some Trade Names
PARAPLATIN
, given 6 times. Most women with germ cell tumors can be cured with removal of the one affected ovary and fallopian tube plus combination chemotherapy, usually with bleomycin Some Trade Names
BLENOXANE
, cisplatin Some Trade Names
PLATINOL
, and etoposide Some Trade Names
VEPESID
. Radiation therapy is rarely used.

Advanced ovarian cancer usually recurs. So after chemotherapy, doctors typically measure levels of cancer markers. If the cancer recurs, chemotherapy (using drugs such as carboplatin Some Trade Names
PARAPLATIN
, doxorubicin Some Trade Names
DOXIL
, etoposide Some Trade Names
VEPESID
, gemcitabine Some Trade Names
GEMZAR
, paclitaxel Some Trade Names
ABRAXANETAXOL
, or topotecan Some Trade Names
HYCAMTIN
) is given.

What Is an Ovarian Cyst?

An ovarian cyst is a fluid-filled sac in or on an ovary. Such cysts are relatively common. Most are noncancerous and disappear on their own. Cancerous cysts are more likely to occur in women older than 40.

Most noncancerous ovarian cysts do not cause symptoms. However, some cause pressure, aching, or a feeling of heaviness in the abdomen. Pain may be felt during sexual intercourse. If a cyst ruptures or becomes twisted, severe stabbing pain is felt in the abdomen. The pain may be accompanied by nausea and fever. Some cysts produce hormones that affect menstrual periods. As a result, periods may be irregular or heavier than normal. In postmenopausal women, such cysts may cause vaginal bleeding. Women who have any of these symptoms should see a doctor.

Doctors may find a cyst during a routine pelvic examination or occasionally suspect it based on symptoms. A pregnancy test is done to exclude that possibility. An ultrasound device may be inserted through the vagina into the uterus (transvaginal ultrasonography) to confirm the diagnosis.

If the cyst appears to be noncancerous, a woman may be asked to return periodically for pelvic examinations as long as the cyst remains. If the cyst could be cancerous, computed tomography (CT) or magnetic resonance imaging (MRI) may be done. If cancer still seems possible, the ovaries may be examined through a laparoscope, inserted through a small incision just below the navel. Blood tests can help confirm or rule out cancer.

For noncancerous cysts, no treatment is necessary. But if a cyst is larger than about 2 inches (5 centimeters) and persists, it may need to be removed. If cancer cannot be ruled out, the ovary is removed. Cancerous cysts plus the affected ovary and fallopian tube are removed.

Surgery may be done through a laparoscope (with only a small incision) or a larger incision in the abdomen.

Hydatidiform Mole

2011-03-11T03:05:00.000-08:00

A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta.

Women appear to be pregnant, but the uterus enlarges much more rapidly than in a normal pregnancy.
Most women have severe nausea and vomiting, vaginal bleeding, and very high blood pressure.
Ultrasonography, blood tests to measure human chorionic gonadotropin (which is produced early during pregnancy) and a biopsy are done.
Moles are removed using dilation and curettage with suction.
If the disorder persists, chemotherapy is needed.

Most often, a hydatidiform mole is an abnormal fertilized egg that develops into a hydatidiform mole rather than a fetus (a condition called molar pregnancy). However, a hydatidiform mole can develop from cells that remain in the uterus after a miscarriage or a full-term pregnancy. Rarely, a hydatidiform mole develops when there is a living fetus. In such cases, the fetus typically dies, and a miscarriage often occurs.

Hydatidiform moles are most common among women under 17 or over 35. In the United States, they occur in about 1 in 2000 pregnancies in the United States. For unknown reasons, moles are almost 10 times more common in Asian countries.

About 80% of hydatidiform moles are not cancerous. About 15 to 20% invade the surrounding tissue and tend to persist. About 2 to 3% become cancerous and spread throughout the body; they are then called choriocarcinomas. Choriocarcinomas can spread quickly through the lymphatic vessels or bloodstream. Hydatidiform moles and choriocarcinomas are types of gestational trophoblastic disease.

Did You Know...

An abnormal fertilized egg or placental tissue can overgrow, causing symptoms similar to those of pregnancy but with a more rapid enlargement of the abdomen.

Symptoms

Women who have a hydatidiform mole feel as if they are pregnant. But because hydatidiform moles grow much faster than a fetus, the abdomen becomes larger much faster than it does in a normal pregnancy. Severe nausea and vomiting are common, and vaginal bleeding may occur. As parts of the mole deteriorate, small amounts of tissue, which resemble a bunch of grapes, may pass through the vagina. These symptoms indicate the need for prompt evaluation by a doctor.

Hydatidiform moles can cause serious complications, including infections and very high blood pressure with increased protein in the urine (preeclampsia or eclampsia—see Pregnancy Complications: Preeclampsia).

If choriocarcinoma develops, women may have other symptoms, caused by spread (metastasis) to other parts of the body.

Diagnosis

Often, doctors can diagnose a hydatidiform mole shortly after conception. The pregnancy test is positive, but no fetal movement and no fetal heartbeat are detected, and the uterus is much larger than expected.

Ultrasonography is done to be sure that the growth is a hydatidiform mole and not a fetus or amniotic sac (which contains the fetus and fluid around it). Blood tests to measure the level of human chorionic gonadotropin (hCG—a hormone normally produced early in pregnancy) are done. If a hydatidiform mole is present, the level is usually very high because the mole produces a large amount of this hormone. A sample of tissue is removed or obtained when it is passed, then examined under a microscope (biopsy) to confirm the diagnosis.

Prognosis

The cure rate for a hydatidiform mole is virtually 100% if the mole has not spread. The cure rate is 60 to 80% for choriocarcinoma that has spread widely. Most women can have children afterwards and do not have a higher risk of having complications, a miscarriage, or children with birth defects.

About 1% of women who have had a hydatidiform mole have another one. So if women have had a hydatidiform mole, ultrasonography is done early in subsequent pregnancies.

Treatment

A hydatidiform mole is completely removed, usually by dilation and curettage (D and C) with suction (see Symptoms and Diagnosis of Gynecologic Disorders: Dilation and Curettage). Only rarely is removal of the uterus (hysterectomy) necessary.

A chest x-ray is done to see whether the mole has become cancerous (that is, a choriocarcinoma) and spread to the lungs. After surgery, the level of human chorionic gonadotropin in the blood is measured to determine whether the hydatidiform mole was completely removed. When removal is complete, the level returns to normal, usually within 10 weeks, and remains normal. If the level does not return to normal (called persistent disease), computed tomography (CT) of the brain, chest, abdomen, and pelvis is done to determine whether choriocarcinoma has developed and spread.

Hydatidiform moles do not require chemotherapy, but persistent disease does. Usually, only one drug ( methotrexate Some Trade Names
TREXALL
or dactinomycin Some Trade Names
COSMEGEN
) is needed. Sometimes both drugs or another combination of chemotherapy drugs is needed.

Women who have had a hydatidiform mole removed are advised not to become pregnant for 1 year. Oral contraceptives are frequently recommended, but other effective contraceptive methods can be used.

Fallopian Tube Cancer

2011-03-11T03:03:00.001-08:00

Fallopian tube cancer develops in the tubes that lead from the ovaries to the uterus.

Most cancers that affect the fallopian tubes have spread from other parts of the body.
At first, women may have vague symptoms, such as abdominal discomfort or bloating, or no symptoms.
Ultrasonography or computed tomography is done to check for abnormalities.
Usually, the uterus, ovaries, and fallopian tubes are removed, followed by chemotherapy.

In the United States, fewer than 1% of gynecologic cancers are fallopian tube cancers. Most often, cancer that affects the fallopian tubes has spread from the ovaries rather than started in the fallopian tubes. Cancer that starts in the fallopian tubes usually affects women aged 50 to 60. It is more likely to develop in women who have had the following:

Long-term inflammation of the fallopian tubes (chronic salpingitis)
Disorders that cause inflammation in other parts of the body, such as tuberculosis
Infertility

More than 95% of fallopian tube cancers are adenocarcinomas, which develop from gland cells. A few are sarcomas, which develop from connective tissue. Fallopian tube cancer spreads in much the same way as ovarian cancer: usually directly to the surrounding area or through the lymphatic system, eventually appearing in distant parts of the body.

Symptoms

Symptoms include vague abdominal discomfort, bloating, and pain in the pelvic area or abdomen. Some women have a watery or blood-tinged discharge from the vagina. When cancer is advanced, the abdominal cavity may fill with fluid (a condition called ascites), and women may feel a large mass in the pelvis.

Diagnosis

Fallopian tube cancer is seldom diagnosed early. Occasionally, it is diagnosed early when a mass or other abnormality is detected during a routine pelvic examination or an imaging test done for another reason. Usually, the cancer is not diagnosed until it is advanced, when it is obvious because a large mass or severe ascites is present.

If cancer is suspected, computed tomography (CT) is usually done. If the results suggest cancer, surgery is done to confirm the diagnosis, determine the extent of spread, and remove as much of the cancer as possible.

Prognosis and Treatment

The prognosis is similar to that for women who have ovarian cancer.

Treatment almost always consists of removal of the uterus (hysterectomy) and removal of the ovaries and fallopian tubes (salpingo-oophorectomy), adjacent lymph nodes, and surrounding tissues. Chemotherapy (as for ovarian cancer) is usually necessary after surgery. The most commonly used chemotherapy drugs are carboplatin Some Trade Names
PARAPLATIN
and paclitaxel Some Trade Names
ABRAXANETAXOL
.

For some cancers, radiation therapy is useful. For cancer that has spread to other parts of the body, removing as much of the cancer as possible improves the prognosis.

Cervical Cancer

2011-03-11T03:01:00.000-08:00

Cervical cancer develops in the cervix (the lower part of the uterus).

Cervical cancer usually results from infection with the human papillomavirus (HPV), transmitted during sexual intercourse.
Cervical cancer may cause irregular vaginal bleeding, but symptoms may not occur until the cancer has enlarged or spread.
Papanicolaou (Pap) tests can usually detect abnormalities, which are then biopsied.
Treatment usually involves removing the cancer and often surrounding tissue, often with radiation therapy and chemotherapy.
Getting regular Pap tests and being vaccinated against HPV can prevent cervical cancer.

The cervix is the lower part of the uterus. It extends into the vagina. In the United States, cervical cancer (cervical carcinoma) is the third most common gynecologic cancer among all women and the most common among younger women. It usually affects women aged 35 to 55, but it can affect women as young as 20.

This cancer is usually caused by the human papillomavirus (HPV), which is transmitted during sexual intercourse. This virus also causes genital warts (see Sexually Transmitted Diseases: Genital Warts). The younger a woman was the first time she had sexual intercourse and the more sex partners she has had, the higher her risk of cervical cancer. Risk is also increased by having intercourse with men whose previous partners had cervical cancer, by smoking cigarettes, and by having a weakened immune system (due to a disorder such as cancer or AIDS or to drugs such as chemotherapy drugs or corticosteroids).

About 80 to 85% of cervical cancers are squamous cell carcinomas, which develop in the flat, skinlike cells covering the cervix. Most other cervical cancers are adenocarcinomas, which develop from gland cells

Cervical cancer begins with slow, progressive changes in normal cells on the surface of the cervix. These changes, called dysplasia or cervical intraepithelial neoplasia (CIN), are considered precancerous. That means that if untreated, they may progress to cancer, sometimes after years.

Cervical cancer begins on the surface of the cervix and can penetrate deep beneath the surface. The cancer can spread directly to nearby tissues, including the vagina. Or it can enter the rich network of small blood and lymphatic vessels inside the cervix, then spread to other parts of the body.

Symptoms

Precancerous changes usually cause no symptoms. In the early stages, cervical cancer may cause no symptoms or cause abnormal bleeding from the vagina, most often after intercourse. Spotting or heavier bleeding may occur between periods, or periods may be unusually heavy. Large cancers are more likely to cause bleeding and may cause a foul-smelling discharge from the vagina and pain in the pelvic area.

If the cancer is widespread, it can cause lower back pain and swelling of the legs. The urinary tract may be blocked, and without treatment, kidney failure and death can result.

Did You Know...

Pap tests have reduced the number of deaths due to cervical cancer by more than 50%.
If all women had Pap tests regularly, deaths due to this cancer could be virtually eliminated.

Diagnosis

Routine Pap tests or other similar tests can detect the beginnings of cervical cancer (see Symptoms and Diagnosis of Gynecologic Disorders: Gynecologic Examination). Pap tests accurately detect up to 90% of cervical cancers, even before symptoms develop. They can also detect dysplasia. Women with dysplasia should be checked again in 3 to 4 months. Dysplasia can be treated, thus helping prevent cancer.

If a growth, a sore, or another abnormal area is seen on the cervix during a pelvic examination or if a Pap test detects dysplasia or cancer, a biopsy is done. Usually, doctors use an instrument with a binocular magnifying lens (colposcope), inserted through the vagina, to examine the cervix and to choose the best biopsy site. Two different types of biopsy are done:

Punch biopsy: A tiny piece of the cervix, selected using the colposcope, is removed.
Endocervical curettage: Tissue that cannot be viewed is scraped from inside the cervix.

These biopsies cause little pain and a small amount of bleeding. The two together usually provide enough tissue for pathologists to make a diagnosis.

If the diagnosis is not clear, a cone biopsy is done to remove a larger cone-shaped piece of tissue. Usually, a thin wire loop with an electrical current running through it is used. This procedure is called the loop electrosurgical excision procedure (LEEP). Alternatively, a laser (using a highly focused beam of light) can be used. Either procedure requires only a local anesthetic and can be done in the doctor's office. A cold (nonelectric) knife is sometimes used, but this procedure requires an operating room and an anesthetic.

If cervical cancer is diagnosed, its exact size and locations (its stage) are determined. Staging begins with a physical examination of the pelvis. Various procedures (such as cystoscopy, a chest x-ray, and sigmoidoscopy) can be used to determine whether the cancer has spread to nearby tissues or to distant parts of the body. Other procedures, such as computed tomography (CT), magnetic resonance imaging (MRI), a barium enema, bone and liver scans, and positron emission tomography (PET) may be done.

Prognosis

Prognosis depends on the stage of the cancer (see Cancers of the Female Reproductive System: Staging Cancers of the Female Reproductive System*). The percentages of women who are alive 5 years after diagnosis and treatment are

Stage I: 80 to 90% of women
Stage II: 60 to 75%
Stage III: 30 to 40%
Stage IV: 15% or fewer

If the cancer is going to recur, it usually does so within 2 years.

Prevention

Pap Tests: The number of deaths due to cervical cancer has been reduced by more than 50% since Pap tests were introduced. Doctors often recommend that women have their first Pap test when they become sexually active or reach the age of 18 and that a Pap test be done once a year. If test results are normal for 3 consecutive years, women may schedule Pap tests every 2 or 3 years as long as they do not change their sexual lifestyle. Any woman who has had cervical cancer or dysplasia should continue to have Pap tests at least once a year. If all women had Pap tests on a regular basis, deaths due to this cancer could be virtually eliminated. However, in the United States, about 50% of women are not tested regularly.

HPV Vaccine: A newly developed vaccine targets the types of HPV that cause most cervical cancer (and genital warts). The vaccine can help prevent cervical cancer but does not treat it. Three doses of the vaccine are given (see Immunization: Human Papillomavirus). The first is followed by one 2 months and one 6 months after the first. Being vaccinated before becoming sexually active is best, but even if women are already sexually active, they should be vaccinated. Using condoms during intercourse can help prevent spread of HPV.

Treatment

Treatment depends on the stage of the cancer.

Early Stages: If only the surface of the cervix is involved, doctors can often completely remove the cancer by removing part of the cervix using the loop electrosurgical excision procedure, a laser, or a cold knife, done during a cone biopsy. These treatments preserve a woman's ability to have children. Because cancer can recur, doctors advise women to return for examinations and Pap tests every 3 months for the first year and every 6 months after that. Rarely, removal of the uterus (hysterectomy) is necessary.

If early-stage cancer involves more than the surface of the cervix, doctors usually do a hysterectomy and give radiation therapy and chemotherapy. If women with early-stage cervical cancer wish to preserve their ability to have children, a procedure called radical trachelectomy may be done. In this procedure, the cervix, the tissue next to the cervix, the upper part of the vagina, and the lymph nodes in the pelvis are removed. The uterus and vagina that remain are attached to each other. Thus, women still can become pregnant. However, babies must be delivered by cesarean section. This treatment appears to be as effective as other more invasive treatments for women with early-stage cervical cancer.

Initial Spread Within the Pelvis: Hysterectomy plus removal of surrounding tissues, ligaments, and lymph nodes (radical hysterectomy) is necessary. The ovaries may be removed. Normal, functioning ovaries in younger women are not removed. Radiation therapy may be used sometimes instead of hysterectomy. Radiation therapy may irritate the bladder or rectum. Later, as a result, the intestine may become blocked, and the bladder and rectum may be damaged. Also, the ovaries usually stop functioning. With either radical hysterectomy or radiation therapy, chemotherapy is usually also used, and about 85 to 90% of women are cured.

Further Spread Within the Pelvis or to Other Organs: Radiation therapy plus chemotherapy (with cisplatin Some Trade Names
PLATINOL
) is preferred. A laparoscope may be used or surgery done to determine whether lymph nodes are involved and thus determine where radiation should be directed.

If the cancer remains in the pelvis after radiation therapy, doctors may recommend surgery to remove all pelvic organs (pelvic exenteration). This procedure cures up to 50% of women.

Extensive Spread or Recurrence: Chemotherapy, usually with cisplatin Some Trade Names
PLATINOL
and topotecan Some Trade Names
HYCAMTIN
, is sometimes recommended. However, chemotherapy reduces the cancer's size and controls its spread in only 15 to 25% of women treated, and this effect is usually only temporary.

Cancer of the Uterus(Endometrial Cancer)

2011-03-11T02:59:00.000-08:00

Cancer of the uterus develops in the lining of the uterus (endometrium) and is thus also called endometrial cancer.

Endometrial cancer usually affects women after menopause.
It sometimes causes abnormal vaginal bleeding.
To diagnosis this cancer, doctors remove a sample of tissue from the endometrium to be analyzed (biopsy).
Usually, the uterus and fallopian tubes are removed, often followed by radiation therapy and sometimes by chemotherapy.

Cancer of the uterus begins in the lining of the uterus (endometrium) and is more precisely termed endometrial cancer (carcinoma). In the United States, it is the most common gynecologic cancer and the fourth most common cancer among women. One in 50 women gets endometrial cancer. This cancer usually develops after menopause, most often in women aged 50 to 65.

More than 80% of endometrial cancers are adenocarcinomas, which develop from gland cells. Fewer than 5% of cancers in the uterus are sarcomas. These cancers develop from connective tissue and tend to be more aggressive.

Causes

Endometrial cancer is more common in developed countries where the diet is high in fat.

The most important risk factors for endometrial cancer are

Obesity
Diabetes
Hypertension

Other factors increase risk because they result in a high level of estrogen but not progesterone Some Trade Names
CRINONEENDOMETRIN
. They include the following:

Having an early start of menstrual periods (menarche ), menopause after age 52, or both
Having menstrual problems (such as excessive bleeding, spotting between menstrual periods, or long intervals without periods)
Not having any children
Having tumors that produce estrogen
Taking high doses of drugs that contain estrogen, such as estrogen therapy without a progestin (synthetic drugs similar to the hormone progesterone Some Trade Names
CRINONEENDOMETRIN
), after menopause
Using tamoxifen for more than 5 years

Estrogen promotes the growth of tissue and rapid cell division in the lining of the uterus (endometrium). Progesterone Some Trade Names
CRINONEENDOMETRIN
helps balance the effects of estrogen. Levels of estrogen are high during part of the menstrual cycle. Thus, having more menstrual periods during a lifetime may increase the risk of endometrial cancer. Tamoxifen, a drug used to treat breast cancer, blocks the effects of estrogen in the breast, but it has the same effects as estrogen in the uterus. Thus, this drug may increase the risk of endometrial cancer. Taking oral contraceptives that contain estrogen and a progestin appears to reduce the risk of endometrial cancer.

Other risk factors include the following:

Having had or having a family member who has had cancer of the breast, ovaries, or possibly the large intestine (colon) or lining of the uterus
Having had radiation therapy directed at the pelvis

Symptoms

Abnormal bleeding from the vagina is the most common early symptom. Abnormal bleeding includes

Bleeding after menopause
Bleeding between menstrual periods
Periods that are irregular, heavy, or longer than normal

One of three women with vaginal bleeding after menopause has endometrial cancer. Women who have vaginal bleeding after menopause should see a doctor promptly. A watery, blood-tinged discharge may also occur. Postmenopausal women may have a vaginal discharge for several weeks or months, followed by vaginal bleeding.

Diagnosis

Doctors may suspect endometrial cancer if women have typical symptoms or if results of a Papanicolaou (Pap) test, usually done as part of a routine examination, are abnormal. If cancer is suspected, doctors take a sample of tissue from the endometrium (endometrial biopsy) in their office and send it to a laboratory for analysis. This test accurately detects endometrial cancer more than 90% of the time. If the diagnosis is still uncertain, doctors scrape tissue from the uterine lining for analysis—a procedure called dilation and curettage (D and C—see Symptoms and Diagnosis of Gynecologic Disorders: Dilation and Curettage). At the same time, doctors may view the interior of the uterus using a thin, flexible viewing tube inserted through the vagina and cervix into the uterus in a procedure called hysteroscopy. Alternatively, an ultrasound device may be inserted through the vagina into the uterus (transvaginal ultrasonography) to evaluate abnormalities.

If endometrial cancer is diagnosed, some or all of the following procedures may be done to determine whether the cancer has spread beyond the uterus: blood tests, kidney and liver function tests, and a chest x-ray. If results of the physical examination or other tests suggest that the cancer has spread beyond the uterus, computed tomography (CT) or magnetic resonance imaging (MRI) is done. Other procedures are sometimes required. Staging is based on information obtained from these procedures and during surgery to remove the cancer.

Prognosis

If endometrial cancer is detected early, nearly 70 to 95% of women who have it survive at least 5 years, and most are cured. The prognosis is better for women whose cancer has not spread beyond the uterus. If the cancer grows relatively slowly, the prognosis is also better. Less than one third of women who have this cancer die of it.

Treatment

Hysterectomy, surgical removal of the uterus, is the mainstay of treatment for women who have endometrial cancer. If the cancer has not spread beyond the uterus, removal of the uterus plus removal of the fallopian tubes and ovaries (salpingo-oophorectomy) almost always cures the cancer. Unless the cancer is very advanced, hysterectomy improves the prognosis. Nearby lymph nodes are usually removed at the same time. These tissues are examined by a pathologist to determine whether the cancer has spread and, if so, how far it has spread. With this information, doctors can determine whether additional treatment (chemotherapy, radiation therapy, or a progestin) is needed after surgery.

For very advanced cancer, treatment varies but usually involves a combination of surgery, radiation therapy, chemotherapy, and occasionally synthetic hormones.

Radiation therapy may be given after surgery in case some undetected cancer cells remain. More than half of women with cancer limited to the uterus do not need radiation therapy. However, if the cancer has spread to the cervix or beyond the uterus, radiation therapy is usually recommended after surgery.

If the cancer has spread beyond the uterus and cervix or recurs, chemotherapy drugs (such as carboplatin Some Trade Names
PARAPLATIN
, cisplatin Some Trade Names
PLATINOL
, cyclophosphamide Some Trade Names
LYOPHILIZED CYTOXAN
, doxorubicin Some Trade Names
DOXIL
, and paclitaxel Some Trade Names
ABRAXANETAXOL
) may be used instead of or sometimes with radiation therapy. These drugs reduce the cancer's size and control its spread in more than half of women treated. However, these drugs are toxic and have many side effects.

If the cancer does not respond to chemotherapy, progestins (synthetic drugs similar to the hormone progesterone Some Trade Names
CRINONEENDOMETRIN
) may be used. These drugs are much less toxic than chemotherapy drugs. In 20 to 25% of women who have cancer that has spread or recurred, a progestin may reduce the cancer's size and control its spread for 2 to 3 years. Treatment is continued as long as the cancer responds to it.

If menopausal symptoms such as hot flashes and vaginal dryness become bothersome after the uterus is removed, hormones such as estrogen, a progestin, or both can taken to relieve them. This treatment is safe and does not increase the risk of developing cancer again.

Understanding Hysterectomy

A hysterectomy is the removal of the uterus. Usually, the uterus is removed through an incision in the lower abdomen. Sometimes the uterus can be removed through the vagina. Either method usually takes about 1 to 2 hours and requires a general anesthetic. Afterward, vaginal bleeding and pain may occur. The hospital stay is usually 2 to 3 days, and recovery may take up to 6 weeks. When the uterus is removed through the vagina, less bleeding occurs, recovery is faster, and there is no visible scar.

Because of advances in technology, hysterectomy may be done using laparoscopy or robotic surgery. Then, the hospital stay is only 1 day. Women usually have less pain after surgery and can return more quickly to normal activities.

In addition to treating certain gynecologic cancers, a hysterectomy may be used to treat prolapse of the uterus, endometriosis, or fibroids (if causing severe symptoms). Sometimes it is done as part of the treatment for cancer of the colon, rectum, or bladder.

There are several types of hysterectomy. The type used depends on the disorder being treated.

Subtotal (supracervical) hysterectomy: Only the upper part of the uterus is removed, but the cervix is not. The fallopian tubes and ovaries may or may not be removed.
Total hysterectomy: The entire uterus including the cervix is removed.
Radical hysterectomy: The entire uterus plus the surrounding tissues, ligaments, and lymph nodes are removed. Both fallopian tubes and ovaries are usually also removed in women older than 45.

After a hysterectomy, menstruation stops. However, a hysterectomy does not cause menopause unless the ovaries are removed also. Removal of the ovaries has the same effects as menopause, so hormone therapy may be recommended. (see Menopause: Hormone Therapy) Many women anticipate feeling depressed or losing interest in sex after a hysterectomy. However, hysterectomy rarely has these effects unless the ovaries are also removed.

Fibrocystic Changes

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Fibrocystic changes (formerly called fibrocystic breast disease) include breast pain, cysts, and lumpiness that are not due to cancer.

Fibrocystic Breast Disease

Most women have some general lumpiness in the breasts, usually in the upper outer part, near the armpit. In the United States, many women have this kind of lumpiness, breast pain, breast cysts, or some combination of these symptoms—a condition called fibrocystic changes.

Normally, the levels of the female hormones estrogen and progesterone Some Trade Names
CRINONEENDOMETRIN
fluctuate during the menstrual cycle. Milk glands and ducts enlarge and breasts retain fluid when levels increase, and the breasts return to normal when levels decrease. (These fluctuations partly explain why breasts are swollen and more sensitive during a particular time of each menstrual cycle.) Fibrocystic changes may result from repeated stimulation by these hormones. The following increase the risk of these changes:

Starting to menstruate at an early age
Having a first baby at age 30 or later
Never having a baby

Other breast disorders, such as infections, can cause these changes.

The lumpy areas may enlarge, causing a feeling of heaviness, discomfort, tenderness to the touch, or a burning pain. The symptoms tend to subside after menopause.

Most fibrocystic changes do not increase the risk of breast cancer, but a few of them do, although only slightly. These changes typically require a biopsy to rule out cancer and may make the breasts appear dense on mammograms. They include the following:

Complex fibroadenoma: The cells that line the breast ducts and connective tissue in the breasts form a benign tumor with many types of changes in tissue.
Moderate or severe hyperplasia: The cells that line the milk glands or ducts multiply too much, and their arrangement may become distorted (called atypical hyperplasia).
Sclerosing adenosis: The number of milk glands increases, and scar tissue forms, distorting the arrangement of milk glands.
Papilloma: Noncancerous, finger-like tumors develop in the cells that line the breast ducts.

Fibrocystic changes may make breast cancer more difficult to detect.

Treatment

Lumps, usually only one lump at a time, may be removed, and a biopsy may be done to rule out cancer. Sometimes the biopsy sample can be withdrawn with a needle, but sometimes it must be removed surgically.

Sometimes cysts are drained, but they tend to recur. No specific treatment is available or required, but certain measures may help relieve symptoms:

Wearing a soft, supportive brassiere
Taking pain relievers

If symptoms are severe, doctors may prescribe drugs, such as danazol (a synthetic male hormone) or tamoxifen (which blocks the effects of estrogen). Because side effects can occur with long-term use, the drugs are usually given for only a short time. Tamoxifen has fewer side effects than danazol.

Fibroadenomas

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Fibroadenomas are small, solid, rubbery noncancerous lumps composed of fibrous and glandular tissue.

Fibroadenomas usually appear in young women, including teenagers. The cause is unknown.

The lumps are easy to move and have clearly defined edges that can be felt during self-examination. They may feel like small, slippery marbles. These characteristics indicate to a doctor that the lumps are less likely to be cancerous. Nonetheless, to be sure that they are not cancerous, the doctor usually removes the lumps. A local anesthetic is used.

Fibroadenomas often recur. If several lumps have been removed and found to be noncancerous, a woman and her doctor may decide against removing new lumps that develop.

Breast Infection and Abscess

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A breast infection (mastitis) is rare, except around the time of childbirth (see Postdelivery Period: Breast Infection) or after an injury or surgery. The most common symptom is a swollen, red area that feels warm and tender. An uncommon type of breast cancer called inflammatory breast cancer (see Breast Disorders: Types) can cause similar symptoms. A breast infection is treated with antibiotics.

A breast abscess, which is even rarer, is a collection of pus in the breast. An abscess may develop if a breast infection is not treated. An abscess is usually drained surgically and may be treated with antibiotics.

Breast Cysts

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Breast cysts are fluid-filled sacs that develop in the breast.

Breast cysts are common. In some women, many cysts develop frequently, sometimes with other fibrocystic changes. The cause of breast cysts is unknown, although injury may be involved. Breast cysts can be tiny or several inches in diameter.

Cysts sometimes cause breast pain. To relieve the pain, a doctor may drain fluid from the cyst with a thin needle. Sometimes the fluid is examined under a microscope to check for cancer. The color and amount are noted. If the fluid is bloody, brown, or cloudy or if the cyst does not disappear or reappears within 12 weeks after it is drained, the entire cyst is removed surgically because cancer in the cyst wall, although rare, is possible.

Breast Cancer

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Among women, breast cancer is the second most common cancer and the second most common cause of cancer deaths.
Typically, the first symptom is a painless lump, usually noticed by the woman.
Monthly self-examination, yearly breast examination by a doctor, and a yearly mammogram for women who are over 50 or at increased risk are recommended.
If a solid lump is detected, a few cells are removed through a needle or the entire lump is surgically removed and examined (biopsied).
Breast cancer almost always requires surgery, sometimes with radiation therapy, chemotherapy, other drugs, or a combination.
Outcome is hard to predict and depends partly on the characteristics and spread of the cancer.

Breast cancer is the second most common cancer among women after skin cancer and, of cancers, is the second most common cause of death among women after lung cancer. In 2006, breast cancer was diagnosed in about 213,000 women in the United States. About one fifth of them will die of it.

Many women fear breast cancer, partly because it is common. However, some of the fear about breast cancer is based on misunderstanding. For example, the statement, “One of every eight women will get breast cancer,” is misleading. That figure is an estimate based on women from birth to age 95. It means that, theoretically, one of eight women who live to age 95 or older will develop breast cancer. However, a 40-year-old woman has only a 1 in 1,200 chance of developing breast cancer during the next year and about a 1 in 120 chance of developing it during the next decade. But as she ages, her risk increases.

What Are the Risks of Developing or Dying of Breast Cancer?
			Risk (%)
	In 10 Years		In 20 Years		In 30 Years
Age (Years)	Develop	Die	Develop	Die	Develop	Die
30	0.4	0.1	2.0	0.6	4.3	1.2
40	1.6	0.5	3.9	1.1	7.1	2.0
50	2.4	0.7	5.7	1.6	9.0	2.6
60	3.6	1.0	7.1	2.0	9.1	2.6
70	4.1	1.2	6.5	1.9	7.1	2.0
Based on information from Feuer EJ et al.: The lifetime risk of developing breast cancer. Journal of the National Cancer Institute 85(11):892-897, 1993.

Several factors affect the risk of developing breast cancer. Thus, for some women, the risk is much higher or lower than average. Most factors that increase risk, such as age, cannot be modified. However, regular exercise, particularly during adolescence and young adulthood, and possibly weight control may reduce the risk of developing breast cancer. Regularly drinking alcoholic beverages may increase the risk.

Did You Know...

Fewer than 1% of women have the genes for breast cancer.

Far more important than trying to modify risk factors is being vigilant about detecting breast cancer so that it can be diagnosed and treated early, when it is more likely to be cured. Early detection is more likely when women have mammograms and do breast self-examinations regularly (see Breast Disorders: Mammography and Breast Disorders: How to Do a Breast Self-Examination).

Risk Factors for Breast Cancer

Age
Increasing age is an important risk factor. About 60% of breast cancers occur in women older than 60. Risk is greatest after age 75.
Previous Breast Cancer
At highest risk are women who have had breast cancer. After the diseased breast is removed, the risk of developing cancer in the remaining breast is about 0.5 to 1.0% each year.
Family History of Breast Cancer
Breast cancer in a first-degree relative (mother, sister, or daughter) increases a woman's risk by 2 to 3 times, but breast cancer in more distant relatives (grandmother, aunt, or cousin) increases the risk only slightly. Breast cancer in two or more first-degree relatives increases a woman's risk by 5 to 6 times.
Breast Cancer Gene
Two separate genes for breast cancer (BRCA1 and BRCA2) have been identified in two separate small groups of women. Fewer than 1% of women have these genes. They are most common among Ashkenazi Jews. If a woman has one of these genes, her chances of developing breast cancer are very high, possibly as high as 50 to 85% by age 80. However, if such a woman develops breast cancer, her chances of dying of breast cancer are not necessarily greater than those of any other woman with breast cancer. Women likely to have one of these genes are those who have several close, usually first-degree relatives who have had breast cancer. For this reason, routine screening for these genes does not appear necessary, except in women who have such a family history. The risk of ovarian cancer is increased in families with both breast cancer genes. The risk of breast cancer in men is increased in families with the BRCA2 gene. Women with one of these genes may need to undergo more frequent testing for breast cancer. Or they may need to try to prevent cancer from developing by taking tamoxifen or raloxifene Some Trade Names
EVISTA
(which is similar to tamoxifen) or sometimes by even having a double mastectomy.
Fibrocystic Changes
Having only certain types of fibrocystic changes seems to increase risk. These changes include those that require a biopsy to rule out breast cancer or those that make the breasts appear dense on a mammogram. For women with such changes, the risk is increased only slightly unless abnormal tissue structure (atypical hyperplasia) is detected during a biopsy or the women have a family history of breast cancer.
Age at First Menstrual Period, at First Pregnancy, and at Menopause
The earlier menstruation begins, the greater the risk of developing breast cancer. The risk is 1.2 to 1.4 times higher for women who first menstruated before age 12 than for those who first menstruated after age 14. The later the first pregnancy occurs and the later menopause occurs, the higher the risk. Never having had a baby doubles the risk of developing breast cancer during a woman's lifetime. These factors probably increase risk because they involve longer exposure to estrogen, which stimulates the growth of certain cancers. (Pregnancy, although it results in high estrogen levels, may reduce the risk of breast cancer.)
Prolonged Use of Oral Contraceptives or Estrogen Therapy
Taking oral contraceptives increases the risk of later developing breast cancer, but only very slightly. Also, the risk is increased mainly for women who started taking them at a young age (such as during their teens) and who have taken them for many years. After women stop taking contraceptives, the risk gradually decreases over the next 10 years to that for other women of the same age.
After menopause, taking hormone therapy that combines estrogen with a progestin for a few years or more increases the risk of breast cancer.
Obesity After Menopause
Risk is somewhat higher for women who are obese after menopause. However, there is no proof that a high-fat diet contributes to the development of breast cancer or that changing the diet can decrease risk. Some studies suggest that obese women who are still menstruating are less likely to develop breast cancer.
Radiation Exposure
Radiation exposure (such as radiation therapy for cancer or significant exposure to x-rays) before age 30 increases risk.

Types

Breast cancer is usually classified by the extent of its spread and by the kind of tissue in which the cancer starts.

Carcinoma in situ means cancer in place. It is the earliest stage of breast cancer. Carcinoma in situ may be large and may even affect a substantial area of the breast, but it has not invaded the surrounding tissues or spread to other parts of the body. More than 15% of all breast cancers diagnosed in the United States are carcinoma in situ. It is usually detected during mammography.

Invasive cancer is further classified as follows.

Localized: The cancer has invaded surrounding tissues but is confined to the breast.
Regional: The cancer has invaded tissues near the breasts, such as the chest wall or lymph nodes.
Distant (metastatic): The cancer has spread from the breast to other parts of the body. Cancer tends to move into the lymphatic vessels in the breast. Most lymphatic vessels in the breast drain into lymph nodes in the armpit (axillary lymph nodes). One function of lymph nodes is to filter out and destroy abnormal or foreign cells, such as cancer cells. If cancer cells get past these lymph nodes, the cancer can spread anywhere in the body. Breast cancer can also spread through the bloodstream to other parts of the body. Breast cancer tends to spread to bones and the brain but can spread to any area, including the lungs, liver, skin, and scalp. Breast cancer can appear in these areas years or even decades after it is first diagnosed and treated. If the cancer has spread to one area, it probably has spread to other areas, even if it cannot be detected right away.

Breast cancer that starts in the milk ducts is called ductal carcinoma. About 90% of all breast cancers are this type. Breast cancer that starts in the milk-producing glands (lobules) is called lobular carcinoma. Breast cancer that starts in fatty or connective tissue, a rare type, is called sarcoma.

Ductal carcinoma in situ is confined to the milk ducts of the breast. It does not invade surrounding breast tissue, but it can spread along the ducts and gradually affect a substantial area of the breast. This type accounts for 20 to 30% of breast cancers. It is detected only during mammography. This type may become invasive.

Lobular carcinoma in situ develops within the milk-producing glands of the breast. It often occurs in several areas of both breasts. Women with this type have a 1 to 2% chance each year of developing invasive breast cancer in the affected or the other breast. This type accounts for 1 to 2% of breast cancers. Usually, lobular carcinoma in situ cannot be seen on a mammogram and is detected only by biopsy.

Invasive ductal carcinoma begins in the milk ducts but breaks through the wall of the ducts, invading the surrounding breast tissue. It can also spread to other parts of the body. It accounts for 65 to 80% of breast cancers.

Invasive lobular carcinoma begins in the milk-producing glands of the breast but invades surrounding breast tissue and spreads to other parts of the body. It is more likely than other types of breast cancer to occur in both breasts. It accounts for 10 to 15% of breast cancers.

Inflammatory breast cancer refers to the symptoms of the cancer rather than the affected tissue. This type is fast growing and often fatal. Cancer cells block the lymphatic vessels in the skin of the breast, causing the breast to appear inflamed: swollen, red, and warm. Usually, inflammatory breast cancer spreads to the lymph nodes in the armpit. The lymph nodes can be felt as hard lumps. However, often no lump may be felt in the breast itself because this cancer is dispersed throughout the breast. Inflammatory breast cancer accounts for about 1% of breast cancers.

Paget's disease of the nipple (see Skin Cancers: Paget's Disease of the Nipple) is a ductal breast cancer. The first symptom is a crusty or scaly nipple sore or a discharge from the nipple. Slightly more than half of the women who have this cancer also have a lump in the breast that can be felt. Paget's disease may be in situ or invasive. Because this disease usually causes little discomfort, women may ignore it for a year or more before seeing a doctor. The prognosis depends on how invasive and how large the cancer is as well as whether it has spread to the lymph nodes.

Rare types of invasive ductal breast cancers include medullary carcinoma, tubular carcinoma, and mucinous (colloid) carcinoma. Mucinous carcinoma tends to develop in older women and to be slow growing. Women with these types of breast cancer have a much better prognosis than women with other types of invasive breast cancer.

Phyllodes breast tumors are relatively rare. About half are cancerous. They originate in breast tissue around milk ducts and milk-producing glands. The tumor spreads to other parts of the body in about 10 to 20% of women who have it.

Characteristics

All cells, including breast cancer cells, have molecules on their surfaces called receptors. A receptor has a specific structure that allows only particular substances to fit into it and thus affect the cell's activity. Whether breast cancer cells have certain receptors affects how quickly the cancer spreads and how it should be treated.

Estrogen and progesterone receptors: Some breast cancer cells have receptors for estrogen. The resulting cancer, described as estrogen receptor-positive, grows or spreads when stimulated by estrogen. This type of cancer is more common among postmenopausal women than among younger women. Some breast cancer cells have receptors for progesterone Some Trade Names
CRINONEENDOMETRIN
. The resulting cancer, described as progesterone Some Trade Names
CRINONEENDOMETRIN
receptor-positive, is stimulated by progesterone Some Trade Names
CRINONEENDOMETRIN
. Breast cancers with estrogen receptors, and possibly those with progesterone Some Trade Names
CRINONEENDOMETRIN
receptors, grow more slowly than those that do not have these receptors, and the prognosis is better.
HER2 (HER2/neu) receptors: Normal breast cells have HER2 receptors, which help them grow. (HER stands for human epithelial growth factor receptor, which is involved in multiplication, survival, and differentiation of cells.) In about 20 to 30% of breast cancers, cancer cells have too many HER2 receptors. Such cancers tend to be very fast growing.

Symptoms

At first, breast cancer causes no symptoms. Most commonly, the first symptom is a lump, which usually feels distinctly different from the surrounding breast tissue. In more than 80% of breast cancer cases, women discover the lump themselves. Usually, scattered lumpy changes in the breast, especially the upper outer region, are not cancerous and indicate fibrocystic changes. A firm, distinctive thickening that appears in one breast but not the other may indicate cancer.

In the early stages, the lump may move freely beneath the skin when it is pushed with the fingers.

In more advanced stages, the lump usually adheres to the chest wall or the skin over it. In these cases, the lump cannot be moved at all or it cannot be moved separately from the skin over it. Women can detect whether they have a cancer that even slightly adheres to the chest wall or skin by lifting their arms over their head while standing in front of a mirror. If a breast contains cancer that adheres to the chest wall or skin, this maneuver may make the skin pucker or one breast appear different from the other.

In very advanced cancer, swollen bumps or festering sores may develop on the skin. Sometimes the skin over the lump is dimpled and leathery and looks like the skin of an orange (peau d'orange) except in color.

The lump may be painful, but pain is an unreliable sign. Pain without a lump is rarely due to breast cancer.

Lymph nodes, particularly those in the armpit on the affected side, may feel like hard small lumps. The lymph nodes may be stuck together or adhere to the skin or chest wall. They are usually painless but may be slightly tender.

In inflammatory breast cancer, the breast is warm, red, and swollen, as if infected (but it is not). The skin of the breast may become dimpled and leathery, like the skin of an orange, or may have ridges. The nipple may turn inward (invert). A discharge from the nipple is common. Often, no lump can be felt in the breast.

Screening

Because breast cancer rarely causes symptoms in its early stages and because early treatment is more likely to be successful, screening is important. Screening is the hunt for a disorder before any symptoms occur.

How to Do a Breast Self-Examination
1. While standing in front of a mirror, look at the breasts. The breasts normally differ slightly in size. Look for changes in the size difference between the breasts and changes in the nipple, such as turning inward (an inverted nipple) or a discharge. Look for puckering or dimpling.
2. Watching closely in the mirror, clasp the hands behind the head and press them against the head. This position helps make subtle changes caused by cancer more noticeable. Look for changes in the shape and contour of the breasts, especially in the lower part of the breasts.
3. Place the hands firmly on the hips and bend slightly toward the mirror, pressing the shoulders and elbows forward. Again, look for changes in shape and contour.
Many women do the next part of the examination in the shower because the hand moves easily over wet, slippery skin.
	4. Raise the left arm. Using three or four fingers of the right hand, probe the left breast thoroughly with the flat part of the fingers. Moving the fingers in small circles around the breast, begin at the nipple and gradually move outward. Press gently but firmly, feeling for any unusual lump or mass under the skin. Be sure to check the whole breast. Also, carefully probe the armpit and the area between the breast and armpit for lumps.
	5. Squeeze the left nipple gently and look for a discharge. (See a doctor if a discharge appears at any time of the month, regardless of whether it happens during breast self-examination.)
Repeat steps 4 and 5 for the right breast, raising the right arm and using the left hand.
6. Lie flat on the back with a pillow or folded towel under the left shoulder and with the left arm overhead. This position flattens the breast and makes it easier to examine. Examine the breast as in steps 4 and 5. Repeat for the right breast.
A woman should repeat this procedure at the same time each month. For menstruating women, 2 or 3 days after their period ends is a good time because the breasts are less likely to be tender and swollen. Postmenopausal women may choose any day of the month that is easy to remember, such as the first.
Adapted from a publication of the National Cancer Institute.

Routine self-examination enables women to detect lumps at an early stage. However, self-examination alone does not reduce the death rate from breast cancer, and it does not detect as many early cancers as routine screening with mammography. Women who do not detect any lumps should continue to see their doctor for breast examinations and to have mammograms as recommended. When tumors are detected by self-examination, the prognosis is usually better, and breast-conserving surgery can usually be done rather than mastectomy.

A breast examination is a routine part of a physical examination. A doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge. The doctor feels (palpates) each breast with a flat hand and checks for enlarged lymph nodes in the armpit—the area most breast cancers invade first—and also above the collarbone. Normal lymph nodes cannot be felt through the skin, so those that can be felt are considered enlarged. However, noncancerous conditions can also cause lymph nodes to enlarge. Lymph nodes that can be felt are checked to see if they adhere to the skin or chest wall and if they are matted together.

Mammography: For this test, x-rays are used to check for abnormal areas in the breast. A technician positions the woman's breast on top of an x-ray plate. An adjustable plastic cover is lowered on top of the breast, firmly compressing the breast. Thus, the breast is flattened so that the maximum amount of tissue can be imaged and examined. X-rays are aimed downward through the breast, producing an image on the x-ray plate. Two x-rays are taken of each breast in this position. Then plates may be placed vertically on either side of the breast, and x-rays are aimed from the side. This position produces a side view of the breast.

Mammography: Screening for Breast Cancer

Mammography is one of the best ways to detect breast cancer early. Mammography is designed to be sensitive enough to detect the possibility of cancer at an early stage, sometimes years before it can be felt. Because mammography is so sensitive, it may indicate cancer when none is present—a false-positive result. About 90% of abnormalities detected during screening (that is, in women with no symptoms or lumps) are not cancer. Typically, when the result is positive, more specific follow-up procedures, usually a breast biopsy, are scheduled to confirm the result. Mammography may miss up to 15% of breast cancers.

Did You Know...

Only about 10% of the abnormalities detected during routine screening with mammography turn out to be cancer.

Having a mammogram every 1 to 2 years can reduce the rate of death due to breast cancer by 25 to 35% among women aged 50 and older. As yet, no study has shown that regularly having mammograms can reduce the death rate among women younger than 50. However, evidence may be harder to obtain because breast cancer is not common among younger women. Many experts recommend that women aged 40 to 49 have mammograms every 1 to 2 years. All experts recommend yearly mammograms for women aged 50 and older.

The dose of radiation used is very low and is considered safe. Mammography may cause some discomfort, but the discomfort lasts only a few seconds. Mammography should be scheduled at a time during the menstrual period when the breasts are less likely to be tender. Deodorants should not be used on the day of the procedure because they can interfere with the image obtained. The entire procedure takes about 15 minutes.

Diagnosis

When a lump or another abnormality is detected in the breast during a physical examination or by a screening procedure, other procedures are necessary. Mammography is done first if it was not the way the abnormality was detected.

Ultrasonography is sometimes used to help distinguish between a fluid-filled sac (cyst) and a solid lump. This distinction is important because cysts are usually not cancerous. Cysts may be monitored (with no treatment) or drained with a small needle and syringe. Sometimes the fluid from the cyst is examined to check for cancer cells. Rarely, when cancer is suspected, cysts are removed.

If the abnormality is a solid lump, which is more likely to be cancerous, a mammogram followed by a biopsy is done. Often, an aspiration biopsy is used: Some cells are removed from the lump through a needle attached to a syringe. If this procedure detects cancer, the diagnosis is confirmed. If no cancer is detected, removal of an additional piece of tissue (incisional biopsy) or of the entire lump (excisional biopsy) is necessary to be sure that the aspiration biopsy did not miss the cancer. Most women do not need to be hospitalized for these procedures. Usually, only a local anesthetic is needed.

If Paget's disease of the nipple is suspected, a biopsy of nipple tissue is usually done. Sometimes this cancer can be diagnosed by examining a sample of the nipple discharge under a microscope.

A pathologist examines the biopsy samples under the microscope to determine whether cancer cells are present. Generally, a biopsy confirms cancer in only a few women with an abnormality detected during mammography. If cancer cells are detected, the sample is analyzed to determine the characteristics of the cancer cells, such as

Whether the cancer cells have estrogen or progesterone Some Trade Names
CRINONEENDOMETRIN
receptors
How many HER2 receptors are present
How quickly the cancer cells are dividing

This information helps doctors estimate how rapidly the cancer may spread and which treatments are more likely to be effective.

A chest x-ray is taken and blood tests, including a complete blood cell count and liver function tests, are done to determine whether the cancer has spread. If the tumor is large, if the lymph nodes are enlarged, or if women have bone pain, imaging of bones throughout the body (a bone scan) may be done. Computed tomography (CT) of the abdomen is done if liver function is abnormal, if the liver is enlarged, or if the cancer has spread within the breast.

Magnetic resonance imaging (MRI) is often done to evaluate breast cancer after it is diagnosed because MRI can accurately determine how large the tumor is, whether the chest wall is involved, and how many tumors are present.

Staging

When cancer is diagnosed, a stage is assigned to it, based on how advanced it is. The stage helps doctors determine the most appropriate treatment and the prognosis. Stages of breast cancer may be described generally as in situ (not invasive) or invasive. Stages may be described in detail and designated by a number (0 through IV).

Stages of Breast Cancer
Stage	Description
In situ carcinoma
0	The tumor is confined, usually to a milk duct or milk-producing gland, and has not invaded surrounding breast tissue.
Localized and regional invasive cancer
I	The tumor is less than ¾ inch (2 centimeters) in diameter and has not spread beyond the breast.
IIA	The tumor is ¾ inch or less in diameter, and it has spread to one to three lymph nodes in the armpit, microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor, or both. or The tumor is larger than ¾ inch but smaller than 2 inches (5 centimeters) in diameter but has not spread beyond the breast.
IIB	The tumor is larger than ¾ inch but smaller than 2 inches in diameter, and it has spread to one to three lymph nodes in the armpit, microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor, or both. or The tumor is larger than 2 inches in diameter but has not spread beyond the breast.
IIIA	The tumor is 2 inches or less in diameter and has spread to four to nine lymph nodes in the armpit or has enlarged at least one lymph node near the breastbone on the same side as the tumor. or The tumor is larger than 2 inches in diameter and has spread to up to nine lymph nodes in the armpit or to lymph nodes near the breastbone.
IIIB	The tumor has spread to the chest wall or skin or has caused breast inflammation (inflammatory breast cancer).
IIIC	The tumor can be any size plus at least one of the following: It has spread to 10 or more lymph nodes in the armpit. It has spread to lymph nodes under or above the collar bone. It has spread to lymph nodes in the armpit and has enlarged at least one lymph node near the breastbone on the same side as the tumor. It has spread to four or more lymph nodes in the armpit, and microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor.
Metastatic cancer
IV	The tumor, regardless of size, has spread to distant organs or tissues, such as the lungs or bones, or to lymph nodes distant from the breast.

Prevention

Taking drugs that decrease the risk of breast cancer (chemoprevention) is recommended for the following women:

Those over age 60
Those who are over age 35 and have had a previous lobular carcinoma in situ
Those who have BRCA1 or BRCA2 gene mutations
Those who have a high risk of developing breast cancer based on the woman's current age, age at menarche, age at first live childbirth, number of first-degree relatives with breast cancer, and results of prior breast biopsies

These drugs include tamoxifen and raloxifene Some Trade Names
EVISTA
. Women should ask their doctor about possible side effects before beginning chemoprevention. Risks of tamoxifen include cancer of the uterus (endometrial cancer), blood clots in the legs or lungs, and cataracts. These risks are higher for older women. Raloxifene Some Trade Names
EVISTA
appears to be about as effective as tamoxifen in postmenopausal women and to have a lower risk of blood clots and cataracts. Both drugs may also increase bone density and thus benefit women who have osteoporosis. For postmenopausal women, raloxifene Some Trade Names
EVISTA
is an alternative to tamoxifen.

Treatment

Usually, treatment begins after the woman's condition has been thoroughly evaluated, about a week or more after the biopsy. Treatment options depend on the stage and type of breast cancer. However, treatment is complex because the different types of breast cancer differ greatly in growth rate, tendency to spread (metastasize), and response to treatment. Also, much is still unknown about breast cancer. Consequently, doctors may have different opinions about the most appropriate treatment for a particular woman.

The preferences of a woman and her doctor affect treatment decisions. Women with breast cancer should ask for a clear explanation of what is known about the cancer and what is still unknown, as well as a complete description of treatment options. Then, they can consider the advantages and disadvantages of the different treatments and accept or reject the options offered. Losing some or all of a breast can be emotionally traumatic. Women must consider how they feel about this treatment, which can deeply affect their sense of wholeness and sexuality.

Doctors may ask women with breast cancer to participate in research studies investigating a new treatment. New treatments aim to improve the chances of survival or quality of life. All women who participate in a research study are treated because a new treatment is compared with other effective treatments. Women should ask their doctor to explain the risks and possible benefits of participation, so that they can make a well-informed decision.

Treatment usually involves surgery and may include radiation therapy, chemotherapy, or hormone-blocking drugs. Often, a combination of these treatments is used.

Surgery for Breast Cancer

Surgery for breast cancer consists of two main options.

In breast-conserving surgery, only the tumor and an area of normal tissue surrounding it are removed. Breast-conserving surgery includes the following:

Lumpectomy: A small amount of surrounding normal tissue is removed.
Wide excision (partial mastectomy): A somewhat larger amount of the surrounding normal tissue is removed
Quadrantectomy: One fourth of the breast is removed.

In mastectomy, all breast tissue is removed.

Surgery: The cancerous tumor and varying amounts of the surrounding tissue are removed. There are two main options for removing the tumor: breast-conserving surgery and removal of the breast (mastectomy). For women with invasive cancer (stage I or higher), mastectomy is no more effective than breast-conserving surgery plus radiation therapy as long as the entire tumor can be removed during breast-conserving surgery. Before surgery, chemotherapy may be used to shrink the tumor before removing it. This approach sometimes enables some women to have breast-conserving surgery rather than mastectomy.

Breast-conserving surgery leaves as much of the breast intact as possible. There are several types:

Lumpectomy is removal of the tumor with a small amount of surrounding normal tissue.
Wide excision or partial mastectomy is removal of the tumor and a somewhat larger amount of surrounding normal tissue.
Quadrantectomy is removal of one fourth of the breast.

Removing the tumor with some normal tissue provides the best chance of preventing cancer from recurring within the breast. Breast-conserving surgery is usually combined with radiation therapy.

The major advantage of breast-conserving surgery is cosmetic: This surgery may help preserve body image. Thus, when the tumor is large in relation to the breast, this type of surgery is less likely to be useful. In such cases, removing the tumor plus some surrounding normal tissue means removing most of the breast. Breast-conserving surgery is usually more appropriate when tumors are small. In about 15% of women who have breast-conserving surgery, the amount of tissue removed is so small that little difference can be seen between the treated and untreated breasts. However, in most women, the treated breast shrinks somewhat and may change in contour.

Mastectomy is the other main surgical option. There are several types:

Simple mastectomy consists of removing all breast tissue but leaving the muscle under the breast and enough skin to cover the wound. Reconstruction of the breast is much easier if these tissues are left. A simple mastectomy, rather than breast-conserving surgery, is usually done when there is a substantial amount of cancer in the milk ducts.
Modified radical mastectomy consists of removing all breast tissue and some lymph nodes in the armpit but leaving the muscle under the breast. This procedure is usually done instead of a radical mastectomy.
Radical mastectomy consists of removing all breast tissue plus the lymph nodes in the armpit and the muscle under the breast. This procedure is rarely done now.

Lymph node surgery (lymph node dissection) is also done if the cancer is or is suspected to be invasive. Nearby lymph nodes (usually about 10 to 20) are removed and examined to determine whether the cancer has spread to them. If cancer cells are detected in the lymph nodes, the cancer is more likely to have spread to other parts of the body. In such cases, additional treatment is needed. Removal of lymph nodes often causes problems because it affects the drainage of fluids in tissues. As a result, fluids may accumulate, causing persistent swelling (lymphedema) of the arm or hand. Arm and shoulder movement may be limited. Lymphedema may be treated by specially trained therapists. Women are taught how to massage the area, which may help the accumulated fluid drain, and how to apply a bandage, which helps keep fluid from reaccumulating. The affected arm should be used as normally as possible, except that the unaffected arm should be used for more heavy lifting. Women should exercise the arm daily as instructed and bandage the affected arm overnight indefinitely. Other problems include temporary or persistent numbness, a persistent burning sensation, and infection.

What Is a Sentinel Lymph Node?

A network of lymphatic vessels and lymph nodes drain fluid from the tissue in the breast. The lymph nodes are designed to trap foreign or abnormal cells (such as bacteria or cancer cells) that may be contained in this fluid. Sometimes cancer cells pass through the nodes into the lymphatic vessels and spread to other parts of the body. Usually, the fluid from breast tissue drains through a single nearby lymph node first, but it may drain through more than one. Such lymph nodes are called sentinel lymph nodes.

Doctors can identify the sentinel lymph node by injecting blue dye or a radioactive substance in the fluid surrounding the breast cells. Doctors use a scanner to observe the dye or detect the radioactive substance when it reaches the first lymph nodes. The sentinel lymph node is then removed and examined to determine whether it contains cancer cells. If it does, other nearby lymph nodes are removed. If the sentinel lymph node does not contain cancer cells, the other lymph nodes are not removed. However, this biopsy is not completely reliable. In about 2 to 3% of women, cancer has spread to other lymph nodes when the sentinel lymph node is clear.

A sentinel lymph node biopsy is an alternative that may minimize or avoid the problems of lymph node surgery. This procedure involves locating and removing the first lymph node (or nodes) that the tumor drains into. If this node contains cancer cells, the other lymph nodes are removed. If it does not, the other lymph nodes are not removed. Whether this procedure is as effective as standard lymph node surgery is being studied.

Breast reconstruction surgery may be done at the same time as a mastectomy or later. A silicone or saline implant or tissue taken from other parts of the woman's body may be used. The safety of silicone implants, which sometimes leak, has been questioned. However, there is almost no evidence suggesting that silicone leakage has serious effects.

Rebuilding a Breast

After a general surgeon removes a breast tumor and the surrounding breast tissue (mastectomy), a plastic surgeon may reconstruct the breast. A silicone or saline implant may be used. Or in a more complex operation, tissue may be taken from other parts of the woman's body, usually the abdomen. Reconstruction may be done at the same time as the mastectomy—a choice that involves being under anesthesia for a longer time—or later—a choice that involves being under anesthesia a second time.

In many women, a reconstructed breast looks more natural than one that has been treated with radiation therapy, especially if the tumor was large.

If a silicone or saline implant is used and enough skin was left to cover it, the sensation in the skin over the implant is relatively normal. However, neither type of implant feels like breast tissue to the touch. If skin from other parts of the body is used to cover the breast, much of the sensation is lost. However, tissue from other parts of the body feels more like breast tissue than does a silicone or saline implant.

Silicone occasionally leaks out of its sack. As a result, an implant can become hard, cause discomfort, and appear less attractive. Also, silicone sometimes enters the bloodstream. Some women are concerned about whether the leaking silicone causes cancer in other parts of the body or rare diseases such as systemic lupus erythematosus (lupus). There is almost no evidence suggesting that silicone leakage has these serious effects, but because it might, the use of silicone implants has decreased, especially among women who have not had breast cancer.

Radiation Therapy: This treatment is used to kill cancer cells at and near the site from which the tumor was removed, including nearby lymph nodes. Radiation therapy after mastectomy reduces the risk of cancer recurring near the site and in nearby lymph nodes. It may improve the chances of survival of women who have large tumors or cancer that has spread to several nearby lymph nodes.

Side effects include swelling in the breast, reddening and blistering of the skin in the treated area, and fatigue. These effects usually disappear within several months, up to about 12 months. Fewer than 5% of women treated with radiation therapy have rib fractures that cause minor discomfort. In about 1% of women, the lungs become mildly inflamed 6 to 18 months after radiation therapy is completed. Inflammation causes a dry cough and shortness of breath during physical activity that last for up to about 6 weeks.

To improve radiation therapy, doctors are studying several new procedures. Many of these aim to target radiation to the cancer more precisely and spare the rest of the breast from the effects of radiation. In one procedure, tiny radioactive seeds are inserted through a catheter to the tumor site. Radiation therapy can be completed in only 5 days. It is not clear whether these new procedures are as effective as traditional radiation therapy.

Drugs: Chemotherapy and hormone-blocking drugs can suppress the growth of cancer cells throughout the body. Chemotherapy and sometimes hormone-blocking drugs are used in addition to surgery and radiation therapy if cancer cells are detected in the lymph nodes and often if they are not. These drugs are often started soon after breast surgery and are continued for several months. Some, such as tamoxifen, may be continued for up to 5 years. These drugs delay the recurrence of cancer and prolong survival in most women. Analyzing the genetic material of the cancer (predictive genomic testing) may help predict which cancers are susceptible to chemotherapy or hormone-blocking drugs.

Chemotherapy is used to kill rapidly multiplying cells or slow their multiplication. Chemotherapy alone cannot cure breast cancer. It must be used with surgery or radiation therapy. Chemotherapy drugs are usually given intravenously in cycles. Sometimes they are given by mouth. Typically, a day of treatment is followed by several weeks of recovery. Using several chemotherapy drugs together is more effective than using a single drug. The choice of drugs depends partly on whether cancer cells are detected in nearby lymph nodes. Commonly used drugs include cyclophosphamide Some Trade Names
LYOPHILIZED CYTOXAN
, doxorubicin Some Trade Names
DOXIL
, epirubicin Some Trade Names
ELLENCE
, fluorouracil Some Trade Names
CARAC
, methotrexate Some Trade Names
TREXALL
, and paclitaxel Some Trade Names
ABRAXANETAXOL
(see Prevention and Treatment of Cancer: Chemotherapy Drugs). Side effects (such as vomiting, nausea, hair loss, and fatigue) vary depending on which drugs are used. Chemotherapy can cause infertility and early menopause by destroying the eggs in the ovaries. Chemotherapy may also suppress the production of blood cells by the bone marrow. So drugs, such as filgrastim Some Trade Names
NEUPOGEN
or pegfilgrastim Some Trade Names
NEULASTA
, may by used to stimulate the bone marrow.

Hormone-blocking drugs interfere with the actions of estrogen or progesterone Some Trade Names
CRINONEENDOMETRIN
, which stimulate the growth of cancer cells that have estrogen or progesterone Some Trade Names
CRINONEENDOMETRIN
receptors. These drugs may be used when cancer cells have these receptors.

Tamoxifen: Tamoxifen, given by mouth, is a selective estrogen-receptor modulator. It binds with estrogen receptors and inhibits growth of breast tissue. In women who have estrogen receptor-positive cancer, tamoxifen increases the likelihood of survival during the first 10 years after diagnosis by about 20 to 25%. Tamoxifen, which is related to estrogen, has some of the benefits and risks of estrogen therapy taken after menopause (see Menopause: Hormone Therapy). For example, it may decrease the risk of osteoporosis and fractures. It increases the risk of blood clots in the legs and lungs. It also substantially increases the risk of developing endometrial cancer. Thus, if women taking tamoxifen have spotting or bleeding from the vagina, they should see their doctor. However, the improvement in survival after breast cancer far outweighs the risk of endometrial cancer. Tamoxifen, unlike estrogen therapy, may worsen the vaginal dryness or hot flashes that occur after menopause. Tamoxifen is usually taken for 5 years.
Aromatase inhibitors: These drugs ( anastrozole Some Trade Names
ARIMIDEX
, exemestane Some Trade Names
AROMASIN
, and letrozole Some Trade Names
FEMARA
) inhibit aromatase (an enzyme that converts some hormones to estrogen) and thus may reduce the production of estrogen. In postmenopausal women, these drugs may be more effective than tamoxifen. These drugs may be given with tamoxifen or after tamoxifen has been used for 5 years. Aromatase inhibitors may increase the risk of osteoporosis.

Monoclonal antibodies are synthetic copies (or slightly modified versions) of natural substances that are part of the body's immune system. These drugs enhance the immune system's ability to fight cancer. Trastuzumab Some Trade Names
HERCEPTIN
, a monoclonal antibody, is used with chemotherapy to treat metastatic breast cancer only when the cancer cells have too many HER2 receptors. This drug binds with HER2 receptors and thus helps prevent cancer cells from multiplying. Trastuzumab Some Trade Names
HERCEPTIN
is usually taken for a year. It can weaken the heart muscle.

Treating Cancer Based on Type
Type	Possible Treatments
Ductal carcinoma in situ	Mastectomy Wide excision with or without radiation therapy
Lobular carcinoma in situ	Observation plus regular examinations and mammograms Tamoxifen or, for some postmenopausal women, raloxifene Some Trade Names EVISTA to reduce the risk of invasive cancer Bilateral mastectomy (rarely) to prevent invasive cancers
Stages I and II (early-stage) cancer	Chemotherapy before surgery if the tumor is larger than 2 inches (5 centimeters) Breast-conserving surgery to remove the tumor and some surrounding tissue, usually followed by radiation therapy Sometimes mastectomy with breast reconstruction After surgery, chemotherapy, hormonal therapy, trastuzumab Some Trade Names HERCEPTIN , or a combination, except in some postmenopausal women with tumors smaller than 0.4 inches (1 centimeter)
Stage III (locally advanced) cancer (including inflammatory breast cancer)	Chemotherapy or sometimes hormonal therapy before surgery to reduce the tumor's size Breast-conserving surgery or mastectomy if the tumor is small enough to be completely removed Mastectomy for inflammatory breast cancer Usually, radiation therapy after surgery Sometimes chemotherapy, hormonal therapy, or both after surgery
Stage IV (metastatic) cancer	If cancer causes symptoms and occurs in several sites, hormone therapy, ovarian ablation therapy*, or chemotherapy If the cancer cells have too many HER2 receptors, trastuzumab Some Trade Names HERCEPTIN Radiation therapy for the following: Metastases to the brain Metastases that recur in the skin Metastases that occur in one area of bone and that cause symptoms For metastases to bone, IV bisphosphonates (such as zoledronate Some Trade Names See Zoledronic acid or pamidronate Some Trade Names AREDIA ) to reduce bone pain and bone loss
Paget's disease of the nipple	Usually, the same as for other types of breast cancer Occasionally, local excision only
Breast cancer that recurs in the breast or nearby structures	Radical or modified radical mastectomy sometimes preceded by chemotherapy or hormone therapy
Phyllodes tumors if they are cancerous	Wide excision Mastectomy if the tumor is large
*Ovarian ablation therapy involves removing the ovaries or using drugs to suppress estrogen production by the ovaries.

Treatment of Noninvasive Cancer (Stage 0)

For ductal carcinoma in situ, treatment usually consists of a simple mastectomy or wide excision with or without radiation therapy.

For lobular carcinoma in situ, treatment is less clear-cut. For many women, the preferred treatment is close observation with no treatment. Observation consists of a physical examination every 6 to 12 months for 5 years and once a year thereafter plus mammography once a year. No treatment is usually needed. Although invasive breast cancer may develop (the risk is 1.3% per year or 26% for 20 years), the invasive cancers that develop are usually not fast growing and can usually be treated effectively. Furthermore, because invasive cancer is equally likely to develop in either breast, the only way to eliminate the risk of breast cancer for women with lobular carcinoma in situ is removal of both breasts (bilateral mastectomy). Some women, particularly those who are at high risk of developing invasive breast cancer, choose this option.

Alternatively, tamoxifen, a hormone-blocking drug, may be given for 5 years. It reduces but does not eliminate the risk of developing invasive cancer. Women with lobular carcinoma in situ are often given tamoxifen, but postmenopausal women may be given raloxifene Some Trade Names
EVISTA
.

Treatment of Localized or Regional Invasive Cancer (Stages I through III)

For cancers that have not spread beyond nearby lymph nodes, treatment almost always includes surgery to remove as much of the tumor as possible. Nearby lymph nodes or the sentinel lymph node are sampled to help stage the cancer.

A simple mastectomy or breast-conserving surgery is commonly used to treat invasive cancer that has spread extensively within the milk ducts (invasive ductal carcinoma). Breast-conserving surgery is used only when the tumor is not too large because the entire tumor plus some of the surrounding normal tissue must be removed.

Whether radiation therapy, chemotherapy, or both are used after surgery depends on how large the tumor is and how many lymph nodes contain cancer cells. Breast-conserving surgery is usually followed by radiation therapy. Sometimes, when the tumor is too large for breast-conserving surgery, chemotherapy is given before surgery to reduce the size of the tumor. If chemotherapy reduces the size of the tumor enough, breast-conserving surgery may be possible. After surgery and radiation therapy, additional chemotherapy is usually given. If the cancer has estrogen receptors, women who are still menstruating are usually given tamoxifen, and postmenopausal women are given an aromatase inhibitor.

Treatment of Cancer That Has Spread (Stage IV)

Breast cancer that has spread beyond the lymph nodes is rarely cured, but most women who have it live at least 2 years and a few live 10 to 20 years. Treatment extends life only slightly but may relieve symptoms and improve quality of life. However, some treatments have troublesome side effects. Thus, the decision of whether to be treated and, if so, which treatment to choose can be highly personal.

Most women are treated with chemotherapy or hormone-blocking drugs. However, chemotherapy, especially regimens that have uncomfortable side effects, are often postponed until symptoms (pain or other discomfort) develop or the cancer starts to worsen quickly. Pain is usually treated with analgesics. Other drugs may be given to relieve other symptoms. Chemotherapy or hormone-blocking drugs are given to relieve symptoms and improve quality of life rather than to prolong life. The most effective chemotherapy regimens for breast cancer that has spread include capecitabine Some Trade Names
XELODA
, cyclophosphamide Some Trade Names
LYOPHILIZED CYTOXAN
, docetaxel Some Trade Names
TAXOTERE
, doxorubicin Some Trade Names
DOXIL
, epirubicin Some Trade Names
ELLENCE
, gemcitabine Some Trade Names
GEMZAR
, paclitaxel Some Trade Names
ABRAXANETAXOL
, and vinorelbine Some Trade Names
NAVELBINE
.

Hormone-blocking drugs are preferred to chemotherapy in certain situations. For example, these drugs may be preferred when the cancer is estrogen receptor-positive, when cancer has not recurred for more than 2 years after diagnosis and initial treatment, or when cancer is not immediately life threatening. Different drugs are used in different situations:

Tamoxifen: For women who are still menstruating, tamoxifen is usually the first hormone-blocking drug used because it has few side effects.
Aromatase inhibitors: For postmenopausal women who have estrogen receptor-positive breast cancer, aromatase inhibitors (such as anastrozole Some Trade Names
ARIMIDEX
, letrozole Some Trade Names
FEMARA
, and exemestane Some Trade Names
AROMASIN
) may be more effective as a first treatment than tamoxifen.
Progestins: These drugs, such as medroxyprogesterone or megestrol Some Trade Names
MEGACE
, may be used instead of aromatase inhibitors and tamoxifen and have almost as few side effects.
Fulvestrant: This drug may be used when tamoxifen is no longer effective. It destroys the estrogen receptors in cancer cells. The most common side effect is stomach upset.

Alternatively, for women who are still menstruating, surgery to remove the ovaries, radiation to destroy them, or drugs to inhibit their activity (such as buserelin Some Trade Names
ETILAMIDE
, goserelin Some Trade Names
ZOLADEX
, or leuprolide Some Trade Names
LUPRON
) may be used to stop estrogen production.

For cancers that have too many HER2 receptors and that have spread throughout the body, trastuzumab Some Trade Names
HERCEPTIN
can be used alone or with chemotherapy such as paclitaxel Some Trade Names
ABRAXANETAXOL
. Trastuzumab Some Trade Names
HERCEPTIN
can also be used with hormone-blocking drugs to treat women who have estrogen receptor-positive breast cancer.

In some situations, radiation therapy may be used instead of or before drugs. For example, if only one area of cancer is detected and that area is in a bone, radiation to that bone might be the only treatment used. Radiation therapy is usually the most effective treatment for cancer that has spread to bone, sometimes keeping it in check for years. It is also often the most effective treatment for cancer that has spread to the brain.

Surgery may be done to remove single tumors in other parts of the body (such as the brain) because such surgery can relieve symptoms.

Bisphosphonates (used to treat osteoporosis), such as pamidronate Some Trade Names
AREDIA
or zoledronate Some Trade Names
See Zoledronic acid
, reduce bone pain and bone loss and may prevent or delay bone problems that can result when cancer spreads to bone.

Treatment of Specific Types of Breast Cancer

For inflammatory breast cancer, treatment usually consists of both chemotherapy and radiation therapy. Mastectomy is usually done.

For Paget's disease of the nipple, treatment is usually similar to that of other types of breast cancer. It often involves simple mastectomy or breast-conserving surgery plus removal of the lymph nodes. Breast-conserving surgery is usually followed by radiation therapy. Less commonly, only the nipple with some surrounding normal tissue is removed.

For phyllodes tumors that are cancerous, treatment usually consists of wide excision. The tumor and a large amount of surrounding normal tissue are removed. If the tumor is large in relation to the breast, a simple mastectomy may be done. After surgical removal, about 20 to 35% of cancers recur near the same site.

Follow-up Care

After treatment is completed, follow-up physical examinations, including examination of the breasts, chest, neck, and armpits, are done every 3 months for 2 years, then every 6 months for 5 years from the date the cancer was diagnosed. Regular mammograms and breast self-examinations are also important. Women should promptly report certain symptoms to their doctor:

Any changes in their breasts
Pain
Loss of appetite or weight
Changes in menstruation
Bleeding from the vagina (if not associated with menstrual periods)
Blurred vision
Any symptoms that seem unusual or that persist

Diagnostic procedures, such as chest x-rays, blood tests, bone scans, and computed tomography (CT), are not needed unless symptoms suggest the cancer has recurred.

The effects of treatment for breast cancer cause many changes in a woman's life. Support from family members and friends can help, as can support groups. Counseling may be helpful.

End-of-Life Issues

For women with metastatic breast cancer, quality of life may deteriorate and the chances that further treatment will prolong life may be small. Staying comfortable may eventually become more important than trying to prolong life. Cancer pain can be adequately controlled with appropriate drugs (see Death and Dying: Pain). So if women are having pain, they should ask their doctor for treatment to relieve it. Treatments can also relieve other troublesome symptoms, such as constipation, difficulty breathing, and nausea. Psychologic and spiritual counseling may also help.

Women with metastatic breast cancer should prepare advance directives indicating the type of care they desire in case they are no longer able to make such decisions (see Legal and Ethical Issues: Advance Directives). Also, making or updating a will is important.

Puberty

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Puberty is a sequence of events in which physical changes occur, resulting in adult physical characteristics and capacity to reproduce. These physical changes are regulated by changes in the levels of hormones that are produced by the pituitary gland—luteinizing hormone and follicle-stimulating hormone. At birth, levels of these hormones are high, but they decrease within a few months and remain low until puberty. Early in puberty, levels of luteinizing hormone and follicle-stimulating hormone increase, stimulating the production of sex hormones. The increased levels of sex hormones (primarily estrogen) result in physical changes, including maturation of the breasts, ovaries, uterus, and vagina. Normally, these changes occur sequentially during puberty, resulting in sexual maturity (see Adolescents:Physical and Sexual Development).

The first change of puberty is usually the start of breast development (breast budding). In girls who live in the United States, this change usually occurs around age 8 to 13. Shortly afterward, pubic and underarm hair begin to grow. The interval from breast budding to the first menstrual period is usually about 2½ years. In the United States, girls, on average, have their first period when they are almost 13. The girl's body shape changes, and the percentage of body fat increases.

The growth spurt accompanying puberty typically begins about when pubic and underarm hair begin to grow. Growth is fastest relatively early in puberty (before menstrual periods begin) and peaks at about age 12. Then growth slows considerably, usually stopping between the ages of 14 and 16

Menstrual Cycle

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Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding. It occurs in approximately monthly cycles throughout a woman's reproductive life, except during pregnancy. Menstruation starts during puberty (at menarche) and stops permanently at menopause (see Menopause: Introduction).

By definition, the menstrual cycle begins with the first day of bleeding, which is counted as day 1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Usually, the cycles vary the most and the intervals between periods are longest in the years immediately after menarche and before menopause.

Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges from ½ to 2½ ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce of blood. Menstrual blood, unlike blood resulting from an injury, usually does not clot unless the bleeding is very heavy.

The menstrual cycle is regulated by hormones. Luteinizing hormone and follicle-stimulating hormone, which are produced by the pituitary gland, promote ovulation and stimulate the ovaries to produce estrogen andprogesterone
. Estrogen and progesterone
stimulate the uterus and breasts to prepare for possible fertilization. The cycle has three phases: follicular (before release of the egg), ovulatory (egg release), and luteal (after egg release).

Changes During the Menstrual Cycle

The menstrual cycle is regulated by the complex interaction of hormones: luteinizing hormone, follicle-stimulating hormone, and the female sex hormones estrogen and progesterone
.

The menstrual cycle begins with menstrual bleeding (menstruation), which marks the first day of the follicular phase. Bleeding occurs after estrogen and progesterone
levels decrease at the end of the previous cycle. This decrease causes the top layers of thickened lining of the uterus (endometrium) to break down and be shed. About this time, the follicle-stimulating hormone level increases slightly, stimulating the development of several ovarian follicles. Each follicle contains an egg. Later, as the follicle-stimulating hormone level decreases, only one follicle continues to develop. This follicle produces estrogen.

The ovulatory phase begins with a surge in luteinizing hormone and follicle-stimulating hormone levels. Luteinizing hormone stimulates egg release (ovulation), which usually occurs 16 to 32 hours after the surge begins. The estrogen level peaks during the surge, and the progesterone
level starts to increase.

During the luteal phase, luteinizing hormone and follicle-stimulating hormone levels decrease. The ruptured follicle closes after releasing the egg and forms a corpus luteum, which produces progester-one. During most of this phase, the estrogen level is high. Progesterone
and estrogen cause the lining of the uterus to thicken more, to prepare for possible fertilization. If the egg is not fertilized, the corpus luteum degenerates and no longer produces progesterone
, the estrogen level decreases, the top layers of the lining break down and are shed, and a new menstrual cycle begins.

Follicular Phase: This phase begins on the first day of menstrual bleeding (day 1). But the main event in this phase is the development of follicles in the ovaries.

At the beginning of the follicular phase, the lining of the uterus (endometrium) is thick with fluids and nutrients designed to nourish an embryo. If no egg has been fertilized, estrogen and progesterone
levels are low. As a result, the top layers of the endometrium are shed, and menstrual bleeding occurs.

About this time, the pituitary gland slightly increases its production of follicle-stimulating hormone. This hormone then stimulates the growth of 3 to 30 follicles. Each follicle contains an egg. Later in the phase, as the level of this hormone decreases, only one of these follicles (called the dominant follicle) continues to grow. It soon begins to produce estrogen, and the other stimulated follicles begin to break down.

On average, the follicular phase lasts about 13 or 14 days. Of the three phases, this phase varies the most in length. It tends to become shorter near menopause. This phase ends when the level of luteinizing hormone increases dramatically (surges). The surge results in release of the egg (ovulation).

Ovulatory Phase: This phase begins when the level of luteinizing hormone surges. Luteinizing hormone stimulates the dominant follicle to bulge from the surface of the ovary and finally rupture, releasing the egg. The level of follicle-stimulating hormone increases to a lesser degree. The function of the increase in follicle-stimulating hormone is not understood

The ovulatory phase usually lasts 16 to 32 hours. It ends when the egg is released.

About 12 to 24 hours after the egg is released, the surge in luteinizing hormone can be detected by measuring the level of this hormone in urine. This measurement can be used to determine when women are fertile. The egg can be fertilized for only up to about 12 hours after its release. Fertilization is more likely when sperm are present in the reproductive tract before the egg is released.

Around the time of ovulation, some women feel a dull pain on one side of the lower abdomen. This pain is known as mittelschmerz (literally, middle pain). The pain may last for a few minutes to a few hours. The pain is felt on the same side as the ovary that released the egg, but the precise cause of the pain is unknown. The pain may precede or follow the rupture of the follicle and may not occur in all cycles. Egg release does not alternate between the two ovaries and appears to be random. If one ovary is removed, the remaining ovary releases an egg every month.

Luteal Phase: This phase begins after ovulation. It lasts about 14 days (unless fertilization occurs) and ends just before a menstrual period. In this phase, the ruptured follicle closes after releasing the egg and forms a structure called a corpus luteum, which produces increasing quantities of progesterone
. The corpus luteum prepares the uterus in case fertilization occurs. The progesterone
produced by the corpus luteum causes the endometrium to thicken, filling with fluids and nutrients to nourish a potential fetus.Progesterone
causes the mucus in the cervix to thicken, so that sperm or bacteria are less likely to enter the uterus. Progesterone
also causes body temperature to increase slightly during the luteal phase and remain elevated until a menstrual period begins. This increase in temperature can be used to estimate whether ovulation has occurred (seeInfertility: Problems With Ovulation). During most of the luteal phase, the estrogen level is high. Estrogen also stimulates the endometrium to thicken.

The increase in estrogen and progesterone
levels causes milk ducts in the breasts to widen (dilate). As a result, the breasts may swell and become tender.

If the egg is not fertilized, the corpus luteum degenerates after 14 days, and a new menstrual cycle begins. If the egg is fertilized, the cells around the developing embryo begin to produce a hormone called human chorionic gonadotropin. This hormone maintains the corpus luteum, which continues to produce progesterone
, until the growing fetus can produce its own hormones. Pregnancy tests are based on detecting an increase in the human chorionic gonadotropin level.

Internal Genital Organs

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The internal genital organs form a pathway (the genital tract). This pathway consists of the following:

Vagina (part of the birth canal), where sperm are deposited and from which a baby can emerge
Uterus, where an embryo can develop into a fetus
Fallopian tubes (oviducts), where a sperm can fertilize an egg
Ovaries, which produce and release eggs

Sperm can travel up the tract, and eggs down the tract.

Internal Female Genital Organs

Vagina: The vagina is a narrow, muscular but elastic organ about 4 to 5 inches long in an adult woman. It connects the external genital organs to the uterus. The vagina is the main female organ of sexual intercourse. The penis is inserted into it. It is the passageway for sperm to the egg and for menstrual bleeding or a baby to the outside.

Usually, there is no space inside the vagina unless it is stretched open—for example, during an examination, sexual intercourse, or childbirth. The lower third of the vagina is surrounded by elastic muscles that control the diameter of its opening. These muscles contract rhythmically and involuntarily during orgasm.

The vagina is lined with a mucous membrane, kept moist by fluids oozing from cells on its surface and by secretions from glands in the cervix (the lower part of the uterus). A small amount of these fluids may pass to the outside as a clear or milky white vaginal discharge, which is normal. During a woman's reproductive years, the lining of the vagina has folds and wrinkles. Before puberty and after menopause (if the woman is not taking estrogen), the lining is smooth.

Uterus and Cervix: The uterus is a thick-walled, muscular, pear-shaped organ located in the middle of the pelvis, behind the bladder, and in front of the rectum. The uterus is anchored in position by several ligaments. The main function of the uterus is to sustain a developing fetus. The uterus consists of the cervix and the main body (corpus).

The cervix is the lower part of the uterus, which protrudes into the upper end of the vagina. It can be seen during a pelvic examination. Like the vagina, the cervix is lined with a mucous membrane, but the mucous membrane of the cervix is smooth.

Sperm can enter and menstrual blood can exit the uterus through a channel in the cervix. The channel is usually narrow, but during labor, the channel widens to let the baby through. The cervix is usually a good barrier against bacteria, except around the time an egg is released by the ovaries (ovulation), during the menstrual period, or during labor. Bacteria that cause sexually transmitted diseases (see Sexually Transmitted Diseases: Introduction) can enter the uterus through the cervix during sexual intercourse.

The channel through the cervix is lined with glands that secrete mucus. This mucus is thick and impenetrable to sperm until just before ovulation. At ovulation, the consistency of the mucus changes so that sperm can swim through it and fertilization can occur. At this time, the mucus-secreting glands of the cervix can store live sperm for up to about 5 days, but occasionally slightly longer. These sperm can later move up through the corpus and into the fallopian tubes to fertilize an egg. Almost all pregnancies result from intercourse that occurs during the 3 days before ovulation. However, pregnancies sometimes result from intercourse that occurs up to 6 days before ovulation or during the 3 days after ovulation. For some women, the time between a menstrual period and ovulation varies from month to month. Consequently, pregnancy can occur at different times during a menstrual cycle.

The corpus of the uterus, which is highly muscular, can stretch to accommodate a growing fetus. Its muscular walls contract during labor to push the baby out through the cervix and the vagina. During the reproductive years, the corpus is twice as long as the cervix. After menopause, the reverse is true.

As part of a woman's reproductive cycle (which usually lasts about a month), the lining of the corpus (endometrium) thickens. If the woman does not become pregnant during that cycle, most of the endometrium is shed and bleeding occurs, resulting in the menstrual period.

Fallopian Tubes: The two fallopian tubes, which are about 2 to 3 inches (about 5 to 7 centimeters) long, extend from the upper edges of the uterus toward the ovaries. The tubes do not directly connect with the ovaries. Instead, the end of each tube flares into a funnel shape with fingerlike extensions (fimbriae). When an egg is released from an ovary, the fimbriae guide the egg into the relatively large opening of a fallopian tube.

The fallopian tubes are lined with tiny hairlike projections (cilia). The cilia and the muscles in the tube's wall propel an egg downward through the tube to the uterus. The egg may be fertilized by a sperm in the fallopian tube (see Normal Pregnancy: Fertilization).

Ovaries: The ovaries are usually pearl-colored, oblong, and about the size of a walnut. They are attached to the uterus by ligaments. In addition to producing female sex hormones (estrogen and progesterone
) and male sex hormones, the ovaries produce and release eggs. The developing egg cells (oocytes) are contained in fluid-filled cavities (follicles) in the wall of the ovaries. Each follicle contains one oocyte.

Effects of Aging

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Around menopause (see Menopause: Introduction), changes in the genital organs occur rapidly. Menstrual cycles stop, and the ovaries stop producing estrogen. After menopause, the tissues of the labia minora, clitoris, vagina, and urethra thin (atrophy). This thinning can result in chronic irritation, dryness, and a discharge from the vagina. Vaginal infections are more likely to develop. Also after menopause, the uterus, fallopian tubes, and ovaries become smaller.

With aging, there is a decrease in the amount of muscle and connective tissue, including that in muscles, ligaments, and other tissues that support the bladder, uterus, vagina, and rectum. As a result, the affected organs may sag or drop down (prolapse), sometimes causing a feeling of pelvic pressure or fullness, difficulty urinating, loss of control of urination or bowel movements (incontinence), or pain during sexual intercourse. Women who have had many children are more likely to have such problems.

Did You Know...
Some women enjoy sexual intercourse more after menopause.
Because there is less estrogen to stimulate milk ducts, the breasts decrease in size and may sag. The connective tissue that supports the breasts also decreases, contributing to sagging. Fibrous tissue in the breasts is replaced with fat, making the breasts less firm.

Despite these changes, many women enjoy sexual activity more after menopause, possibly because they are no longer able to become pregnant. In addition, after menopause, the ovaries and adrenal glands continue to produce male sex hormones. Male sex hormones help maintain the sex drive, slow the loss of muscle tissue, and contribute to an overall sense of well-being.

Internal Female Genital Organs

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At the beginning of the tract, just inside the opening of the vagina, is the hymen, a mucous membrane. In virgins, the hymen usually encircles the opening like a tight ring, but it may completely cover the opening. The hymen helps protect the genital tract but is not necessary for health. It may tear at the first attempt at sexual intercourse, or it may be so soft and pliable that no tearing occurs. The hymen may also be torn during exercise or insertion of a tampon or diaphragm. Tearing usually causes slight bleeding. In women who have had intercourse, the hymen may be unnoticeable or may form small tags of tissue around the vaginal opening.

Vagina: The vagina is a narrow, muscular but elastic organ about 4 to 5 inches long in an adult woman. It connects the external genital organs to the uterus. The vagina is the main female organ of sexual intercourse. The penis is inserted into it. It is the passageway for sperm to the egg and for menstrual bleeding or a baby to the outside.

Usually, there is no space inside the vagina unless it is stretched open—for example, during an examination, sexual intercourse, or childbirth. The lower third of the vagina is surrounded by elastic muscles that control the diameter of its opening. These muscles contract rhythmically and involuntarily during orgasm.

The vagina is lined with a mucous membrane, kept moist by fluids oozing from cells on its surface and by secretions from glands in the cervix (the lower part of the uterus). A small amount of these fluids may pass to the outside as a clear or milky white vaginal discharge, which is normal. During a woman's reproductive years, the lining of the vagina has folds and wrinkles. Before puberty and after menopause (if the woman is not taking estrogen), the lining is smooth.

Uterus and Cervix: The uterus is a thick-walled, muscular, pear-shaped organ located in the middle of the pelvis, behind the bladder, and in front of the rectum. The uterus is anchored in position by several ligaments. The main function of the uterus is to sustain a developing fetus. The uterus consists of the cervix and the main body (corpus).

The cervix is the lower part of the uterus, which protrudes into the upper end of the vagina. It can be seen during a pelvic examination. Like the vagina, the cervix is lined with a mucous membrane, but the mucous membrane of the cervix is smooth.

Sperm can enter and menstrual blood can exit the uterus through a channel in the cervix. The channel is usually narrow, but during labor, the channel widens to let the baby through. The cervix is usually a good barrier against bacteria, except around the time an egg is released by the ovaries (ovulation), during the menstrual period, or during labor. Bacteria that cause sexually transmitted diseases (see Sexually Transmitted Diseases: Introduction) can enter the uterus through the cervix during sexual intercourse.

The channel through the cervix is lined with glands that secrete mucus. This mucus is thick and impenetrable to sperm until just before ovulation. At ovulation, the consistency of the mucus changes so that sperm can swim through it and fertilization can occur. At this time, the mucus-secreting glands of the cervix can store live sperm for up to about 5 days, but occasionally slightly longer. These sperm can later move up through the corpus and into the fallopian tubes to fertilize an egg. Almost all pregnancies result from intercourse that occurs during the 3 days before ovulation. However, pregnancies sometimes result from intercourse that occurs up to 6 days before ovulation or during the 3 days after ovulation. For some women, the time between a menstrual period and ovulation varies from month to month. Consequently, pregnancy can occur at different times during a menstrual cycle.

The corpus of the uterus, which is highly muscular, can stretch to accommodate a growing fetus. Its muscular walls contract during labor to push the baby out through the cervix and the vagina. During the reproductive years, the corpus is twice as long as the cervix. After menopause, the reverse is true.

As part of a woman's reproductive cycle (which usually lasts about a month), the lining of the corpus (endometrium) thickens. If the woman does not become pregnant during that cycle, most of the endometrium is shed and bleeding occurs, resulting in the menstrual period.

Fallopian Tubes: The two fallopian tubes, which are about 2 to 3 inches (about 5 to 7 centimeters) long, extend from the upper edges of the uterus toward the ovaries. The tubes do not directly connect with the ovaries. Instead, the end of each tube flares into a funnel shape with fingerlike extensions (fimbriae). When an egg is released from an ovary, the fimbriae guide the egg into the relatively large opening of a fallopian tube.

The fallopian tubes are lined with tiny hairlike projections (cilia). The cilia and the muscles in the tube's wall propel an egg downward through the tube to the uterus. The egg may be fertilized by a sperm in the fallopian tube (see Normal Pregnancy: Fertilization).

Ovaries: The ovaries are usually pearl-colored, oblong, and about the size of a walnut. They are attached to the uterus by ligaments. In addition to producing female sex hormones (estrogen and progesterone

) and male sex hormones, the ovaries produce and release eggs. The developing egg cells (oocytes) are contained in fluid-filled cavities (follicles) in the wall of the ovaries. Each follicle contains one oocyte.

Nice conditions

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Provocative movements

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The most difficult types of sexual intercourse

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Enlarge penis size pictures

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Increase the size or penis enlargement

Introduction:
Consists of the male reproductive system of the penis and testicles and prostate gland and seminal vesicles Penis consists of spongy body which is responsible for erectile dysfunction the penis and inside there is a channel called the channel through which urine passes from the urine as well as sperm The length of the penis in the case of relaxation between 6.7 to 4.11 cm The length of the penis in the case of erectile dysfunction between 12.7-15.25 cm and the diameter of the penis 11.4-14 cm To increase or enlarge the penis there are exercises can be exercised manually and these exercises showed 100% complete shift in the size of the penis But this increase in penis size does not occur over night and overnight, but should exercise five days per week and continue to exercise a period of not less than 6 months After two or three weeks from the beginning exercises will notice an increase in penis size and the increase in the case of relaxation 2-inch (5 cm) compared to one inch in the case of erectile dysfunction and when you continue to exercise you will notice a real change and large in size of the penis after 6 months Exercise These exercises 5 days per week at one hour each day while taking two days rest, either consecutive or separate. Where a period of rest period and complete healing of the cells.

How do these exercises to increase penis size??
Penis consists of 3 rooms of sponge tissue and suck the blood of these tissues up to the bar and then lead to get an erection When you exercise on an ongoing basis and correct there is an expansion in the size of the rooms becomes able to absorb large amounts of blood and this leads to bigger penis size and purpose of the exercise to shed tensile strength and stretch the tissue responsible for the erection of the penis where lead these forces to an increase in tissue growth Alantsabip in be gradual and the new cells.
Legal Notice: (legal notice): -

I hope every person looking for ways to enlarge penis consulting urologist to get medical advice as to whether this exercise does not affect it, especially people with certain diseases such as diabetes and cirrhosis of the liver and respiratory diseases and other diseases that affect the flow of blood and oxygen to the penis and the process of renewal Alkhalai. We are in this site is not responsible for any injuries or health problems occur directly or indirectly as a result of what is to follow in this report.
Symptoms must be observed during the exercise: -
1 - There are bubbles on the penis is often a result of the use of pressure on the penis severely for a long time. 2 - sores in the penis to stretch the penis resulting in many 3 - swelling - resulting from the use of heavy weight on the penis for a long time and this affects the nerves in the penis, leading to infections and then swelling in the penis and the penis if the swelling may lead to atrophy and then the non-amenability to have an erection. Must stop exercise when you see these symptoms to completely disappear.
** Before starting to exercise should consider the following: -
1 - Shaving the pubic area of the hair to avoid pulling or hair pulling during the exercises. 2 - Eat a good diet rich in vitamins, minerals and proteins, where that food has no effect on the work of the penis as well as eating good amounts of water. 3 - the psychological state have a significant impact on this process where it is necessary to have a good mood before starting to exercise, and if you do not believe that these exercises will lead to bigger penis size it is because the negative impact on the process and makes it difficult to enlarge penis size to get. 4 - Develop a moisturizer on the penis, especially before exercise (Algelk) and prefers not to use soap and shampoo, since these substances lead to redness and irritation in the skin of the penis in long-term survival in addition to dryness of the skin and the occurrence of cracks and does not favor the use of Vaselinenormal type, where he was holding exercises. Prefer to use Vaseline with great care (vasline intensive care) where it can remain for a long time on the skin without causing irritation or damage in the skin of the penis and does not impede the movement of the hand as quickly as required during the exercises.

5 - Measuring the penis - before starting exercises enlarge penis size you must measure the penis: - First: - The size of the penis in the case of erectile dysfunction Must stand and endure the penile erection in the case of perpendicular to the body place the ruler next to the penis from the pubic bone and then read off the ruler to be up to the top of the head of the penis. And can measure the length of the penis without an erection erectile- Must stand up and be adjacent to the right knee left knee. - Hold the penis from the region that is located below the penis head and drag it forward and put a ruler next to the penis perpendicular to the pubic bone and a reading of the ruler to the top of the head of the penis.

Second: - measure the width of the penis in the case of erectile dysfunction: And by using a tape measure, measure penis circumference in the case of erectile dysfunction in the mid-point of the length of the penis.
Third: - measure the length of the penis in the case of relaxation: Can be measured in the penis when it is in the case of relaxation using the fingers of the hand can be expressed about the length of the penis by 5 or 4 fingers. And can be measured in the penis in the case of relaxation by using the ruler by putting over the penis and push the other side of the ruler toward the abdomen and then record the length of the penis starting from base of the penis towards the apex of the penis.

- Sign sleep on the back and from then measure the length of thepenis by using fingers or a ruler to score less than the length of therod as possible.

Vitamins and minerals and their impact on sexual activity: -
When your practice to enlarge the size of the program of the penisthere are types of vitamins and

Of minerals and herbs that should be contained in the daily diet were found to provide the body with a large card enhances the ability of nationality.
Vitamins: - 1000-2000 mg of vitamin C twice or three times a day. 20-30 mg of zinc (Zinc) 300-100 mg of vitamin A 400-200 mg of magnesium (mg) 500-100 international units (IU) of vitamin D 60-50 mg of Thiamin - Thiamin
Minerals that increase sexual activity:
1-525 mg of calcium. 200-200 micrograms of vitamin B12 3-150 mg of vitamin E 4-25 mg of potassium. 500-400 micrograms of folic acid.
- There are these vitamins and minerals in the pharmacies in the form of tablets.
To increase the amount of fluid outside of the penis when you ejaculate: -
Advise you to take 1000-1500 mg of the amino acid called L-Arginine per day so that helps to increase the amount of semen when you ejaculate and gives erections strong. - Advised to take 100 mg of it two hours before intercourse and must be cautious and not to eat large quantities of this article within 24 hours and when you see the side effects are advised to stop treatment. Consult your doctor before use.
Special exercises maximize the size of the penis: -
First: - the heating process of the important processes and the necessary process before starting any exercise to enlarge penis size, because the heating and allow a greater amount of blood to enter the penile tissues, as well as make the skin more flexible, making it easier to exercise.
There are some ways to keep warm: -
1 - wash towel hot or warm water and then we wrapped the towel around the penis, whether in the case of relaxation or erection leave the towel for a minute or minutes, and then restore the ball again, and then after we finished drying the area well.
2 - way Jacuzzi with light massage of the penis and not more than 10 minutes.
Second: - Exercise stretch or draw: - (25-30 minutes)
1 - After you start the process of heating penis penis exercise and relaxation in the case of Hold the penis by hand and press on the penis by hand and should not be pushed to the limit interrupt blood circulation in the penis. 2 - then never pull the penis to the outside by hand from the base of the penis head to drag this process must be as much as possible without pain continue the process of drawing 5 minutes after every minute of this five minutes, tried to pull strongly and more slowly. 3 - After completion of the withdrawal for 5 minutes, give the penis a break for one minute and make a circular motion of the rod by hand without pressure on him in order to facilitate the flow of blood in the penis. 4 - Repeat the process of withdrawal for a period of 4-5 times every time five minutes after the end of each time you withdraw the penis to the different directions up and down the right and the left and then restore the relaxation process as in No. 3 5 - After the expiry of the five Cashouts each one five minutes to pull the penis forward more vigorously for one minute and then withdraw the penis during 10 minutes Cashouts simple forward. Can note the difference in the size of the penis after two or three weeks and the difference is very clear after 3-4 months.

** Note when you penis in the maintenance of this exercise is a thumb in the back wall of the rod and the four fingers on the anteriorwall of the rod.

- no other way to exercise or stretch drawing: -

This method involves withdrawal of the penis in the case ofrelaxation and in the case of erectile dysfunction: -

1 - using the right hand grabbed the penis and pull it forward 10 times 15 seconds each pull. 2 - Replace the withdrawal of the penis to the right 10 times and 10 times to the left and down 10 times. 3 - When an erection in the penis penis grabbed by hand and pull it in front of ten times. 4 - and then repeat the process of withdrawal of the penis to the right ten times and to the left 10 times. 5 - when you drag the bar to the right and left multiply the penis gently and in the case of erectile dysfunction thigh towards ten times in each direction.
Third: - Exercise and turnover growth for a period of one minute
In this exercise, you move the rod in hand, whirling 30 times as much as make sure that the testis is covered by the second hand so as not to hurt during exercise.
This exercise increases blood flow to the penis gently and gives the state of semi-erection of the penis may need in the next exercise.
IV: A Olgelk (Jelq Method) ten minutes to twenty minutes
This is the way of the most popular methods for more than a hundred years old and can by this method to access the excellent results to enlarge the penis size and you should know that this method does not give results in day and night, but if applied properly the results show after five weeks of slightly But 6 months after the change is significant and this method is called Balasthlab or milking process.
How do we apply this method???
1 - Always remember to warm the penis, as previously stated. 2 - Use oil to moisten the penis such as Vaseline with great care and do not use soap or shampoo. 3 - Hold the penis by hand thumb and index finger and never clicking on the base of the penis and then drag in the form of milking from the base of the penis down towards the head of the penis and then repeat the exercise with the other after 3 seconds you will reach the state of semi-erection is required. 4 - Hold the base of the penis with pressure by the left hand by the thumb and index finger to form the letter O 5 - Hold the penis and then the right hand and driven in a manner similar to any milking pressure and withdrawn from the base of the penis to the head of the penis. 6 - Then we change the hands on the sites, respectively solve any of the right hand place the left hand and left hand the right place.
Repeat the exercise in the first week 200-300 visits per day strongly medium for 10 minutes. Repeat 300-500 in the second week back in the day strongly medium for 15 minutes. Repeat 500 times or more per day in the third week and more strongly as possible for 20 minutes
- If you find yourself and come to a full erection during exercise, stop the exercise for a few minutes into the penis to return to the case of semi-erection and then repeat the exercise. If you feel a desire to stop ejaculation exercise for a few minutes to go to this desire for libel.
Repeat this exercise 5 days each week. - During this exercise, notes that the head of the penis will expand and enter the amount due to more blood to it. You will notice in the first two weeks with redness or swelling of blueness, but this will decrease with time Algelk method should include all parts of the penis except the head of the penis.
Results obtained from this method are the results of a permanent increase in penis size in the case of erectile dysfunction and relax and in the case of erectile dysfunction increase more than the case of relaxation. Frequently asked questions about the way Algelk: - 1 - How much pressure should I be using during the exercise?? We can not determine the amount of pressure because this varies from man to another and the amount of carries, but should not feel pain as a result of pressure during exercise any pain that is determined by the amount of pressure. 2 - What do I do if I lose erection during exercise?? Most men can maintain an erection during the exercise, but if you lose you must re-erection penis to the case of semi-erection and remember always that the exercise can not be exercised except in the case of semi-erection. 3 - How do you know that exercise is being properly?? That the color of the penis where the penis becomes the color of dark red or dark purple, and without a sense of pain and if I felt the pain should ease the pressure on the penis. 4 - Is there a specific time for exercise, and is preferably before exercise or after sexual intercourse?? There is no specific time which may be conducted at any time and is not affected by the process of citizenship. 5 - occurs when the penis swells and swelling after the milking process, to what? If you have undergone a circumcision will happen before you have a bulge in the place that represents the effect of circumcision process hundreds of times after milking, but this method does not have any adverse effect it is the result of fluid build-up and will disappear after several hours
*** NOTE: Remember always that way Algelk exercise and penis in the case of semi-erection, while avoiding a full erection and ejaculation, and avoid, because the full erection with the way Algelk exposure increases the likelihood of penile tissues to rupture.

Five: - exercise reduce muscle PC

PC is an abbreviation of a muscle called Pubococcygeus and to be located almost from the bottom of the testicles to the anal regionand surrounding the muscle of the anus and prostate gland.
This is the muscle responsible for the strength of ejaculation in menand the process of training this muscle helps you get:

1 - strong erection.
2 - Strengthening the ejaculation.
3 - control of premature ejaculation.
4 - increase the effectiveness of the prostate gland.
How does this exercise??

Before you apply, you must exercise to learn how to be able to reduce the muscle PC Imagine yourself in a state prison and then try to urinate in the urine will feel a sudden movement or muscle contraction PC
There are several types of exercises to reduce the muscle and can choose any type of exercises practiced daily pictures:
1 - reduced muscle PC this exercise is a reduction and softening of the PC muscles repeatedly can start 40 times a day and then begin to increase day by day and by stamina to be able to reach 250-400 times a day the good thing about this exercise is that it can exercise anywhere in the home or office without anyone knowing it.
2 - cut with the pressure of the muscle PC: - This exercise is similar to the previous exercise and the only difference is we start by heating the muscle and then begin the process of reducing and softening of the muscle PC and when we get to the tenth time remaining muscle in the case of contraction for 25 seconds then take a rest for a minute and then return the ball once again preferred to practice this exercise five times a day.
3 - Increasing the period of reduced muscle PC in this exercise, we increase the duration of the process of reducing muscle PC 35 seconds, then relax and reduce muscle once again for 35 seconds and so on.
4 - depletion of muscle PC begin to exercise sitting position comfortable, and then heating the muscle and then begin the process of reducing the strong muscle PC of 30-50 times and a slow and after we have maintenance of the penis firmly for 10 seconds followed this process to reduce and relax the muscle of the PC in a quick 150 When you reach the last time Sign reduce the muscle for more than a period as possible and then take a break for 3 minutes and then finish the exercise, the work of the 40 times reduced strong muscle PC should then be a sense of exhaustion and a sense of burning in the area of the PC is the exercise of the most difficult exercises and it is more useful thanthe rest of the exercises.
VI: - massage and heating for 5 or 10 minutes
After the end of the exercises we massage thin rod for a period of minutes can be used with the massage cream to enlarge the size of the penis is made of herbs and then we have heating again as we start the first time and then draining the area, this massage and heating increases the amount of blood reaching the penis and stimulates the cells that have been crash during exercises to rebuild itself.
Premature Ejaculation:
Ejaculation occurs very quickly after erection at a time do not wish for that person and to treat these as follows:
1 - can afford a long period of sexual enjoyment without the occurrence of ejaculation and that exercise called Exercise 1-10 No. 1 represents the phase of the onset of sexual arousal when you reach No. 10 represents the phase of orgasm and ejaculation, and No. 9 represents a stage before the stage of ejaculation, and is a stage can not stop or back off.
When masturbating to reach the stage No. 8 stop and then restart the practice of masturbation Repeat this exercise for a period of 15 minutes and you'll notice after the expiry of this period you can libel when it wants.
2 - The second way to control premature ejaculation is the practice of exercises to strengthen the PC muscle as over the former.
3 - The third way when having sex and feel you have reached the phase of excitement Remove the penis from the vagina where it remains only the tip of the penis into the vagina and wait for 30 seconds, until the excitement Sign Bad free penis again into the vagina can help you this way on delay ejaculation.
*** For a strong and lasting erections longer do the following: -
1 - Food: - reduction of food rich in fat and a lot of food rich in fiber such as fruits and vegetables was found that the high level of fat in the blood fills the vessels in the penis, causing a shortage in the erection and must contain the quantities of food such as zincKalhntp grain, barley, rice and corn as well as shells and others.
2 - Smoking should stop smoking, where it has found an important role in the occurrence of problems and deficits in erectile dysfunction.
3 - Hold the penis between the fingers of the index finger and thumb where the thumb on the front of the bar and the index finger on the back wall of the rod, then take a deep breath and withhold the self, and then squeeze the penis between my finger index finger and thumb from the beginning of the penis this exercise leads to increased blood flow to the head of the penis.
Repeat this exercise 9 times a day every time you withhold the breath and counting to the number 9 with each number Z-power era of the penis towards the head of the penis that the muscles in the penis needs oxygen to live and the greater the blood flow to the penis are these muscles saturated with oxygen resulting in to the lack of an erectile dysfunction or deficit in erectile dysfunction.
Questions that deserve answers: -
1 - When should I make exercises?? At any time, some men prefer to conduct exercises in the morning and others prefer to conduct the night before going to sleep. 2 - Can I libel before exercise or during or after?? Both should not be tossing a few hours before the start of exercise and prefers not to libel after the end of the exercise before the passage of a few hours and that during ejaculation occurs because many of the chemical changes in the body such as the low level of the hormone Altestostiron and strain occurs in all connective tissue in the body 0 3 - When I see the exercises Gelk blisters and pain in the penis? If you feel discomfort in the penis slightly, it continued to exercise a natural heat penis do not forget at the beginning of exercise but if blisters appear and the pain is severe you should stop exercise for a few days to occur in the healing of ulcers and do not forget heating penis before starting exercises. 4 - When can I see an increase in penis size?? The first increase in the size of the penis occurs after 2-3 weeks of starting exercise and the increase in the size of the penis relax more in the case of what is in the case of erectile dysfunction. 5 - How to control my penis without erection exercises Algelk?? Does not practice special exercises and Algelk when the penis in the case of erectile dysfunction in the first weeks of an exercise occurs erection in the penis and in this case, you should stop and wait a few seconds or minutes to be relieved of erectile dysfunction. But after several weeks and several months, the penis becomes accustomed to the exercises and the erection process becomes easy and possible to control. 6 - Can I exercise twice a day?? Both is not recommended because the time medical healing tissues of the body is 48 hours and this depends on the type of tissue where the muscle tissue faster healing and healing of nerve tissue, and when you exercise twice a day does not give enough time for the penile tissues to heal fully, which gives results negative enlarge penis size. 7 - How can I find a muscle PC?? This easy process during urination Stop the flow of urine without the use of hand and without reducing the anus and reduction of the abdomen, and repeat this exercise, you will notice after a period of time you will be able to reduce this muscle when what you want. 8 - Do I have to do the process of heating the penis always?? The process of heating the penis and it is necessary for two purposes: - The first purpose: - working on relaxation of connective tissue in the process of stretching the penis becomes easy and less prone to rupture them. The second purpose: - heating works to increase blood flow to the penis, which in turn leads to increase the amount of oxygen and nutrients reaching the penis. 9 - how many months should continue to perform exercises?? You can hold these exercises forever if you like, but be advised that not less than 6 months, where they observed a significant difference in the size of the penis after 6 months but if you want to exercise only this time more than the increase in penis size 1 / 2 inches each year. 10 - Can I practice exercises 7 days a week?? Both should give the penis a rest for two days this is the period necessary to cure and heal the muscle cells of the penis 11 - can not I make the entire exercise at one time a day, Can I distribute them within 24 hours?? Yes it can.

Photos situation sexual Persian

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The conditions of sexual

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Things that tear the hymen, what things to tear the hymen

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How do you know the girl herself she is a virgin??

This poses a question many of the girls who live in fear of enormous concern that the hymen may rupture.

We say: "Have you ever had sex? Is something Bmahblk income, whether man rod or anything else?

That the answer is affirmative, you are not virgin. And a specialist doctor can be sure of that. And except that you are a virgin Chty proof to the contrary.

Is it possible to determine the date in which it is torn virginity??
After that attach to the wound, it is impossible to refer to the age of examination or disruption to the date of occurrence. Can only Balummen following the rupture to know that a recent view of the lack of fully wound.
How closed hymen?
Torn hymen at first intercourse. And only with the introduction of anything into the vagina. Whether a man's penis or a finger or anything else.

Do you tear the membrane from the first time or be required several times?
There is no rule. Gelba what is torn apart from the first intercourse. But that was extreme pressure membrane may require several attempts.

What are closed membrane?

Anything enters the vagina. A man's penis, finger or finger. Or any tool for masturbation. Required abduction labia which may bend and cover the membrane.

Do you tear the membrane with water such as shower or Aldavq Rinser?
Probability is very weak. Stream must be very strong. And labia away.

Can cause masturbation / masturbation rupture Babakarp:??
Those who can exercise that masturbation is tearing her virginity that made her finger or any other tool masturbating to the inside of the vagina.

But you can enjoy masturbation the clitoris and labia Bdlk from the outside without causing it any damage to the hymen. Recall that the hymen is located at a depth of 2 cm from the surface of the vagina. Answer to this question also asks for tampering Bfaragha.

Do you tear the membrane sexually State?

Can be enjoyed on the same face annotated masturbation, but the bar man. And that the clitoris and labia Bdlk from abroad, and in the same way by using the finger during Alastnme, but it's not easy, Valotharp severe sexual partners may lose the ability to observe and cohesion, the desire is the desire of instinctive penetration may be difficult to resist.

Can cause itching vulvar rupture of membrane?
Of course not, far from Valashvar virginity.

Do you tear the membrane to fall on the vulva?
Until the membrane ruptures because of the fall must be the girl on something protruding legs and arm's length.

Virginity Balochwer protected. Fall on the vulva, or a shock may directly injure the vagina without tearing the membrane.

Other words, ruptured hymen need to enter something into the vagina. And the probability torn precipitated directly is very enthralled

You can wash virginity when you have sex without disarmament underwear?
It is almost impossible. Rupture of virginity Titalb abduction labia. And access to the vulva, which lies at a depth of 2 cm from the surface of the vagina. In this case rupture of the membrane can not only tear apart the panty.

Possibility of rupture of the membrane during contact without stripping is almost impossible due to the fact that the membrane is at a distance from the labia that cover and protect it from after the clothes.

Do I have to fully enter the penis into the vagina to tear the membrane to be sufficient entry a little bit?

Stated that the hymen is located at a depth of 2 cm from the surface of the labia

Virginity is a veil of natural orifices.

Achtergah that something larger than the aperture size of natural ripped it. If what we call the "little income" is more than 2 cm. Maybe .... I say maybe. This may be may rip the membrane, either enter a whole or that the income of the head. As long as the penis has penetrated the hole is smaller than strong Semsgah regardless of the length of the penis.

The same thing applies to the finger

Can cause rupture of the membrane insertion of fingers directly:?
Not
Because the membrane contains the natural orifices, fingers that can enter through smoothly, without violence and without tearing virginity. It depends on the size of the hole natural, that was wider than the size of the finger may facilitate the passage without resistance, without any damage to the membrane.
But the introduction of numerous finger violently and repeatedly, and is leaning on the edge of the slot may cause a natural tear.

Can cause a rupture of virginity Sports

Everything is possible, but it is very rare possibility. As we said above: the hymen is torn apart when you enter something into the vagina. And the membrane is protected because it is at a depth of 2 cm from the surface of the vagina.

Does this mean exit pollution underwear during blood sport to the membrane may rupture
Of course not, any region may scratch the skin causing the loss of a few Qtra of blood. And may it be the blood of the session, or bleeding women.

Can cause tightening of the labia hymen rupture?
Pull the labia may occur wounds and scratches by the command and causes the loss of a few drops of blood. But it does not tear the membrane and does not Thtkh.

Can cause infections, women's membrane rupture?
Answer: nothing to do with them.

Can cause rupture of the membrane of Pain:?
The vast majority of cases does not cause rupture of virginity, only a sense of viewer does not last more than a moment. This sense did not prevent the billions of women to marry and who started sexual life without any hindrance.

Ms. suffered the first sexual intercourse rarely happens. And that the event is often caused by fear and dread of the first night, this fear, the girl that the contraction of muscles strongly forcing it from the partner to resort to force Wegerhaa penetration.

Partners may suffer from the sexual relationship second, and because of the scratching that occurred during the first relationship. Prefer this situation to wait two or three days or even a week until the wound coalesced.

Does this mean for vulval pain that may rupture the membrane?
Of course not. There are no endings, only a few sensory membrane. And pain caused by pudendal shower or trauma or fall. Of the causes is the last rupture of the membrane. And often result in this pain for trauma is much more sensitive labia of the membrane.

Can cause rupture bleeding?
The vast majority of cases associated with rupture of virginity out a few drops of blood. And in some cases you may get this rip without any bleeding, and without that it pays to doubt the purity of the girl.

And it is very rare that the first intercourse is associated with rupture of the Peoples Republic hymen requires medical intervention for hemostasis of bleeding. And we reiterate that this is very rare.

Virginity does not depend on several drops of blood flowing and may not be flowing at the first intercourse.

And the bleeding does not mean that every time that the membrane may rupture, you may lose her as much or as little of the blood is not concerned with membrane, such as:
Scratch or wound surface
Menstruation came without dates
The ovulation may be associated sometimes with some blood Aldhaiat

May arise during the life of the girl several hormonal disturbances, causing what we call Nzovat functional. This may be no apparent reason may be due to different situations and emotional and mental distress resulting from examinations or family problems.

The emotional meeting interesting incites vaginal secretions, even if it did not get intercourse, you may recite the brown mixed with menstrual blood residue was when the girl gets larger hemorrhages and functional without that we can find out the cause.

All of these reasons lie behind the simple Alenzova that may occur to the girl outside the menstrual period does not unrelated to the membrane of virginity.

You could tear the membrane without bleeding?
Yes, of course. Membrane may be a few bloody ischemia. Or a wide aperture to facilitate passage of the penis torn and without bleeding. That is to say: sometimes the girl a virgin untouched and no bleeding at membrane rupture

Is the resolution of the membrane is easy:?
Strength of the hymen varies from girl to another. Sometimes simple Evdah penetration and expands easily enters the penis without partners feel any resistance, and sometimes it is the membrane more resistant to the degree may require Msaap doctor.

Is there a better position for the resolution of the membrane:?
There is no rule in this regard, the best position is a situation in which his partner relaxes and allows the muscles Bartha.

To avoid Eelam girl could for a man to Ertik the lower zone of the vagina towards the anus. "Referred to the picture on behalf of the Forum vagina back" and is the least painful place for relief. This allows you to stay away from the clitoris during sexual intercourse seethes and becomes very sensitive.

Difficulties in the resolution of the membrane:
The vast majority of cases in which the partners can not complete the first sexual encounter, the reason is fear and muscle spasm that prevents penetration.

Rare cases may be caused by a membrane, high-strength, or congenital malformation to the reproductive system (eg the case and there is a veil, or peritonitis, or the absence of the vagina) and require consultation with a doctor.
Situation of impossibility of penetration of the penis, nothing prevents the command from the experience of entering a finger, or the use of lubricants, whether pharmaceutical or household (a drop of oil or butter)

Is there medical advice after the resolution of the membrane:?
Advises the girl after the first intercourse wash the area with soap and water from the outside. There is no justification for the introduction of the liquid inside the vagina. And advised by drying the area well after washing and with the abduction of the labia without fear. Should not hesitate to consult a doctor that Mrs. continued bleeding or pain after the first relationship.

Is it possible to return the membrane alone:?
Of course not
Can not be repaired rupture of the membrane is not alone and do not use creams and ointments.
The only way that could be just the man that girl's a virgin, is to hold sewing surgery to re-narrowing of the hole was torn up after the first intercourse. And sexual intercourse of a new cause of Ceylon a few drops of blood just the man that the girl was a virgin.

Can a man that knows about the surgical repair?
It's difficult, and requires a sexual partner to have experienced sexual practices.

Does that mean blood flow at the Virgin rupture of membrane.?
Of course not. Blood may be issued by the scratch of a place other than the membrane and may come from inside the vagina, is a functional bleeding may be a girl for some reason or even without reason.
And the form of blood that comes out does not reflect the source and can not say for sure that this blood comes from a ruptured membrane.

Is the membrane is affected by menstrual?
Menopause does not affect on the membrane. But out of the natural ostium. Some rare cases, which give birth to the girl and membrane is pierced, it is causing her menstrual blood pool, which may require surgical intervention.

Can a virgin bear that happened on the vulva ejaculation without penetration?

Chance of getting pregnant that happened ejaculation on the vulva from the outside is very weak, it requires that the defamation had obtained any period of ovulation half of the session. And to be abundant cervical mucus to reach the vagina.

Photos ways of sexual intercourse

2011-03-08T12:40:00.000-08:00

Is love stronger after sexual intercourse or before

2011-03-08T12:22:00.000-08:00

People are different in that some of them have post-coital stronger love and could be proved that kiss, and be like the description of him something appropriate love him, and when he tastes it has the most love and to him the most nostalgic, has proven that the Prophet peace be upon him in an interview with the mystic's Angels Lord Almighty that he asks them about their slaves, and He knows they will say: They are still praising thee and Ihamdonk and Iqdsonk says: Are they saw me? They say: No, he says:

So what if they saw me? Angels says: "If they saw you they would have the most praise and sanctification Thameda and then say: They ask thee Paradise says: Did you saw? Vcolon: No, he says: So what if they saw? Says the angels: "If they saw, they would most have a request and he mentioned the hadeeth 0 and is known to be the love of tasted something appropriate and not be patient with him stronger than the love of not Ivgah, but same-fed him, and affection between the couple and love after intercourse the greatest of which was accepted by 0 and the reason is natural that heart lust mixed with the pleasure of the eye, and if they see eye coveted heart If the body proceeded to the body met lust for the thrill of the heart and thrill the eye and direct, if the difference in this case was the same dispute to the most, and yearning to the greatest as it was said:

Aangaha and restraint after the exciting *** to it and after hugs Tdani

And kiss her mouth, so go away Sbapti *** Victd is delivered from Hayman

And he was not the amount of air that my *** to heal the lips sipping

As if my heart is not a cure Glèlè *** only to see the spirits Tmetzjan

Group II:

She considered that a sour love and sexual intercourse nullifies or weakens it, and you need Bomurmnha:

That sexual intercourse is the purpose for which requests in love so long as the lover asking Fhqh fixed, if arrived at the end spent Torah, and refrigerate the heat application, and Tefit fire of his love 0 said: This is the case with every student to anything if the nail tags, Kzman if Roy and hungry if satiety, there is no meaning to the request After 0 and nail them: he is forbidden by the nail and fond of self-love what prevented him, as he said:

And someone of infatuation in love that prevented *** I love anything to humans what to avoid
He claimed that each was required between the mistress and the lover of his half up to her navel, receive him what he wants of the annexation and kissing and sucking, and the bottom half is haraam for him, and in that folk poet said:

Vllhab absolute halves of hand *** and hubby split is fine impervious

It was for some Arabs: What gain, if any of you with his mistress acetic them? He said: touching and kissing

0 and similar, said: "Do Ittaulan to have intercourse? He said: "my father and mother this is not Avahq

This student was born 0

Abstract:

Discourse between the two teams that fornication spoil and love must end their love to the hostility and hatred as witnessed by sight, all for the love of God is the latest, regardless ...

Young wife renewed sexual ability of men

2011-03-08T12:09:00.000-08:00

Married 55-year-old man on a girl of 20 years. And ask about his marriage with the wife to inform you of what good Iaabuahmad? Man, everyone shut up I said what? Said Mndhu I got married about 30 years. During the past ten years I felt that my ability Gansipkd is over and you do not copulate my wife in the month, more than twice that were not one because of preoccupation with my wife at home and the children and the lack of interest in the process of sexual between us. Has surrendered to the status quo over the past few years. One day, a place my eyes on the news tells the story of experiment on rats conducted in Britain. I said what? He said: Bring a couple of big rats in age and two young couple in the Age of sexual hormone were measured with the old mouse and found zero% was measured sex hormone I have a young mouse and found 100% Enter the young mouse with a mouse in the old cage. And login with the old mouse young mouse in a cage and left three months. Then were extricated and measurement of sexual hormone in the old mouse and found 100% and found more active and dynamic. Was measured sex hormone in the young mouse and found zero%, which is in a deplorable state lists almost to bear. The man said:

I sat thinking long in this experiment and decided to go into the experience myself a girl and a young girl 20 years old and married, as you know. Praise God prepared my ability to sexual and if I'm still young Azolh almost daily and Tadlt my temper and I feel strong and active than before.

I wished him luck and an invitation to him longevity.

Dear we have the first two trials on animals and the other by man. Is the wife really small Age renewed sexual ability of men?.