May 2003: Taking Care of Yourself

Shed fear, regain quality of life?

Question from Jewel: How do you ever get over the fear that your cancer is still there and will show up in some other part of your body? How can you have a good quality of life again?

Answers —Marisa Weiss, M.D., president and founder: As you move past treatment and are wrestling with this fear, it's important to identify ways that you can take care of yourself.

Anne McTiernan, M.D., Ph.D.: One good way to take care of yourself and improve your quality of life is to exercise. There have been several clinical trials showing that cancer survivors have an improved quality of life, decreased fatigue, and improved fitness in as little as 12 weeks of following an exercise program. This typically means doing some kind of aerobic activity at least three times a week.

Marisa Weiss, M.D., president and founder: How much exercise each day?

Anne McTiernan, M.D., Ph.D.: The studies have shown that about 30-45 minutes each day is needed.

Marisa Weiss, M.D., president and founder: How can a woman get started on an exercise program when parts of her body hurt, ache, or are in some way uncomfortable?

Anne McTiernan, M.D., Ph.D.: Many women are quite fatigued after breast cancer treatment. They are less fit than they were before diagnosis, and they're not exercising as much as they were before diagnosis. Because of this, they need to start their exercise program at a slower rate than they would otherwise. That means starting with about 10 minutes of aerobic exercise a day, three days a week, and adding five minutes each day or so over a one or two-week period.

Marisa Weiss, M.D., president and founder: What should a woman do if her arm and armpit hurt, and what should she do if her range of motion is limited on one side?

Anne McTiernan, M.D., Ph.D.: If you have arm problems following surgery, the first thing to do is get evaluated by your surgeon or a physical therapist to see what your capabilities and limitations are, and then to develop a program with the help of a physical therapist. If you don't have access to a physical therapist, consider trying some of the exercises in our book Breast Fitness: An Optimal Exercise and Health Plan for Reducing Your Risk of Breast Cancer, or any other book written about exercise for breast cancer survivors.

Marisa Weiss, M.D., president and founder: If a woman follows this program of exercising for 30-45 minutes, three days a week, and if she eats the same amount of food, how much weight might she be able to lose over a 12-week time period?

Anne McTiernan, M.D., Ph.D.: She won't lose much weight from exercise alone, but she will experience an improved quality of life and feel less fatigued. For weight loss, people need to do considerably more exercise and reduce their calorie intake. Some researchers have found that an hour a day of exercise—and reducing calories—is optimal for weight loss.

Change feelings of self-consciousness?

Question from Alex: My husband has been very supportive throughout my ordeal. However, when we're intimate I'm very self-conscious about him touching me where my breast used to be. How can I change these feelings?

Answer —Marisa Weiss, M.D., president and founder: It's normal to be self-conscious. You've had a significant change in your body as well as the loss of a body part that was very sensual. Some of my patients tell their partners to limit their touching to the side where the breast is still there. Over time, as things normalize and get better, you may feel more confident about how attractive you are, and you may choose to invite your partner to begin touching the area where your breast used to be.

I have a patient who had a double mastectomy. At the time of her surgery, she was unmarried and without a boyfriend. Later on, she ended up meeting a great guy, and she learned to feel comfortable with him touching both sides of her chest. Interestingly, he ended up finding an erogenous zone in her armpit!

The main thing is, don't assume that if you feel unattractive, your partner feels the same. Usually your partner finds you just as attractive as before, but is likely to sense your awkwardness and become awkward as well. Good communication is the key to getting over this hurdle.

Vitamins to take during chemo?

Question from Marie: What vitamins should I take or not take during chemotherapy?

Answers —Anne McTiernan, M.D., Ph.D.: There is not a lot of data available about which vitamins are good and which vitamins are not good to take during chemotherapy. Most physicians and researchers suggest taking a multivitamin pill, but NOT taking excessive amounts of any vitamin or supplement. There is even some suggestion that certain vitamins, including folate, when taken in excess, may counteract the effects of some chemotherapy drugs. So the best strategy is to consume a diet that's as healthful as possible, including lots of vegetables and fruit. And if you really want to take a vitamin, take a multivitamin.

Marisa Weiss, M.D., president and founder: This is also true during radiation therapy. Most radiation oncologists suggest that their patients avoid taking antioxidant vitamins in supplemental form. If you take concentrated amounts of these agents, it's possible that they may interfere with the effectiveness of the radiation.

Anne McTiernan, M.D., Ph.D.: The American Cancer Society is updating its recommendations for nutrition, supplements, and physical activity. The new recommendations will be available in the fall.

Marisa Weiss, M.D., president and founder: You can read about their current recommendations here.

Painful joints on aromatase inhibitors?

Question from Cyndal: I exercised throughout my treatment, from surgery through chemo and radiation. Now I am on Arimidex and my hips get so painful after I exercise that they throb.

Answers —Anne McTiernan, M.D., Ph.D.: Some women do experience joint discomfort on aromatase inhibitors, and you might want to take some non-steroidal medicines like ibuprofen to ease the pain. However, many who are not on medication experience pain in the hips from exercise. Often, the pain is due to overuse, and the best way to combat overuse is to cross-train—do different types of exercise on different days so you're using different muscle groups and not overstressing one area.

Doing weight training a couple of days a week can also be helpful—on the lower as well as the upper body. This will strengthen the muscles around your joints, which, in turn, will reduce your risk of pain and injury. Most experts recommend stretching after exercise to reduce pain.

Marisa Weiss, M.D., president and founder: How about stretching before exercise?

Anne McTiernan, M.D., Ph.D.: Studies do not show that stretching before exercise reduces the risk of injury, but it does reduce pain. There's an excellent book on stretching called Bob Anderson's Stretching Book, and it's available at all the usual bookstores.

Marisa Weiss, M.D., president and founder: You don't burn many calories stretching, however.

Anne McTiernan, M.D., Ph.D.: But stretching is important for flexibility and pain reduction. The book I recommended shows pictures of stretches for many types of exercise.

Marisa Weiss, M.D., president and founder: What do you advise a patient who says she can't exercise because she has problems with her knees, hips, or some other body part that may be getting in the way of exercise?

Anne McTiernan, M.D., Ph.D.: If someone is having a problem with a specific part of her body, the muscles around that area are probably weak. People often have knee problems if their quadriceps muscles are weak, for example. Strength training exercises that concentrate on muscles around specific joints are very important, and there are many strength-training videos available. I recommend Strong Women Stay Young, by Miriam Nelson. It's a video and a book, but I especially recommend the video. It has very simple strength training exercises to help women gain strength around the joints that cause them the most problems.

Another way to help with problem areas is to cross-train. Don't do the same type of exercise everyday; varying your routine will make working out more fun and reduce your risk of injury.

Marisa Weiss, M.D., president and founder: If a woman has lymphedema (swelling of the arm due to backed-up lymph fluid), what accommodations should she make while exercising? For example, can she lift weights with that arm? And if so, how much weight is it safe for her to lift?

Anne McTiernan, M.D., Ph.D.: There's not a lot of information about exercise with lymphedema; however, one recent clinical trial showed that strength training did not have any adverse effect on lymphedema.

Women starting out should begin with the lowest possible weight, which is the weight of the arm alone. Do the exercise with no added weight at first, and then add one pound, and move up very slowly. We usually recommend doing eight repetitions and then resting from that exercise for a couple of minutes. During that "rest" time you can work another muscle group and then do eight repetitions of the first exercise again. Many women with lymphedema find that exercise is much more comfortable if they wear a special sleeve or bandage.

Marisa Weiss, M.D., president and founder: If you get an elasticized sleeve, make sure it is measured specifically for your arm by a physical therapist or an expert in medical supplies. If you apply bandaging, make sure you get proper instruction from an expert. These bandages are applied in very specific ways. Generally, the amount of pressure increases as the bandage goes from the hand up to the shoulder. It has to be applied firmly but not too tightly. With training you can avoid wrapping it in such a way that there are holes between the bandage strips, and so it's applied evenly all the way up.

Repetitve motions, heavy lifting cause lymphedema?

Question from Cyndal: I've heard that experts recommend that women avoid engaging in repetitive motions or lifting more than ten pounds to prevent lymphedema. Is this true?

Answers —Anne McTiernan, M.D., Ph.D.: You should always check with your surgeon to find out what's appropriate, because it will depend on the condition of your particular arm. If you have access to a physical therapist, she or he can help you develop a strength-training program and progress with it. Without more clinical information, we really can't recommend that women should or should not go above the ten-pound limit that some surgeons recommend.

Marisa Weiss, M.D., president and founder: If you can comfortably lift ten pounds on the affected side of your body, but can easily lift 20 pounds on the other side, is it a bad idea to lift uneven amounts of weight?

Anne McTiernan, M.D., Ph.D.: For some exercises, lifting unequal amounts of weight shouldn't pose problems. If you are using weight-training machines, however, they may be set up so that both of arms lift the same amount of weight—so it really depends on what you're doing.

Suggestions for good night's sleep?

Question from Magdalena: I have trouble sleeping. Sometimes it takes me one or two hours before I get to sleep, and then I wake up around 3 and stay awake for several hours. This tires me out even more. I don't like taking sleeping pills; do you have any other suggestions?

Answers —Anne McTiernan, M.D., Ph.D.: There are several things that can help everybody—including breast cancer survivors—get a good night's sleep. One thing is having a regular sleep routine, going to bed at the same time each night and getting up at the same time each morning. It's also important to avoid caffeine in the afternoon or evening, and avoid excess alcohol. Alcohol helps people fall asleep but then it wakes them up after a few hours and they have trouble falling back asleep.

Exercise has been shown to improve sleep, but one needs to do it early in the day and not after dinner. Some breast cancer survivors find that they have night sweats, which wake them up. For these women, making sure not to overdress when you go to bed, wearing cool night clothes, and not putting on too many blankets may decrease the chances of having night sweats.

Marisa Weiss, M.D., president and founder: For sure, many women who've had breast cancer have nightmares or wake up with anxiety or unanswered questions. It is really helpful to sort out what is keeping you up at night—what's waking you up or what's keeping you from getting back to sleep. If it's anxiety, for example, talk to the doctor on your team with whom you feel most comfortable. Simply airing your concerns can help relieve anxiety. Support groups can also be very helpful in processing your concerns and giving you greater peace of mind so you are freer to have a good night's sleep.

There are also effective medications to try, if anxiety persists. All of the changes in your body from treatment, including the hot flashes that Dr. McTiernan just mentioned—which can be triggered by hormonal therapy or premature menopause after chemotherapy—can contribute to the disruption of many of your body's rhythms, including sleep. So dealing with sleep problems really does require careful thought, and changes, along with trial and error.

How soon to exercise after mastectomy?

Question from Casey: How soon can I exercise after having a mastectomy?

Answer —Anne McTiernan, M.D., Ph.D.: There are several exercises that can be done soon after your surgery, as long as your surgeon says it's OK. These are exercises to improve range of motion on the side where you had surgery. These exercises can help prevent shoulder stiffness and get those muscles working better again. There are several books for breast cancer survivors that describe exactly what these exercises entail. In terms of more intensive exercise, it really depends on the individual woman and how she's feeling and the recommendations she gets from her surgeon.

We know that most women err on the other side; they become inactive after their breast cancer diagnosis and treatment rather than too active. So the first goal is to gradually return to the level of activity you were able to handle before you were diagnosed.

True to avoid sun while on chemo?

Question from Carolanne: Summer has always been my best time to be outside gardening, playing with the kids and all those fun things. But I heard that I'm supposed to avoid the sun while I'm on chemo. Is this true?

Answer —Marisa Weiss, M.D., president and founder: Some chemotherapy drugs can make your skin more sensitive to the sun. Go over this question carefully with your doctor. If you have a vacation planned, or if you enjoy being outside in warm weather, by all means go. But be sure to protect yourself against the harmful effects of the sun. This is important if you are on chemotherapy, or if you are long past finishing treatment.

Generally, you'll be safe if you use a cream or lotion with a sun protection factor (SPF) of 30 or greater, or if you wear sun-protective clothing. I like clothing from a company called Sun Precautions because it effectively blocks the sun and it's nice and cool. It is a bit pricey, but the garments last a long time. You can also just wear a large, man's shirt. Let the cuffs hang down to cover your hands and fold the collar up so it covers your neck. (It's also quite stylish!) Wear a hat, too, but remember that a hat has to have a brim of at least five inches to really protect your face. But don't deprive yourself of things you enjoy doing. There's usually a solution that will allow you to enjoy yourself and stay safe at the same time.

Reasons for weight gain?

Question from Carol: I was diagnosed with breast cancer on June 16, 2002 and I was wondering why I can feel so good, and then have a couple of days that put me down. Shouldn't I be over that by now? Also, even though I bike ride almost every day, I still need to lose weight. But I'm on tamoxifen and some women say it's hard to lose weight while you are on tamoxifen. I have also started taking coral calcium. Do you know anything about that?

Answers —Anne McTiernan, M.D., Ph.D.: While many people think tamoxifen is associated with weight gain, we've found in our studies of over 1,000 breast cancer patients that women who are using tamoxifen are actually less overweight than women who are not using tamoxifen. I think one of the reasons women gain weight after a breast cancer diagnosis is that they change their exercise and eating habits. Often, they reduce the amount of activity that they do and they become more likely to eat 'comfort food' rather than healthful food. In combination, those two things can result in weight gain. But it's never too late to reverse this pattern.

We're finding that breast cancer patients do very well with a weight loss program that combines healthy eating and increased activity. This doesn't mean you need to feel hungry. We find that many women are not fully aware of what they're eating; they're not aware of their calorie intake and they don't really know how much fat they're consuming. Once they become aware, it's easier to make the right food choices and lose weight.

Marisa Weiss, M.D., president and founder: Many of you may have gained weight during chemotherapy because of the comfort eating Dr. McTiernan just mentioned, and also because of medications, such as steroids, that you may have been given to ease side effects. You may also be on long-term medications that are associated with weight gain; some antidepressants, for example. But as Dr. McTiernan said, as difficult as this problem can be, a careful plan of exercise and dietary changes can enable many women to make progress in this area. The fact that most foods now have labeling can help you know what's in the food you eat. This can help you can make modifications in your diet.

Regarding the calcium, there are many different sources of calcium. They all work, but remember that your body can only absorb a limited amount of calcium at a time. Generally, you should take 500mg three times a day. Some preparations involve taking 600mg twice a day. I wouldn't go higher than that for any one dose. Take into consideration how much calcium you are taking in through your diet as well.

Anne McTiernan, M.D., Ph.D.: Most experts recommend about 1200-1500mg of calcium per day, and for many women the best way to get it is through food. A glass of milk has about 300mg of calcium, and there are many places on the web where you can get information about the calcium content of various foods. But if you can't eat dairy foods or don't like them, taking calcium supplements is the best alternative.

Suggestions for getting rid of hot flashes?

Question from Michelle: I was operated on 2 weeks ago for breast cancer and find it very difficult to get a good night's sleep, let alone deal with all the flashes during the day. What do you suggest to get rid of flashes besides soy milk? I am 70.

Answer —Anne McTiernan, M.D., Ph.D.: As we mentioned before, many women who have been diagnosed with breast cancer may be suffering from menopausal symptoms, either from stopping hormone therapy or from taking medication—often tamoxifen. Since breast cancer patients are usually advised to avoid hormone therapy for menopause symptoms, they need to rely on other means.

There are some medications that you can try, so first talk with your doctor. But there are other things many women have used through the ages— like wearing layered clothing, not being afraid to open a window, avoiding hot or spicy food, and avoiding alcohol. Remember that hot flash triggers vary from woman to woman, so each woman can figure out what triggers flashes for her, and try to avoid those things.

Tips on weight loss during treatment?

Question from Rose: What should you do if you lose weight during treatment? I've lost 15 lbs. My doctor does not want me to take vitamins, yet I feel I need something.

Answer —Anne McTiernan, M.D., Ph.D.: Some women lose weight during treatment, often because of nausea or lack of appetite. If you're not underweight, then the most important thing is to keep as healthy a diet as possible. That means eating a diet that's high in vegetables and fruit and high in protein. If you eat five to eight servings of vegetables and fruit a day, you shouldn't need to take any supplemental vitamins.

Editor's note: See more information on eating to maintain your body weight in Breastcancer.org's Nutrition Section.

Advice on tamoxifen and leg cramps?

Question from Rachel: Leg cramps frequently wake me up during the night. I am on tamoxifen and understand that causes the cramps. I drink tonic water to no avail. Any suggestions?

Answer —Marisa Weiss, M.D., president and founder: This symptom you're dealing with requires an individual evaluation by your doctor because there are a number of things that can contribute to leg cramps. It may be from a significant change in the chemical balance in your body. It may be due to hormonal changes resulting from tamoxifen. If the leg cramps are due to tamoxifen, your doctor is likely to be able to help. Sometimes leg agitation can be a side-effect of medication. Leg cramps that occur while walking, or sometimes at night, can signal blood vessel problems.

Can port-a-caths limit exercise?

Question from Ruta319: Do port-a-caths in any way limit the type/amount of exercise that one can do?

Answers —Anne McTiernan, M.D., Ph.D.: A port-a-cath is a plastic tube that the surgeon inserts into a woman's large vein so she can receive chemotherapy on an ongoing basis.

Marisa Weiss, M.D., president and founder: If you have a catheter that sticks out of your skin, you shouldn't swim.

Anne McTiernan, M.D., Ph.D.: We also recommend that you not do upper body exercise in the area where you have the port-a-cath. Avoid strength training that would use the chest muscles.

Marisa Weiss, M.D., president and founder: If you have the type of "port" that lies beneath the skin's surface, swimming is not a problem. But you may want to limit any exercise that causes stress on that region.

Reason for dizziness after surgery?

Question from Snowlady: Why do I get dizzy when I bend over? This has been happening since my surgery.

Answers —Anne McTiernan, M.D., Ph.D.: If you're dizzy when you get up from bending over, you might just be getting up too quickly, or you may be slightly dehydrated. So it's important to make sure that you have an adequate fluid intake. Many women don't take in enough fluid and tend to run a little bit on the dehydrated side. Water is enough if you're eating and if you're having regular meals.

If you're a competitive athlete, we don't recommend excessive intake of water, however, because it can contribute to chemical/electrolyte imbalances. One of the best guides is: if you're feeling thirsty, drink water. If you're getting dizzy when you bend over, there could be something else going on—maybe some problem with your inner ears—and that's something that should be evaluated by your physician.

Marisa Weiss, M.D., president and founder: Part of your balance center lies within the ear.

Weight gain side effect of Effexor?

Question from Micki: You mention antidepressants causing weight gain. I just received an Rx for Effexor to combat hot flashes and the doctor mentioned that it is also prescribed for depression. Is weight gain one of its side effects?

Answer —Marisa Weiss, M.D., president and founder: The dose of Effexor that is usually used for the treatment of hot flashes is up to 75mg a day. The dose for Effexor used to treat depression is usually higher than that. Weight gain does not seem to be a problem at the lower doses of Effexor used for hot flashes.

Okay to take more calcium than recommended?

Question from Magdalena: What can happen if we take more calcium than what you have recommended? I have osteoporosis.

Answers —Anne McTiernan, M.D., Ph.D.: Women with osteoporosis are often advised to take higher doses of calcium and also to take more vitamin D than what is recommended for the general population. Vitamin D is recommended because it helps with absorption of calcium. There's one very large clinical trial that is ongoing now to test the effect of calcium and vitamin D on fractures due to osteoporosis, and the results of that trial will be out in two years. But until that time, most physicians are recommending that women with osteoporosis do get a high dietary or supplemental intake of calcium and vitamin D.

Marisa Weiss, M.D., president and founder: Some women experience constipation from calcium, so if you take higher than the usual doses, this may become an issue for you. If you have any problems with your kidneys or form kidney stones, you need to talk to your doctor before you take supplemental calcium to make sure it's right for you.

How much alcohol is safe for survivors?

Question from Annabelle: I know that breast cancer survivors should watch their alcohol consumption, but how much alcohol is too much?

Answers —Anne McTiernan, M.D., Ph.D.: We don't have good data on how much alcohol is safe for breast cancer survivors. We do know, however, that the risk of getting breast cancer increases for women who drink more than 2 drinks a day. A drink of alcohol would be five ounces of wine or one can of beer or one shot of hard liquor. So the recommendation is to keep to fewer than two drinks a day. It makes sense that these guidelines may also apply to women with breast cancer since they're at risk of getting another breast cancer in the future.

Marisa Weiss, M.D., president and founder: Of course, it's very important not to mix alcohol with some of the medications you might be taking, like Ativan or pain medication. And of course you have to protect your life in all ways, so no drinking and driving. I have to say that for all the women who are going through treatment of breast cancer, think how hard you have worked to protect your life, so after you get through all this, remember to take care of yourself in many ways including using safety belts, not smoking, and being careful when you are drinking. And, of course, exercise.

Scuba diving safe while undergoing radiation?

Question from Flo: Can I scuba dive when I am undergoing radiation? My friends will help me lift my gear, and I feel I have the energy.

Answers —Marisa Weiss, M.D., president and founder: Radiation should not interfere with your ability to go scuba diving as long as your skin is intact. If your skin is very irritated or if there are any open regions, swimming is probably not a great idea. Scuba diving requires careful instruction. Before I would do that exciting sport, I would make sure you have careful instruction and not just casual instruction from friends.

Anne McTiernan, M.D., Ph.D.: Many times beginners scuba dive in a pool and quite often it's recommended that people undergoing radiation therapy not have chlorine exposure to the skin. So get your training either in fresh water or salt water. The chlorine really dries out the skin and it can make the radiation reaction worse.

Solutions for irritated, ugly port-a-cath scar?

Question from Cyndal: The port-a-cath removal has left an ugly scar that is continually irritated, especially by car seat belts. Any solutions?

Answers —Marisa Weiss, M.D., president and founder: Some women develop heaped-up scar tissue (keloids) in areas that have been traumatized by any kind of surgical procedure. Dermatologists may be able to lessen this reaction using a laser. You might also want to try wrapping foam or bubble wrap around the safety belt and then covering it with fabric.

Anne McTiernan, M.D., Ph.D.: You can also purchase ready-made covers for safety belts made out of lambskin material.

How long to feel well again after treatment?

Question from Sassy: How long after treatment (chemo, radiation, now tamoxifen) does it usually take before you feel well again?

Answers —Anne McTiernan, M.D., Ph.D.: In our studies where we follow women with breast cancer, we find that it's extremely varied. Some women feel just fine throughout treatment, and some women take a couple of years to feel like they're back to where they were before being diagnosed. So it's very individual.

Marisa Weiss, M.D., president and founder: My general rule of thumb—which is not at all scientific—is that the time it takes to feel like yourself again is the same as the length of time between the first scare prior to diagnosis (feeling the lump) to the last day of treatment.

For example, if the period of time between finding the lump and finishing all your therapy, not including the five years of tamoxifen, is eight months it's going to take about eight months before you start feeling more like yourself again. However, long-term hormonal therapy can certainly influence how you feel.

Of course, many other things can also influence the way you feel. For example, if you've gained weight or if you have persistent pain and discomfort following surgery, or if you lost your hair and it's taking longer than you expected for it to grow in again, or if you were thrown into premature menopause, then it's likely that you're going to feel different than you did before you were diagnosed.

Also, as time passes during and after treatment, all of us are growing older. So we become more aware of the effects of aging that can make us feel different than we did before. The main thing is that you want to keep moving in the right direction, recovering your precious energy, your sense of fun, and to preserve the things in your life that gave you meaning so that you can build a new kind of normal for yourself. What that 'new normal' is going to be like and how long it takes to get there—as Dr. McTiernan said—does vary a great deal from woman to woman.

The fact is, there is only one of you, and how you handle this and how all these things affect you will be unique to you. But you can still learn a lot from other women who've been there before and who may have a lot of advice, guidance and support to share. The Discussion Boards at Breastcancer.org are a great place to go to tap into a lot of this essential information and support.

Finally, remember that getting better involves having good days and bad days. Don't expect to feel progress every day. There will be times when you feel you're making good progress and other days when you may feel that you're slipping back. Hang on for the ride and keep yourself headed forward whenever you can.

How to act with recently diagnosed friend?

Question from Xan: My best friend was recently diagnosed with breast cancer. She's always been such a strong, independent person. I don't know what to say to her, but I don't want to lose her either. Help!

Answer —Marisa Weiss, M.D., president and founder: The most important thing is to be there for her. Make yourself available to take her where she needs to go, and be there to listen and to support her. And when you are hanging out with her, she'll let you know how you can be most helpful. Just knowing that you care and that you're there will make an enormous difference to her. What a great friend she has in you! There are a lot of places within the Discussion Boards at Breastcancer.org where women list the things that would help them the most.

Does exercise help with libido?

Question from Tami T: Does exercise help with libido?

Answer —Anne McTiernan, M.D., Ph.D.: Very little research has been done in this area. However, in a study that we finished last year, we got some interesting results. We studied postmenopausal women without breast cancer. We placed half the women in an exercise group and half in a stretching group. Many of the women in the exercise group—who exercised aerobically for 45 minutes a day, five days a week—offered the information that their sex lives had improved. They attributed it to having more energy, to feeling better about themselves, and, for some of them, losing some weight and gaining some strength and flexibility.

We were so intrigued by what they told us that we have a new study involving men and women, and we're asking questions about sexual satisfaction. For the individual woman, the best thing is to try some exercise and after a few months, see what she thinks.

Get back motivation to take care of self?

Question from Miss Julie: I always took excellent care of myself BEFORE breast cancer, but now I don't seem to do so well. I guess that's because it doesn't seem to make any difference. How can I get back my motivation?

Answers —Anne McTiernan, M.D., Ph.D.: I'm sure the fact that you took good care of yourself before being diagnosed with breast cancer DID make a difference. First of all, we know that women who weigh less have a better prognosis, so anything you did in the past to keep fit and keep your weight down will translate into a better prognosis, even though you did develop breast cancer.

Whatever you did before that was helpful to you will also be helpful in the future. What you can realize now is that if you keep your weight down, exercise, and eat healthy, you will improve how you feel and may well improve your outcome. Just having that knowledge will, hopefully, stimulate you to get back to where you were before you were diagnosed.

Marisa Weiss, M.D., president and founder: It's very normal upon a diagnosis of breast cancer that each woman struggles with this new reality and asks herself why this happened, what she did "wrong," and what she can change in the future that's going to make a difference. Many women also get frustrated with mammography, for example, if they were getting mammograms every year and the mammograms didn't find the breast cancer early.

We're hoping that with all the research Dr. McTiernan is doing with her colleagues, we can come up with better answers as to why this happens and what you can do to be in the best health in the future. But try not to knock yourself and be too self-critical. Your personal energy is precious, and if you can channel that into healthy eating and exercise in the future, that would be a step in the right direction.

Talk to children about diagnosis?

Question from Tabi: I've just been diagnosed with breast cancer. I have a 15, 13, and a 4-year-old. How do I tell them? What do I tell them?

Answer —Marisa Weiss, M.D., president and founder: You are a busy woman and mother! Each of your children is of a different age and maturity and is likely to need different types of information. It's going to be important to spend some time with each of your children individually. In that setting, get the discussion going and try to be as open and relaxed as you can, because this will invite your child to express him/herself more freely.

In general, the best approach is to answer their questions directly, and after you've provided an answer, stop and listen to the response. With a lot of listening, you can really do your best job at figuring out what your child needs and what to say next. Keeping things as normal as possible around the house is good whenever you can. Don't whisper because that worries your children. Know that children often blame themselves for what happens to Mom. This is particularly true of your older children. So it's really important to say that this happened and it's nobody's fault.

It's good to bring your children with you to a doctor's visit if they express interest, so they can see rather than imagine what you are dealing with. Just as it's reassuring to you to have good doctors and nurses on your team, it is also very reassuring for your children. We have a conference transcript on Breastcancer.org that deals with this tough challenge. Children really are resilient and they will absolutely take your lead how to manage this.

This is true about any part of life. Your kids are always watching you to see how you handle various situations. That's how they learn how to react to good things and difficult things. That doesn't mean you have to be an actress when you are feeling down. It's OK to cry openly, as long as the children see you move through it. And when you get to the other side, let them know it's OK that you're sad, and that's why you were crying, but that now you're better and they helped you feel better. If you can give your children a job to do, like helping you make dinner or getting the newspaper or folding the laundry or reading you the newspaper or massaging your feet, you are giving them a very important opportunity to help you get better, and that is really important.

Editor's Note: See more information on talking to your kids about your diagnosis in Breastcancer.org's section Talking to Your Family and Friends About Breast Cancer.

Advice for muscle pain after treatment?

Question from Allie: I have had a lot of trouble with my muscles and ligaments following treatment. I did exercise during treatment, but it seems as if the chemo settled in my muscles afterwards. I am swimming but find I am forever hurting a muscle. What can I do?

Answers —Anne McTiernan, M.D., Ph.D.: The best way to reduce muscle pain is through a stretching program, and since you're having a lot of problems with muscle pain, perhaps a regular stretching program like yoga would be beneficial. Stretching has some very strong physiological effects. In addition to lengthening muscle, it helps it to use energy better, it helps to get rid of some of the toxins that can break down in muscle, and it's very relaxing and enjoyable.

Yoga is one of the best ways of doing stretching in a regular program. It can be intense or very calm and comforting, so following one of the more relaxing yoga programs would probably be best if you're having a lot of muscle pain. You can do yoga every day for short periods of time. You can either take a yoga class at a local gym or yoga studio, or get one of the many excellent yoga tapes available and do it in your home.

Marisa Weiss, M.D., president and founder: As you move through and beyond treatment, you need to push for peace of mind and try to create it for yourself. One deal you could make with yourself is to say that while you're exercising, you're going to keep your mind on peaceful thoughts and things that bring you pleasure. Promise yourself that during those sessions, you're going to hold yourself back from worry, burning questions, and nightmare scenarios. If you can keep this promise to yourself, exercise can become particularly enjoyable.