A Woman's Guide to Heart Attack

Her Guide to a Heart Attack: Recognizing Female Heart Attack Symptoms
By Katherine Kam
Reviewed by Michael W. Smith, MD

On a Monday morning in April, Merle Rose, a New Jersey woman, experienced what some doctors call "female heart attack symptoms;" a feeling of indigestion and extreme fatigue. Later, she had nausea, vomiting and fainting.

But she never had chest pain-a "typical" male heart attack sign. When she got to the emergency room, doctors couldn't find any sign of heart attack and Rose says, "They would have sent me home."

As Rose's experience shows, many doctors-and women themselves--still don't realize that female heart attack symptoms can look very different than those of men. In fact, according to a study of women's early heart attack signs published in Circulation, women have more unrecognized heart attacks than men and are more likely to be, "mistakenly diagnosed and discharged from emergency departments."

In the emergency room, physicians had assumed she had a gastrointestinal illness. But at the time, no one told Rose that she had suffered a heart attack.

When an outside cardiologist recommended by Rose's regular doctor ordered testing that uncovered major blockages, doctors still made no mention of heart attack, she says.

So when did she finally get word? Not until several months later, when she visited a new female cardiologist. This doctor told her in retrospect that she had suffered a textbook case of undiagnosed female heart attack.

"That's the first I ever heard," Rose says. "This doctor told me, 'They didn't connect the dots.'"
Female Heart Attack Symptoms: What are They?

These chest-related heart attack signs often appear in men, and many women get them, too:

* Pressure, fullness or a squeezing pain in the center of the chest, which may spread to the neck, shoulder or jaw;
* Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath;

But many women don't have chest pain. In the Circulation study on early female heart attack symptoms, researchers found that during a heart attack, 43% of the 515 women studied had no "acute chest pain... a 'hallmark symptom in men,'" according to study authors.

Nevertheless, the study cited evidence that many emergency room doctors still look mainly for chest pain. Only a minority check for the other types of symptoms that women tend to develop. As a result, doctors may miss heart attacks in women.

"Although women can have chest tightness as a symptom of a heart attack, it's also important for women to recognize that might not be their symptom," says Nieca Goldberg, MD, a cardiologist and chief of Women's Cardiac Care at Lenox Hill Hospital in New York City and author of "The Women's Healthy Heart Program."

"Women commonly have symptoms of shortness of breath, unexplained fatigue, or pressure in the lower chest, so they easily mistake it as a stomach ailment."

In the Circulation study, common female heart attack symptoms include:

* shortness of breath (57.9%)
* weakness (54.8%)
* unusual fatigue (42.9%)

Women also had these symptoms:

* Nausea
* Dizziness
* Lower chest discomfort
* Upper abdominal pressure or discomfort that may feel like indigestion
* Back pain
Female Heart Attack Symptoms: Warning Signs That a Heart Attack May Be Coming

In the weeks preceding an actual heart attack, some of these symptoms may even appear as early warning signs, according to the Circulation study.

Goldberg, who is familiar with the study, says, "About six weeks before the actual heart attack, women were more likely to experience shortness of breath, unexplained fatigue or stomach pain as an early warning sign that they might have a blocked artery."

Rose was a prime candidate for a heart attack: a family history of heart disease, high blood pressure, high cholesterol and type 2 diabetes. Long before her heart attack, she had struggled with extreme fatigue.

"I felt like I was being rolled over by a steam engine-couldn't make plans," she says. Doctors put her on antidepressants. She also developed shortness of breath. "I was constantly gasping for breath." But because of the depression diagnosis, "I thought this was an anxiety issue."

"I did have symptoms of heart disease," Rose says. "They just didn't connect it and I didn't connect it."

If you get early warning signs, call your doctor and talk about the possibility of heart disease.

"That's the time to come in for an evaluation," says Goldberg.

On the day of a heart attack, these symptoms can strike without any provocation; for example, shortness of breath may come without physical activity. Symptoms can appear during rest or even awaken a woman from sleep, and they're much worse, Goldberg says.

"They just come on and they're severe. I had one patient describing that she was so short of breath that she could barely talk to the 911 operator."
Female Heart Attack Symptoms: Calling 911

If you believe you're having heart attack symptoms, dial 911 right away for an ambulance to take you to the emergency room. Wait no more than 5 minutes.

"As a doctor, I know from experience that when chest pains or other symptoms occur, most women are reluctant to call 911," Goldberg says. "That's precious time that we could be saving your heart muscle."

Women often worry about being embarrassed if they're not having a heart attack after all, she says. But embarrassment will pass without causing long-term damage; a heart attack may not.

Others don't appreciate the seriousness of the situation. One of Goldberg's patients had heart attack symptoms at age 57 and insisted on straightening up her house before she let her husband call 911. "This delay could have been fatal," Goldberg says.

Calling for an ambulance is better than taking a taxi or having someone else drive you, Goldberg says. And unless you have absolutely no other option, you shouldn't drive yourself. "You don't want to pass out driving your car," she says.

A big advantage to calling 911: emergency medical personnel can start treatment, such as oxygen, heart medication, and pain relievers, as soon as they arrive, says Mohamud Daya, MD, MS, an associate professor of emergency services at Oregon Health and Science University.

One more compelling reason to go by ambulance: "When you come into the emergency room with the [cardiac] monitor hooked up, you're really taken seriously," Goldberg says. "You look the part."
Female Heart Attack Symptoms In the Emergency Room

When you reach the emergency room, describe your symptoms, but don't offer your own conclusions, Goldberg says. "I wouldn't go through this whole dissertation about how, 'Oh, I thought it was a stomachache, I thought it was this.' You should just tell the doctor how you feel. Don't interpret it for them."

If it doesn't occur to the emergency room doctor to check for heart attack, be bold. Goldberg tells women to say outright: "I think I'm having a heart attack." Because many doctors still don't recognize that women's symptoms differ, they may mistake them for arthritis, pulled muscles, indigestion, gastrointestinal problems, or even anxiety and hypochondria.

In short, female heart attack symptoms may be missed-and dismissed. When one of Goldberg's patients entered the emergency room with such symptoms, doctors gave her antacids. "She said, 'Listen, I'm diabetic and women's heart disease symptoms can be different, and unless you give me an EKG, I'm not leaving this place.' And the next day, she had a bypass."

Of course, stomach pain could prove to be nothing more than a bad case of gastrointestinal illness. "But what I tell all my patients is, 'It's best to check out your heart first because a potential heart attack is life-threatening,'" Goldberg says.

And if your fear of heart problems turns out to be unfounded, don't sweat it, she adds. Doctors would much rather diagnose you with indigestion than a heart attack.


SOURCES: Merle Rose.

Nieca Goldberg, MD, chief of Women's Cardiac Care, Lenox Hill Hospital, New York.

Mohamud Daya, MD, MS, associate professor of emergency services at Oregon Health and Science University.

Mayo Clinic.

National Heart, Lung, and Blood Institute.

American Heart Association.

McSweeney, JC et al. "Women's Early Warning Symptoms of Acute Myocardial Infarction," Circulation, 2003 Nov 25;108(21):2619-23.
Reviewed on July 24, 2008

Kawasaki Disease: What You Need To Know

Kawasaki Disease: No Link to Travolta Death
Childhood Kawasaki Disease Unlikely Cause of Seizures in Travolta's Teenage Son Jett Travolta
By Daniel J. DeNoon
Reviewed by Louise Chang, MD

Jan. 5, 2009 -- Jett Travolta's childhood brush with Kawasaki disease is highly unlikely to have caused the seizures that may have led to his death, a Kawasaki expert tells WebMD.

Jett Travolta, the 16-year-old son of actors John Travolta and Kelly Preston, died on Jan. 2. The teen, known to have suffered frequent seizures, struck his head against the bathtub in the hotel where his family was staying, according to media reports.

Kawasaki disease is a mysterious and frightening illness. Might Kawasaki disease have caused Jett Travolta's seizures?

WebMD asked Kawasaki disease expert Nathan Litman, MD, chief of infectious disease and director of pediatrics at New York's Montefiore Medical Center.

"I am unaware of any association of Kawasaki disease with seizures," Litman tells WebMD.

Kawasaki disease can leave a person with an abnormally narrow coronary artery, and this can lead to a future heart attack. Early reports suggest Jett Travolta did not suffer a heart attack; an autopsy is under way.
Kawasaki Disease: Mysterious Ailment on the Rise

Nobody knows what causes Kawasaki disease, but it can be deadly. It's not common in the U.S., although incidence is increasing in Japan.

First described in Japanese medical literature by pediatrician Tomisaku Kawasaki, MD, the disease is a disease of childhood. Litman says 80% of cases occur in children under 5. Cases are very rare in anyone over the age of 10.

John Travolta has said in interviews that his son had Kawasaki disease when he was about 2 years old. In an interview with CNN's Larry King in 2001, Travolta expressed the opinion that the illness was brought on by Jett's overexposure to cleaning products, particularly carpet cleaner.

Science has yet to discover the cause, although most researchers think it's an infectious agent, probably a virus.

That would account for why it strikes early in life, why most cases occur in the winter, and why there are Kawasaki outbreaks. But an infectious agent would likely spread in families, and Litman says it's rare to see more than one child in a family come down with Kawasaki disease.

The classic symptom of Kawasaki disease -- technically known as mucocutaneous lymph node syndrome -- is a high fever lasting for five days or longer. Other symptoms include:

* Pinkeye (conjunctivitis) in both eyes, but without purulent discharge.
* Redness of the lips, tongue, and lining of the mouth. Lips are often cracked or bleeding.
* A swollen cervical lymph node larger than 1.5 millimeters in diameter.
* A red rash on the body, which may be flat or bumpy and which may have different patterns.
* Changes in the extremities: swollen hands and feet with redness of the palms and soles. In the second week of illness, there may be peeling of the skin starting around the fingernails and extending to the arms.

Kawasaki disease is diagnosed when a child has five days of high fever and any four of the five symptoms listed above.

There may be other troublesome features, Litman says: swelling of the gallbladder, diarrhea, and painful swelling of the joints. But the scariest thing about Kawasaki disease is its possible effects on the heart.
Kawasaki Disease and Heart Trouble

"The most troublesome feature of Kawasaki disease is involvement of the heart," Litman says. "What worries everyone is that in the convalescent phase, about 10 days into the illness, there may be inflammation of the coronary arteries, which can result in aneurysm formation. This can cause turbulence throughout the artery and cause [narrowing] of the artery, which could cause a heart attack."

If not treated, one in five children with Kawasaki disease would get coronary aneurysms. Fortunately, treatment cuts this risk to about one in 20.

Treatment involves a high dose of immune globulin and a high-dose aspirin until the fever goes down. Once the fever goes away, the child's aspirin dose is reduced and doctors perform an echocardiogram to check for heart abnormalities.

"This generally results in a return to a happy state," Litman says. "In kids who do develop aneurysms, some may resolve, but this may still be a forerunner of adult-type coronary artery disease. They may be left with residual stenosis [narrowing of a heart artery] that can cause a future heart attack."

So if Kawasaki disease didn't cause Jett Travolta's seizures, what did? Seizures are the result of an electrical storm in a part of the brain. Some people simply develop frequent seizures for no apparent reason. Sometimes the cause is a trauma, infection, or tumor.

Media reports have suggested that Jett Travolta may have suffered from autism. The Church of Scientology, of which his parents are members, does not believe that autism is a valid diagnosis, and the Travolta family has rejected the idea that Jett had autism.

However, among children diagnosed with autism, there is a high prevalence of seizure disorder.

SOURCES:

Nathan Litman, MD, chief of infectious disease and director of pediatrics, Montefiore Medical Center, New York.

WebMD Medical Reference from Healthwise: "Kawasaki Disease Overview."

Levisohn, P.M. Epilepsia, 2007; vol 48: pp 33-55.

Associated Press.

CNN.com

TMZ.com

Your Best Breasts

Your Best Breasts
By Beth Howard

A decade-by-decade look at the latest news on cancer, the ups and downs of surgical enhancement--even how to find the perfect bra.

In the dramedy that constitutes a woman's life, the brain and heart play the starring roles--but breasts surely have a major part. They start turning heads as soon as they make their debut; they nurture babies with milk uniquely suited to an infant's needs. They provide pleasure, bolster body image, and inspire pride and satisfaction. But as you get older, all that front-and-center attention has a downside. Where they once heralded your youth, your breasts may now seem to announce your decline. They can be a source of discomfort--and as you enter the years of higher cancer risk, they probably cause you some worry now and then.

Despite this dramatic shift, you don't hear much about how best to cope with these changes. And except for frequent reminders about getting mammograms, there isn't even much info about how to keep your breasts healthy for the long haul. What's needed: an owner's manual for the over-40 breast, with a guide to cancer prevention and treatment, help with everyday problems, and a no-hype look at how to preserve perk--including surgical options and the lift you can find in a lingerie drawer (if you know what you're looking for). Got breasts? We've got answers.
INSIDE STORY: How the Breast Ages

* Your breast has more of the milk-producing glands called lobules in its upper outer quadrant. Result: That area is particularly prone to pre-period tenderness--and to the development of tumors.
* The milk ducts transport milk to the nipple. About 95% of breast cancers begin within the ducts.
* Fat fills the spaces between the lobules and ducts--more of it as you get older. That increases sag, but has a bonus: It makes mammograms easier to read.

BREAST PAIN: What's Normal, What's Not

In the run-up to menopause, your breasts can feel like a battleground--the scene of all manner of lumps, pains, and general aggravations. Thank goodness, most of these breast bothers have nothing to do with cancer. (Studies show that pain is the sole symptom of breast cancer in 2% of cases or less.) But don't just feel reassured--feel better. Here's how.

You have: Lumpiness or thickened and tender areas

It may be: Fibrocystic breast changes, a condition that affects so many women (more than 60%, estimates say) that it's considered a version of normal. Researchers don't entirely understand the cause, although they lay blame at least partly on hormones. The thickened, rubbery feeling comes from fibrous tissue--the same sort of tissue in scars. The lumps are due to fluid-filled cysts. Breasts may also feel full and achy and have a clear yellow or greenish discharge. Rest easy: Fibrocystic breast changes don't increase breast cancer risk. And though the problem typically worsens in the years before menopause, most women find relief as their hormones quiet down.

Try this: Reduce your caffeine consumption--it exacerbates soreness in up to 50% of women. NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin and ibuprofen help some women, as do vitamin E (800 IU daily) and evening primrose oil (1,500 to 3,000 mg daily). Research on primrose oil is mixed, but it can't hurt you. If pain is severe, your doctor may prescribe a drug to block the effect of your reproductive hormones.

You have: A single, distinct lump

It may be: A cyst. In 80% of cases, a lump is not due to cancer. Cysts are usually firm and round; they can be smaller than a BB or as big as a grape, sometimes larger. They often disappear after your period but can recur with the next cycle.

Try this: Because there's always the possibility of cancer, tell your doctor about any new or dominant lump. NSAIDs may help ease pain.

You have: Thick green or black discharge

It may be: Mammary duct ectasia, which just means that one of your milk ducts has become inflamed and clogged. As many as 1 in 4 women develops the condition during or after menopause. Other signs of the problem: soreness, a lump or thickening, an inverted nipple, or the pain, swelling, and redness of mastitis (breast infection).

Try this: Warm compresses, NSAIDs, and a supportive bra often help. But you should have your doctor take a look. Antibiotics may be necessary--and you may need the duct surgically removed if the problem doesn't get better.
CANCER: The Best Detection & Care

40s Your risk of developing breast cancer in this decade: 1 in 70

You should know:

* After years of bickering, most experts now agree that mammograms save lives for women over age 40. Alas, only 64% of 40-somethings show up for regular screenings, according to the American Cancer Society (ACS).
* If cancer is found, be prepared for intensive treatment. Cancer in these years tends to be more aggressive and less likely to respond to estrogen-blocking therapies such as tamoxifen. But younger women typically can tolerate more treatment side effects, so you can get larger, more effective doses of chemo drugs, says Gabriel Hortobagyi, MD, chairman of the breast medical oncology department at the University of Texas M.?D. Anderson Cancer Center. "On average, chemo in women younger than 50 reduces recurrence rates by as much as 55%, compared with 20 to 30% in older women," Hortobagyi says.

Essential steps:

* Don't forget your mammogram. Even with the recent drop in incidence, your risk of developing cancer remains higher than for younger women--yet mammography rates in this age group have fallen 7% since 2000. Early detection pays off: Breast cancer that develops in a woman's 50s is more likely to be estrogen receptor positive, so there are more drugs available to treat it.
60s Your risk of developing breast cancer in this decade: 1 in 28

You should know:

* Though your risk is increasing, so is the power of one major weapon in your arsenal: Mammograms may be more effective now, because your breasts likely contain a greater proportion of fat than in younger days. (Fat typically appears as black on x-rays, while everything else--including cancer--appears as shades of white.) According to a new analysis from the Mayo Clinic, the breasts of women over age 60 are about half as dense as in the years before menopause.
* Cancer may be more common, but it progresses less quickly. It takes 2.1 years for tumors to double in size among women in their 60s, compared with 1.4 years for women in their 50s.

Essential steps:

* Learn about cancer preventives. (Age is a woman's biggest risk factor.) Raloxifene, already approved for preventing and treating osteoporosis, was okayed last October for postmenopausal women at high risk of breast cancer. Like tamoxifen, the first effective preventive for the disease, it also bolsters bones, says Banu Arun, MD, an associate professor in breast medical oncology at M.D. Anderson.

70s Your risk of developing breast cancer in this decade: 1 in 26

You should know:

* Although researchers say that practitioners are more likely to skip mammograms in their elderly patients, the screening can still save lives, according to data from the Albert Einstein College of Medicine. "As long as a woman is generally healthy," says breast surgeon Laura L. Morris, MD, MBA, medical director for Women's Health Services at Indiana University, "mammograms can benefit a woman in her 80s and even beyond that."

Essential steps:

* Don't settle for treatment "lite." Doctors used to be less likely to offer older breast cancer patients all the therapies recommended by the National Institutes of Health. Age increases the odds of other health conditions such as heart disease, which can make some treatments risky--but even if an elderly patient is healthy, her doctor may assume she isn't up for a punishing regimen. Fortunately, such bias is diminishing as doctors gain experience with treating older patients, says Richard J. Bleicher, MD, a breast surgeon at the Fox Chase Cancer Center in Philadelphia. If you're concerned, he suggests, ask if the treatments you're offered are the standard of care.

NIP/TUCK: The Fixes and Risks

A life well lived leaves traces on your body: laugh lines, crow's feet, and, yes, breasts that aren't as firm as they used to be. One perfectly good reaction: Shrugging at the changes--especially if the shrugging is done in the right bra (see box at right). But for some women, that gesture doesn't have the desired oomph. More than 163,000 women over age 40 got gravity-defying help from a scalpel in 2007, spurred on by improved surgical techniques and the return of the silicone implant. Here, Prevention investigates the benefits and downsides of nips, tucks, and more.
Lift

The rate of lift surgery has nearly doubled since 2000, according to the American Society of Plastic Surgeons (ASPS), with well over 53,000 procedures in 2007.

How it works: By removing excess skin and tightening the surrounding tissue, surgeons can raise and reshape the breasts. A new technique leaves a smaller scar that can be neatly camouflaged by the nipple's areola--although many factors determine whether this less conspicuous approach or the older anchor lift is right for you.

Downside: The procedure can't replace lost volume, so if breast deflation is a big issue for you in addition to sag, a lift may not be adequate.

Breast Implants

The number of women over 40 getting breast implants increased by 17% between 2005 and 2006; in 2007, more than 107,000 women in that age range got the procedure.

How it works: Adding implants during a breast lift helps with sag and loss of volume. A 1994 study from Washington University School of Medicine found that 95% of women felt better about themselves after the surgery. But it presents a tough choice: saline or silicone. Silicone implants look and feel more natural than saline, but in 1992, they were pulled off the market for use in cosmetic procedures because of concerns they might raise the risk of scleroderma or other disorders. Now, after several large National Cancer Institute studies, silicone is back. "Breast implants have been studied more extensively than any other medical device," says Donna-Bea Tillman, PhD, director of the Office of Device Evaluation at the FDA. "And our experts concluded that they're safe and effective."

Downside: About 10% of implants--saline or silicone--rupture within 5 years, and the rate goes up as time passes. To make sure ruptured implants are detected and removed, women should get an MRI 3 years after surgery and then again every 2 years (in addition to their annual mammogram). Implants can also harden--it happens with up to 80% of the silicone variety and 40% of saline ones. All told, most women need to replace or remove an implant within 15 to 20 years, says Walter L. Erhardt, MD, past president of the ASPS. Implants can also make mammograms harder to read, though technologists who perform the exam make adjustments. A study from the University of Washington found that mammograms missed 55% of breast cancers in women with implants, versus only 33% among women without them. Fortunately, there's no sign that the murky mammograms affect mortality. "Women with augmentation may be more breast aware and seek medical care more quickly," suggests study author Diana L. Miglioretti, PhD.

Reduction

More than half of reduction surgeries were in 40-plus women in 2007, according to the ASPS; more than 56,000 women over 40 got the procedure. Small wonder: By that age, the health effects of large breasts--chafed skin, back and neck pain, and grooves in the shoulders from ill-fitting bras--are mounting. In a recent study, discomfort was vanquished or greatly reduced 1 year after surgery for 88% of patients. "Women invariably say they wish they'd had it sooner," Erhardt says. Benefits go beyond comfort. Breast exams and mammograms are often easier to perform and more effective after surgery. And some research suggests it can even reduce the risk of breast cancer, especially in those over age 50.

Bonus: Because of the health problems that can result from uncomfortably large breasts, insurance often picks up the tab.

Downside: The surgery can cause a loss of nipple sensation, and in some cases, can result in asymmetry of the breasts.
6 habits That Can Save Your Life

Some risk factors for breast cancer--such as the age you started menstruating--can't be changed, but these key habits help keep cancer at bay, no matter when you start.

1. Keep moving "Exercise lowers levels of estrogen, which is linked to breast cancer," says the ACS's Debbie Saslow. It's best to get 45 to 60 minutes of heart-thumping activity most days of the week, but moderate levels (30 minutes, 5 days a week) can make a difference. You're never too old: A recent study in the British Medical Journal showed that postmenopausal women (along with those with a normal body mass index, or BMI) get more of a benefit from regular sweat sessions than other women.

2. Get--and stay--slim After menopause, obese women have double the risk of breast cancer compared with women of a healthy weight. But weight gain among previously trim women also bodes ill. "Gaining even 20 pounds of weight as an adult increases risk," says Heather Spencer Feigelson, PhD, MPH, strategic director of genetic epidemiology at the ACS.

3. Take vitamin D More and more studies demonstrate the cancer-fighting power of this vitamin. The latest piece of evidence, reported at the recent meeting of the American Society of Clinical Oncologists: Breast cancer patients who were deficient in vitamin D were 94% more likely to have their cancer spread than women with adequate D levels. "I advise women to take 800 to 1,000 IU a day," says Andrew Kaunitz, MD, a professor of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville.

4. Drink lightly, if at all New data from the National Cancer Institute shows that women who have one or two drinks daily increase the risk of the most common kind of breast cancer by 32%--and those who drink more hike their risk by 51%. Experts recommend no more than a glass a day.

5. Keep hormones temporary Long-term use of HT can increase breast cancer risk, the Women's Health Initiative demonstrated--and new research shows the heightened risk persists several years after you stop. Take hormones only if menopausal symptoms are unmanageable, and limit time on the therapy to no more than 5 years. Consider alternatives, such as SSRI antidepressants for hot flashes and vaginal creams with estrogen for dry genital tissues.

6. Forget self-exams, but be self-aware After hearing for years that you should do a monthly breast self-exam, you might be surprised to learn that it's now considered optional. Studies have found that it doesn't save lives and can increase the odds of an unnecessary biopsy. But many doctors are reluctant to completely abandon it. "About 15% of breast cancer is detected by women themselves," says Eva Singletary, MD, a professor of surgical oncology at M.D. Anderson. So doctors still want you to get to know your breasts--and alert your provider to anything outside the norm for you.

6 habits That Can Save Your Life

Some risk factors for breast cancer--such as the age you started menstruating--can't be changed, but these key habits help keep cancer at bay, no matter when you start.

1. Keep moving "Exercise lowers levels of estrogen, which is linked to breast cancer," says the ACS's Debbie Saslow. It's best to get 45 to 60 minutes of heart-thumping activity most days of the week, but moderate levels (30 minutes, 5 days a week) can make a difference. You're never too old: A recent study in the British Medical Journal showed that postmenopausal women (along with those with a normal body mass index, or BMI) get more of a benefit from regular sweat sessions than other women.

2. Get--and stay--slim After menopause, obese women have double the risk of breast cancer compared with women of a healthy weight. But weight gain among previously trim women also bodes ill. "Gaining even 20 pounds of weight as an adult increases risk," says Heather Spencer Feigelson, PhD, MPH, strategic director of genetic epidemiology at the ACS.

3. Take vitamin D More and more studies demonstrate the cancer-fighting power of this vitamin. The latest piece of evidence, reported at the recent meeting of the American Society of Clinical Oncologists: Breast cancer patients who were deficient in vitamin D were 94% more likely to have their cancer spread than women with adequate D levels. "I advise women to take 800 to 1,000 IU a day," says Andrew Kaunitz, MD, a professor of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville.

4. Drink lightly, if at all New data from the National Cancer Institute shows that women who have one or two drinks daily increase the risk of the most common kind of breast cancer by 32%--and those who drink more hike their risk by 51%. Experts recommend no more than a glass a day.

5. Keep hormones temporary Long-term use of HT can increase breast cancer risk, the Women's Health Initiative demonstrated--and new research shows the heightened risk persists several years after you stop. Take hormones only if menopausal symptoms are unmanageable, and limit time on the therapy to no more than 5 years. Consider alternatives, such as SSRI antidepressants for hot flashes and vaginal creams with estrogen for dry genital tissues.

6. Forget self-exams, but be self-aware After hearing for years that you should do a monthly breast self-exam, you might be surprised to learn that it's now considered optional. Studies have found that it doesn't save lives and can increase the odds of an unnecessary biopsy. But many doctors are reluctant to completely abandon it. "About 15% of breast cancer is detected by women themselves," says Eva Singletary, MD, a professor of surgical oncology at M.D. Anderson. So doctors still want you to get to know your breasts--and alert your provider to anything outside the norm for you.