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Female Problems - Breast

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - My partner had breast cancer last year. Luckily it was confined to a lump, which she had removed very quickly. She has been put forward for augmentation (implants), but she wishes to start diving and we would like to know what we have to do to get her started, i.e. dive medical, dive insurance and when she has the augmentation are there any limits on depth etc. She is otherwise healthy and fit - at work her role includes being a trained instructor for Breakaway Techniques and Therapeutic Management of Violence and Aggression (Control and Restraint). Thanks for your advice.

A - That’s one of the most outstanding job titles I’ve heard in a long while. It almost topples my previous favourite, “Grand Poobah of the Joy Gang”, bestowed upon an employee of a certain US ice cream producer (by himself, no less). A flagrant argument between the two of you should be arranged, for the sole purpose of generating amusing headlines. I digress. Breast implants are almost always saline- or silicone-based these days, and they are not susceptible to pressure-induced damage. Various implants were subjected to simulated dives in a hyperbaric chamber in one study, which found negligible bubble formation and volume changes which resolved with time. Therefore in general, no diving restrictions apply. A couple of words of advice though: avoid tight BCD chest straps as these can increase the risk of rupturing the implants, and if they’re silicone-based they may affect buoyancy as they’re heavier than water (saline ones are obviously neutrally buoyant). Clearly she shouldn't dive around the time of the procedure, but once all has healed up she will be fine.

Q - I am a 59 year old woman who has been diving for 11 years, with 800 dives under my (admittedly large) weight belt. Other than being a bit overweight I am fit, eat healthily and exercise regularly. Whilst diving last year I had a problem with my left breast. Each time I dived it became swollen and painful, with a lump under my armpit, soon afterwards. This only lasted an hour or so, because when back at the resort the symptoms disappeared. Could the pressure from deep dives cause this problem?

A - Breast pain and swelling can be due to a few different things. Monthly changes in breast size due to hormones are ruled out here by the close association with your diving. Obvious factors such as tight BCD straps can be responsible, squeezing the circulation so that fluid accumulates in the chest. Normally this occurs on both sides, however, and is easily relieved by loosening gear. Sometimes a chest wall swelling can be a symptom of a bend, resulting from bubbles blocking lymphatic vessels. These normally carry a clear fluid (lymph) which has important functions related to the immune system. If the lymphatics are damaged or obstructed, lymph can leak out and give rise to a swelling called lymphoedema. I would suggest, if this is a recurrent phenomenon, that you get checked out by your local dive doc prior to diving again.

Q - I had a mastectomy 2 years ago. Unfortunately I got an infection shortly after the surgery and the wound opened up into an abscess about the size of a 50 pence piece which went down to the bone. It took quite a while to heal as I'd had radiotherapy on the area a few months previously. Tissue built up from the bottom of the wound and it eventually healed up in about 3 months.

Having finished chemo 6 months later I went back to diving last weekend. We did two dives, the first had a max depth of 21m, the second was 15m. When I showered later that evening I noticed a lot of bruising and blood blisters around the edge of the scar tissue. It certainly wasn't there that morning. The scar is around the same place as my chest valve would be on my dry suit. As this area is completely numb I could have bruised the new scar tissue whilst using the chest valve without realising it. I just wanted to check that it couldn't be an indication of air trapped in the wound or some other weird diving-related problem.

A - In surgical circles they call this delayed repair “healing by secondary intention”, a fantastic cop-out term that implies it’s all a bit of an afterthought. Basically it means the surgeons are powerless to do anything about it so it’s left to heal by itself. 6 months down the line, I doubt there would be any air trapped in the wound, as the healing has been slow enough to allow any gas to diffuse out. As you say, the more plausible explanation is that the bruising and blistering came from a suit squeeze and/or direct pressure from the valve on the area around the scar. After a mastectomy numbness is not uncommon in and around the wound, so although numbness can be a sign of DCI I think it’s more likely to be due to the knife in this case. So rest easy, allow things to clear up before you next dive, and if it happens again it might be time for a new dry suit.

Q - Hi, I have recently given birth to a baby girl, and I am breastfeeding. I had been hoping to return to the water as soon as possible but I have concerns about the effect the pressure changes may have on my milk supply. Is there any advice you can give me on when I can return to diving and the effects it will have for continuing to breastfeed or if it is likely to cause mastitis?

A - Congratulations on bringing another potential diver into the world. This is a question that has been looked into in some detail. Milk supply does not seem to be affected by pressure, although it may cause a bit of leakage (probably unnoticeable in the water). Engorged breasts can be a bit tricky to squeeze into a tight-fitting wetsuit, so you may have to prepare for some discomfort. One way round this is to use a breast pump to empty the blighters before you dive, or, better still, give the little nipper a quick feed just before going in... There have been concerns voiced about possible transmission of inert gas bubbles to the baby, but these are unfounded - nitrogen bubbles have not been seen in breast milk, and even if microbubbles did form, they would only end up in baby’s gut – which is full of gas anyway (as you have probably found out by now). Mastitis (infection of the breast tissue) from marine organisms is possible, particularly if the nipples are cracked or sore, and so I wouldn't dive until the nipples are healed over. There is one other potential issue: breastfeeding and prolonged immersion can both precipitate dehydration, so it's vitally important to keep the fluid intake up, both to avoid DCI and any reduction in the volume of breast milk produced.

Q - 3 months ago I did one dive to a depth of 33m. We had a surface interval for 1 hour before travelling back over the hills. While travelling I had a slight pain in my right breast so I undone my bra and removed it. But then the pain started in both breasts and the pain was really unbareable. Later that day I noticed unusual marks around my breasts. Today is Monday and my breasts are still tender, was this a skin bend?

A - Steady on there sister, I’m feeling rather faint – no more breast-baring on the way home please! There are sporadic reports of breast pain as an unusual symptom of decompression illness in the literature. The interesting thing about your story is that the symptoms seemed to appear soon after the diving, and worsened as you crossed the hills on your way back, only a small increase in altitude. If there were any provocative factors on the dive, such as dehydration, missed safety stops or rapid ascents, then you would have to consider DCI as a strong possibility. It is also worth noting that bends such as these have a high correlation with PFO (Patent Foramen Ovale, one of the so-called “hole in the heart” conditions that can predispose to DCI), so that would need to be checked out too. Some female divers do experience breast tenderness as a regular post-dive phenomenon however, something for which there is no reliable explanation that I know of. Theories abound of various hormone imbalances causing the pains, in much the same way as with pre-menstrual breast tenderness, but there is no adequately explained reason this should happen with exposure to pressure or compressed gases.

Q - Please could you advise me if I require a full medical before I can resume diving.

In February 2004 I had a mastectomy & reconstruction due to breast cancer. It was caught early enough for me not to require radiotherapy or chemotherapy but I do now take Tamoxifen tablets once daily. My date of birth is 14th March 1961. I am basically quite a fit person and resumed horse riding some months ago. I am now keen to get back to diving having had a year off and would appreciate your advice.

A - Bad luck, but good they got it early enough.

You are fine to dive. There are some things more important than diving, and I think you put it in perspective really.

Q - My girlfriend has passed her PADI Open water diver, she now discovers she has Multiple Sclerosis (relapse and remitting) she has no symptoms and has had a diving medical. Should she go on to do her advanced open water diver.

Also can you dive with silicone implants.

A - The current regulations are that anyone who has MS and dives should stay out of the water for 1 year after a relapse of the problem, and in that year should not experience any symptoms of the problem or worsening of the condition.

So if your girlfriend has been free of the problem for 12 months then she is OK to go in again. As for an advanced course, MS can easily mimic DCS, and I would advise that she stays out of the deep and just depth limits to 20m and preferably use nitrox as it is safer if used with air tables. This is because if she surfaces after a deep dive and has any sort of neurological symptom, then it will always have to be assumed to be a bend, rather than a slight problem with her existing MS. This may lead to unnecessary decompressions in a chamber.

Before each diving season I would also recommend a full neurological assessment to map what problems she has prediving, such as any weakness or sensory loss as again this could be misconstrued as a bend too.

As for silicone, I have spoken to a couple of plastic surgeons, and they both say that the modern gel type implants are completely safe, however the old style implants which are silicone bags filled with fluid may have a very small chance of leakage if pressures are extreme. My suggestion in these older breast surgery cases is to check with the manufacturer as to what pressures they can guarantee safety.

Q - I would like some advice on breast enlargement (versus diving). I have a condition which means that one of my breasts is about half the size of the other, and have been offered an enlargement of the smaller breast.
Could you tell me if there have been studies on the effect of the pressure etc of diving with implants? As my plan is to become a dive guide abroad within the next few years, this would drastically change my plans if there were any implications.

A - No worries here for you. Remember it is only air that gets compressed underwater, so unless the surgeon is going to use an inflated lilo for your op, you will be fine.

Breast enlargement utilises either silicone or other fluid filled sacs for the desired effect. These are not compressible at all at depth. There has been some research I have read, but it mainly concerns slow leakage from the sacs, due to pressure from a tight wet suit or over inflated BCD. Ask your doctor for the most sturdy of implants, as if you are going to guide there could be a lot of wear and tear in the chest area.

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