Why is hitting your funny bone anything but funny? Does sneezing really make your eyes pop out of your head? And why, no matter how hard you try, can't you stop from yawning when the person next to you yawns? Here are some of life's little medical mysteries -- solved.

Hitting Your Funny Bone

The funny thing is, the funny bone isn't a bone at all, but a nerve, and hitting it is anything but funny -- in fact, it's painful.

The nerve that is referred to as the funny bone is the ulnar nerve, which extends down the arm, across the elbow, and into the hand. It provides sensation to the little and ring fingers and activates many of the muscles in the hand, according to the American Association of Orthopaedic Surgeons web site.

"The ulnar nerve happens to be very superficially placed in the back of your elbow," says Ed Toriello, MD, a fellow of the American Academy of Orthopaedic Surgeons.  "At this spot, it lies directly under the skin and runs in a hard, bony groove on its way to your hand."

Why is hitting it guaranteed to make you cringe with pain, rather than laugh, as its nickname suggests?

"Nerves are very temperamental and sensitive structures," says Toriello, who is an orthopaedic surgeon in private practice in New York.  "For this reason, nerves generally course deep in muscles, where they are protected from direct contact with the things we bump into during our normal course of living.  The ulnar nerve at the elbow is an exception, because it lies in a spot that is very vulnerable and protected only by a thin layer of skin."

When you bump the back of your elbow directly over the ulnar nerve, it's caught between what you hit and the bony groove, explains Toriello. A painful electrical impulse is discharged from the nerve, which runs through the arm and into the little and ring fingers.

So shouldn't it be called the painful nerve, instead of the funny bone? One theory is that the name funny bone is a pun on the Latin word humerus, which describes the part of the arm between the shoulder and the elbow, according to the Indiana University School of Medicine web site, Sound Medicine.

Another theory is that the "funny" in funny bone means strange rather than ha-ha.

"My suspicion is that the first person who experienced this sensation when he or she struck their elbow did not find it fun, but rather found it an odd sensation since it didn't seem to happen when they bumped other parts of their body," says Toriello.  "So I think 'funny' in this context really means 'odd or 'strange.'"

Mystery solved.

Eye-Popping Information

Let's get one thing straight: "It is very unlikely our eyes will extrude or 'pop out' if we sneeze too forcefully," says Brian Smart, MD, chairman of the Asthma and Allergy Center of the DuPage Medical Group in Illinois.

Well, if the reason we close our eyes when we sneeze isn't to keep them from popping out of our heads, then why bother?

"Similar to the reflex that occurs when your knee kicks after it's hit with a medical hammer, or the way your hand pulls away from something hot when you burn it, closing your eyes when you sneeze is a powerful reflex," says Smart, who is also a spokesman for the American Academy of Allergy, Asthma and Immunology. "You can try and force yourself to keep your eyes open when you sneeze, but it's hard to do."

Another piece of folklore: We sneeze with our eyes closed to keep the stuff we sneeze out from getting in our eyes. Survey says?

"It is also unlikely that the substances we sneeze will get into our eyes, since the substances we sneeze travel some distance," says Smart. "Incidentally, the fact that we sneeze a considerable distance leads me to remind people to always cover their mouths when they sneeze. This will help slow the spread of respiratory disease, and is simply good manners."

Don't forget to say gesundheit.

Reading This Will Make You Yawn

Sometimes, even thinking about yawning will make you yawn. And when the person next to you does it, forget about it -- you'll yawn, too. With all this talk about yawning, in fact, you've probably already yawned.

"A yawn is an instinctive behavior: You don't have to learn to do it, and yawns are even present before birth," says Robert Provine, a professor of psychology and neuroscience at the University of Maryland, Baltimore County.

Is the myth that yawns are actually contagious true?

"When one person in a group yawns, over half of the people in the group will yawn within five minutes, and the rest will at least be tempted to yawn," says Provine, who has been researching yawning for more than 20 years. "What is surprising is that virtually anything having to do with yawning triggers a contagious reaction."

Provine explains that while yawning is highly contagious, so are other human behaviors, like laughter, and this reaction is actually very normal -- and ancient.

"When you see someone else yawn, you don't think to yourself, 'Well, I'll yawn, too," says Provine. "It just happens -- it's instinctive, and it's a very primal aspect of human behavior that goes back to ancient herd mentality."

Mysteries, Solved

Now that you know why yawns are contagious and why your funny bone should actually be called a painful nerve, here are other medical mysteries, unraveled:

Why do you lose your sense of taste when your nose is stuffy? According to the American Academy of Family Physicians web site, the flavor of food involves both taste and smell. If your nose is stuffy, you are left to rely on only half of the flavor equation: just your taste buds, and those buds can only differentiate between four or five different molecules, while the nose can distinguish between about 10,000. In short, your nose knows.

Is brain freeze really your brain gone cold? In an editorial in the British Medical Journal, author Joseph Hulihan describes ice cream headache, commonly known as brain freeze, as a pain that begins a few seconds after eating cold foods or beverages, peaks in 30-60 seconds, and is located in the mid frontal area of the brain. Why does it occur? It's been studied as an example of referred pain, or pain that starts in one part of the body, but is felt in another. In the case of brain freeze, the pain originates in the mouth and is referred through the tongue to the brain. The good news is that brain freeze isn't deadly, and no treatment is usually required. In fact, writes Hulihan, "Ice cream abstinence is not indicated."

Why can't you get the Disney ditty "It's a Small World" out of your head? According to a University of Cincinnati news release, marketing professor James J. Kellaris, PhD, explains that this song is a leading earworm -- a tune that gets stuck in your head and won't let go. Earworms are experienced by more than 97% of the population, according to the release, and drive a person crazy from a few hours to over a week.  Why do earworms strike? Overexposure to music can play a role, as can stress, fatigue, or pressure. So relax, and let earworms find someone else to feed on.

Sleep Tight

Now that you know the answers to some of life's medical mysteries, sleep tight, and don't let the bed bugs bite.

(One last mystery solved: Bed bugs aren't only the stuff of childhood rhymes: they're real, and they do bite. Think you have bed bugs? They're 1/4 inch long, reddish-brown, and are usually detected by welts and irritations on the skin that aren't there when you go to bed but are when you wake up, according to the University of Kentucky Entomology web site. Solution? Call pest control.)

On the other hand, data from the National Cancer Institute (NCI) also show that black women are less likely than white women to be diagnosed with other cancers that can be harder to detect, grow more rapidly and defy treatment, such as ovarian cancer, melanoma, and leukemia.

Black women's health advocates say the single best thing you can do to lower your risk of cancer is to sit down with your elders and get a sense of your family's medical history. Knowing your family tree can help you decide what kinds of screening tests to ask for and lifestyle changes to make.

"I happened to know that my grandmother had breast cancer because she showed me the scar," says Faith Fancher, a breast cancer survivor whose mother was among the first black family practitioners in the state of Tennessee. "But that is something that I think most (black) women don't know."

Here are four of the most common cancers among black women, along with what you can do to protect yourself:

1. Breast cancer is a leading cause of cancer death among black women and by far the most common cancer among all women, black or white. The incidence of breast cancer is lower among African-American women, yet this group has a higher rate of breast cancer deaths -- possibly because cancers tend to be detected at a later stage in blacks than whites.

   Consequently, black women are less likely to survive when cancer strikes: Their 5-year survival rate is 71%, compared with 87% for white women. The survival rate for black women jumps to 89% if the cancer is diagnosed before it has spread. Yet 44% of newly diagnosed breast cancers found in African-American women have spread to areas beyond the breast compared with 35% for white women.

   What to do: Breast self-exam and mammography are vital; early diagnosis is critical. Charles J. McDonald, MD, past president of the American Cancer Society (ACS), says black women should undergo their first mammograms at age 30, a full 10 years before the recommended age for white women. The National Medical Association, a national organization for African-American physicians, also supports early screening. Breast self-exam should begin as soon as a girl menstruates, McDonald says. Black women might also consider a low-fat diet and regular exercise, both of which have been shown in studies to lower a woman's risk of breast cancer, decrease heart disease, and improve overall well-being.

    

2. Colorectal cancer is a case of good news, bad news: The drop in deaths from colorectal cancers since the early 1990s is the second-biggest reason for the overall decline in cancer deaths among women. Yet black women continue to be at greater risk for this disease, with a reported 46.7 cases per 100,000 women for the period from 1987 to 1991, compared with a rate of 39.9 among white women.

   As in any other type of cancer, it's important to be tested early, and here, African-Americans have more reason to be vigilant: One reason that colorectal cancer deaths are higher among black Americans is that they are not being screened for the disease as often as other populations, says Deborah Kirkland, manager of the colorectal cancer division for the ACS. A recent study by researchers at Wake Forest University found that the main reason that many low-income, African-American women do not have sigmoidoscopies is that their doctors don't recommend the exam, possibly because they believe that the patient will not be able to pay the cost.

   What to do: Talk to your doctor about the three standard screening options for colorectal cancer: a yearly fecal occult blood test plus a flexible sigmoidoscopy every 5 years, a colonoscopy every 10 years, or a barium enema every 5 to 10 years.

   Currently, the ACS recommends that testing begin at age 50, but screening can start as early as age 21 for those with a family history of the disease. If you're African-American and you have even one first-generation family member who has been diagnosed with this cancer (a mother, an aunt, and male relatives, too), that's all the reason you need to learn about the tests and ask your doctor when you should begin getting them.

    

3. Lung cancer is the third most common cancer among black females. It is also one of the most preventable; tobacco smoking is the principal culprit. Unfortunately, lung cancer deaths among black women may grow, given that smoking rates among African-American teenagers have increased over the past 10 years, according to McDonald.

   What to do: Don't smoke. If you do, quit. And if your partner or your teenagers smoke, consider asking them to stop, for your benefit as well as their own. Unfortunately, there is no screening test for lung cancer before symptoms develop, so proactive steps are the only option.

    

4. Cervical cancer is one cancer that "we're well on the way, in this country, of conquering," says McDonald. Why? Yearly pelvic exams and Pap smears are effective screening techniques, and thanks to a massive public service campaign during the 1990s, more and more women -- black and white -- are beginning to get the message that these simple tests save lives.

Nevertheless, the incidence and mortality rates for cervical cancer are higher among black women than for white women. This is likely because black women tend to have fewer Pap smears and not because of genetics. Two studies presented at the annual meeting of the Society of Gynecologic Oncologists in February 2000 found that there was no difference in survival rates among black and white women after controlling for factors such as sexual history and access to appropriate medical care.

The incidence of invasive cervical cancer among black women also increases rapidly with age. So older women need to be just as vigilant as young women about getting screened.

What to do: Get your Pap smear regularly -- be religious about it. Don't put it off for any reason. And while you're at it, take your mother with you.

Beatrice Motamedi is a health and medical writer based in Oakland, Calif., who has written for Hippocrates, Newsweek, Wired, and many other national publications.

As in television, each picture tells a story: There's Faith, smiling as she wins a journalism award. There's Faith, tanned and glowing during a trip to Mexico. There's Faith in a black halter dress, looking just like Whitney Houston with her tousled hair and red lipstick.

But look at Faith Fancher herself today, and you see a different woman.

The woman in the photographs is bald now, curled up on the sofa with Lazarus and wearing an old pair of blue sweatpants. Her hair is gone, all of it, even her eyebrows. "I haven't shaved in eight months," says Fancher, laughing ruefully. "I look like a peeled egg."

Like her tousled hair in the photo (actually a wig), Fancher's slinky halter was also an illusion, carefully fitted to hide her port, a plastic tube surgically inserted into her chest through which chemotherapy drugs drip into her bloodstream. Only the red lipstick remains, a vivid reminder that Fancher, 49, is very much alive despite two bouts with breast cancer.

Diagnosed in 1997, Fancher had a mastectomy. Then last June, she found "a little pimple" in her reconstructed breast, in which a small amount of tissue had been allowed to remain. It was cancerous; Fancher had a lumpectomy, chemotherapy, and radiation, which left her too weak to work or even putter in her garden.

Yet she continues to make the rounds of luncheons and fund-raisers, fired by a simple fact that she repeats again and again: While black women are less likely than white women to get breast cancer, they are much more likely to die from it.

"It knocked me for a loop," says Fancher, who spends much of her time now lobbying for more money for early-detection programs, including mammography and breast self-exam. "I mean, my first thought was, why are we dying?"

Why, indeed. A study by National Cancer Institute (NCI) researchers, published in the journal Archives of Family Medicine in November 1999, revealed an alarming increase in the already troubling gap between black and white mortality rates due to breast cancer, from 16% in 1990 to 29% in 1995. And the NCI data show that the five-year survival rate for black women with breast cancer is 71%, compared with 87% for white women.

Experts have traditionally explained the discrepancy between black and white survival rates by noting that black women tend not to seek help until their cancers are already at an advanced stage. But the authors of the NCI report found that mortality among black women during the 1960s and 1970s was actually lower compared with that of whites until 1981, when mortality for whites began to drop sharply in response to more aggressive screening programs and better chemotherapy protocols.

And that leads to a disturbing conclusion, says Otis Brawley, MD, one of the study's authors: That black women have somehow been cheated out of the advances that have taken place over the past 20 years in mammography, chemotherapy, and powerhouse drugs such as tamoxifen.

Brawley blames poor access to health care and lower standards of care for black women. "While we have evidence that equal treatment yields equal outcomes, we also have evidence that in breast cancer there is not equal treatment," says Brawley, who is also head of the NCI's Office of Special Populations. "A lot of black women do not get nearly as good treatment for breast cancer as do white women."

One problem is screening: Despite steady increases in mammography use by black women during the 1980s and 1990s, an article in the Journal of the National Cancer Institute in March 2000 said that black women are still less likely than white women to have access to low-cost screening programs where they live.

But others point to a possible genetic cause. "When you look at the biology of the tumors that are often found in African-American women, the tumors are a little bit more aggressive, and the cell types are much more atypical than (those of) the average white woman," says Charles J. McDonald, MD, a cancer specialist and immediate past president of the American Cancer Society (ACS). Heredity also appears to play a role in why black women get cancer at a younger age, he says.

According to NCI data, black women are more likely to be diagnosed with cancer before they are 40, when cancers are most aggressive; more likely to be diagnosed at an advanced stage; and less likely to survive five years after diagnosis. Clinical studies report that black women also are up to twice as likely to be diagnosed with breast cancers that are estrogen-receptor (ER) negative, meaning they resist popular estrogen-blocking drugs, such as tamoxifen, which work by starving ER-positive tumors of the hormone they need to grow.

It all adds up to a puzzling scenario that contrasts sharply with the overall decline in cancer deaths since 1991. Among black women from 1986 to 1997, cancer incidence rose and mortality fell only slightly, whereas among white women incidence has remained relatively steady and mortality has dropped.

While unequal access to health care and poor quality of care are often cited as the reasons behind these numbers, it is tumor biology -- the idea that there may actually be a "black" breast cancer that strikes earlier and grows faster -- that prompts the most fear among black women. Studies have yet to prove it exists, though anecdotal reports suggest a genetic link.

Zora Brown was just 21 when she sought out a doctor and told a tale so devastating it could have been a Greek myth: Breast cancer in four generations, including her great-grandmother, her grandmother, her mother, and three sisters.

"My doctor threw her papers up in the air and said, 'Good Lord,' " says Brown, 51, founder of the Breast Cancer Resource Committee, a Washington, D.C.-based advocacy group. Brown's doctor then got on the phone, calling an oncologist, a surgeon, and an internist, who agreed to serve as Brown's medical team.

That team was ready in 1981, when Brown was diagnosed with cancer in her right breast, and again in 1997 when cancer was detected in the left. After two mastectomies, Brown says she is "fit and healthy." But a niece, Lea, died of breast cancer last year at the age of 29, and Brown says most of the women in her family have tested positively for BRCA-1, the gene linked to breast cancer.

Brawley says that Brown's case illustrates an uncomfortable truth: While she may be genetically predisposed to breast cancer, it's certain she would have died without good care. "And there's a bunch of black women who don't get optimal therapy," he says.

The fact that black mortality rates have stubbornly refused to drop in recent years, Brawley says, could be due to higher rates of poverty and obesity among black women, which make them more likely to develop cancers as well as less likely to get good care.

Meanwhile, he worries that talk of a "black" cancer could hurt women on the other end of the income scale. "I meet a whole lot of educated black women (with ER-positive tumors) who won't take tamoxifen because they hear that it hasn't been proven in African-Americans," Brawley says.

For Faith Fancher, the answer is to push early detection, a strategy that helps all women of all colors, particularly those at high risk. "I believe in mammography -- that's how I found my first cancer," says Fancher. "And I believe in breast self-exam -- that's how I found the second one."

She also pushes practical help: Her nonprofit group, Friends of Faith, pays for cab fare and child care so that women with cancer can get the treatment they need. Such "micro-grants," she hopes, will make a difference. "If we are worried that black women are dying at a high rate," Fancher says, "we ought to do something about it."

Beatrice Motamedi is a health and medical writer based in Oakland, Calif., who has written for Hippocrates, Newsweek, Wired, and many other national publications.

Before Smith has time to fake a stomach ache, Bruce Bekkar, MD, a Kaiser obstetrician-gynecologist, persuades him to come on in. "You're in the right place," says Bekkar, who teaches the class called "PMS, the Menopause, and You."

This three-hour crash course for men about women's anatomy and health concerns is believed to be the only one of its kind in the United States, although Bekkar hopes it will become a trend. His premise is straightforward: Teach men to understand why their wives or girlfriends may sometimes feel crabby, bloated, or on fire. By doing so, relationships are saved, and often grow stronger. Trouble brews, he says, when guys don't understand what their wives or girlfriends are going through.

Soon, Smith is sitting in the classroom, surrounded by 13 other men, most of whom look as uncomfortable as he does. They busy themselves reading handouts, eyes glued to the printed materials. Bekkar, who has taught the classes monthly for two years and always has a full house, warms them up quickly with his easy lecture style, punctuated by jokes, jazzy slides, and a wit honed by his stand-up stint at a San Diego comedy club. As he teaches the men, women attend a similar class next door to discuss their own concerns about PMS and menopause. Some of them are the girlfriends and wives of the guys in the class.

While most of the men are here because their partners asked them to come, about a third came to the class even though their wives didn't. James, 50, became concerned a few months ago when his wife Jan showed signs of unusual behavior. Three times in six months she forgot to mail the credit card bill. "Never in her life has this happened," he says. She was feeling stressed-out and out of control. When his wife's friend suggested it could be menopause, James decided to come and get educated.

Ignorance Is Widespread

As his class settles in, Bekkar assures them that they're not the only ones in the dark about women's anatomy. As proof, he displays the drawings he collected at a focus group conducted while the class was in the discussion phase. He asked several men, ranging in age from 25 to 55, to draw and label the female reproductive system as accurately as they could.

He shows three of the winning drawings, which he also includes in his book, Your Guy's Guide to Gynecology, written with his colleague, Udo Wahn, MD. "This is one of the better ones," says Bekkar, grinning. The "first prize" drawing Bekkar refers to is a childish picture that resembles a faceless rabbit with ears (the ears are actually meant to be the fallopian tubes). Another winning drawing looks like a close-up of the same rabbit, and the third, charitably speaking, could be compared to a flower. And these were drawn, Bekkar points out, by educated men: a banker, a computer consultant, and an administrator.

Undoing the Ignorance

Using a blitz of slides, background music, and nonstop patter, Bekkar plunges in. He shows the men accurate pictures of the female anatomy, drawn simply on a slide with crucial parts labeled. Another slide shows the complicated ebb and flow of hormones during a typical monthly cycle.

Then he introduces premenstrual syndrome, or PMS. PMS is defined as physical or emotional symptoms, or both, that precede menstruation and that are severe enough to disrupt work or other activities.

Most women experience some symptoms, such as breast tenderness, bloating, crying spells, or anxiety, but some women are affected more severely. Women who have PMS, he says, may feel "powerless and guilty. It's not like they wake up and say, 'I'm going to be hard on my partner.' "

Just when stuff begins to get heavy, Bekkar turns comic and shows a slide entitled "The Top Ten List of Things We Don't Recommend You Say to a Woman With PMS" while he plays David Letterman's background music. Among the no-nos: "Hey, those jeans used to be real loose on you, didn't they?" and "Aw, c'mon -- that PMS stuff is all in your head!"

Next, Bekkar turns to menopause. First he defines it (the cessation of monthly periods, occurring on average around age 51), then discusses symptoms (fatigue, hot flashes, forgetfulness, decreased sex drive, heavier periods before they cease entirely), and finally, treatments (synthetic hormones, natural [plant-based] hormone substitutes, and other remedies).

Squashing That Fix-It Mentality

Knowledge is power, but is only part of the equation, says Bekkar. Men must also overcome their urge to fix, fix, fix -- and, instead, "shut up and listen." He calls these the "four magic words." The 14 guys in class smirk when they hear this.

To illustrate, Bekkar cites an example of a woman with PMS who has had a hard day at work. She flew off the handle with a co-worker and now feels terrible. At home, she wants to talk to her partner about it. If he's like most men, Bekkar says, her partner quickly suggests how to fix the situation.

Instead, guys should listen, give their partner time to vent, and then ask a question pertaining to what she just said -- showing they really thought about her words.

After Bekkar gave his "shut-up-and-listen" drill at one class, one man approached him during the break and said, "My girlfriend has been telling me this for eight years." Somehow, hearing it from Bekkar made it ring true.

Helping Out More

Besides listening, a guy whose partner has PMS can help out more around the house when symptoms flare up, be understanding of her moods, and encourage her to exercise. "That does not mean pointing to the door while munching a big bag of Doritos and saying, 'Honey, take a lap around the block,' " Bekkar says. Instead, he suggests, offer to watch young children while she works out or suggest going for a walk together.

Men with partners going through menopause might help by being patient about sex, encouraging their partner to stay on hormones or other medications, if prescribed, and to keep doctor's appointments, Bekkar says. Most women appreciate their partner's help in trying to decide on the best options.

Report Cards

At the end of the class, Bekkar gives each guy a "supportive guy" diploma. At the bottom is a cartoon-like supportive guy, looking muscular in a Superman costume.

Smith, the originally hesitant student, was glad he came. He hoped to gain an understanding of what his girlfriend, 52 and menopausal, was going through -- and he did. He had already mastered some of Bekkar's suggestions: "I try to keep things as mellow as possible," he says. He also listens -- and reassures. His girlfriend was concerned that her symptoms, particularly her heavy menstrual flow, were getting in the way of the relationship. In true supportive-guy style, he reminded her that relationships aren't all about sex.

As for James, when his wife, Jan, learned he had sought out the class and enrolled, she says, "My first reaction was shock -- that they would have this class and that he would go. It kind of shocked me out of my denial [about menopause]. His going persuaded me to go to the doctor. And I was touched that he cared enough to go."

Although Small was healthy with no hint of cancer, her tests came back positive. She agonized for weeks, then chose a drastic measure that many women in good health would find unthinkable: She decided to have her breasts and ovaries surgically removed. "Although I wanted to have more children, I figured it would be better to be alive for the two I already had," she says.

Now that tests are available to identify mutations of the breast cancer gene, known as BRCA, women can find out whether they are at greatly increased risk of developing the disease -- even if they're cancer-free so far. The question is: What should they do with that knowledge? According to a study published in the June 10, 2000 issue of the Lancet, 50% are choosing preventive double mastectomies, meaning that both of their breasts are removed.

That decision comes with a lot of sleepless nights and troubling questions these women must grapple with. It's one that will radically change their lives. "You're taking away a part of the female body," says Small. "But I saw what my mother and sister went through, and I didn't want to repeat that."

Women at High Risk

Indeed, a woman makes the decision to have her breasts removed in the face of horrifying odds. Although mutations of the BRCA-1 or BRCA-2 genes do not guarantee that a woman will develop breast cancer, they substantially raise her risk. Women with BRCA mutations run a lifetime risk as high as 4 in 5 of developing the disease, says Victor Vogel, MD, director of the Comprehensive Breast Program at the University of Pittsburgh Cancer Institute/Magee Women's Hospital. Their lifetime risk of developing ovarian cancer is also elevated to 2 in 5. In comparison, about 1 in 8 women in the general population will develop breast cancer in their lifetimes, many in old age, and only 1 in 100 will have ovarian cancer, says Vogel.

Once a woman finds she carries one of the mutations, she is left with a difficult choice, he says. She can hope for the best and get frequent mammograms. She can take the cancer-preventive drug, tamoxifen, which has been shown to reduce a woman's risk of developing breast cancer by about 50%. She can have only her ovaries removed, which also reduces the risk of breast cancer by about 50%. Or she can opt to have her breasts, and often also her ovaries, removed.

A study published in the January 14, 1999 issue of the New England Journal of Medicine found that women with a strong family history of breast cancer (not specifically those who tested positive for the breast cancer gene) reduced their risk of developing the disease by 90% if they had both breasts removed. Though having a double mastectomy is not an absolute guarantee that a woman will stay cancer-free, the 10% who did develop tumors after the surgery may have had undetected cancers at the time of the operation, Vogel says.

Not the Only Option

While slightly more than 50% of women who learned that they carried one of the BRCA mutations opted for a double mastectomy in the Lancet study, it's clearly not the only option. Even when breast cancer does occur, tumors in women with BRCA mutations aren't any more virulent than cancers in other women, says Anne Blackwood, MD, an assistant professor of medicine and epidemiology in the division of hematology and oncology at the University of Pennsylvania Medical Center in Philadelphia. If the cancer is caught early, a simple lumpectomy -- where doctors remove the cancerous mass but leave the rest of the breast intact -- may suffice.

If other choices exist, then, why have so many women opted to have their breasts removed? Often the decision comes down to whether a woman can live with the knowledge that she has a good chance of developing breast cancer, says Linda Vahdat, MD, an assistant professor of medicine at Columbia Presbyterian Medical Center in New York City. "What matters is your level of fear," she says. "If you have a high level of fear, you probably should have a prophylactic [preventive] mastectomy. If you can put it behind you and go on with your life, you may want to do something else."

Women have to do what will give them the least amount of stress, says Vogel. Once they know about their elevated risk, some simply can't escape the gnawing fear. "Women have told me, 'I want them gone. Every day I wake up and wonder if today is the day I will develop breast cancer,' " he says.

But other women are loath to part with their breasts because their physical appearance and sexuality are so tied to their identity, Vogel says. For these women, breast reconstruction -- no matter how good the rebuilt breasts look -- may not be enough. "It's not the same as having a normal breast," he says. "You lose all sensation."

After the Surgery

While women who undergo preventive mastectomies greatly reduce their odds of breast cancer, there are other risks associated with the procedure itself, Vahdat says. General anesthesia can cause various complications, the most serious of which, in extremely rare cases, is death. There are also risks of blood clots and infection, especially with the longer surgeries needed to remove the breasts and reconstruct them with a woman's own fat tissue.

Since the breast cancer gene also increases the risk that a woman will develop ovarian cancer, she may choose to have her ovaries removed as well -- which sends her into immediate menopause. This means her risk of heart disease and osteoporosis will rise unless she begins hormone replacement therapy. The good news in that circumstance, Vogel says, is that these women don't have to worry about the potentially increased risk of breast or ovarian cancer that goes along with such therapy.

Breast reconstruction is another option to consider. There are two main choices: breasts filled out with fat taken from elsewhere on the woman's body or those shaped with saline implants. Those fashioned from a woman's own fat have the advantage of feeling more like a real breast, Vahdat says. But for some women, implants are the only viable option. Small says she would have preferred to have breasts formed from her own fat, but she was too thin.

Still, Small says she's happy with the results. "I had the most wonderful reconstructive surgeon," she says. "It took a long time. They had to reconstruct the nipples and stretch the skin. But they look very good."

Making the Decision

With all of these factors to consider, Vogel suggests that women who learn they are positive for one of the BRCA mutations take some time -- perhaps three to six months -- before making a final decision. "We tell women not to do anything in a hurry," Vogel says. "We tell them to talk to people. And we remind them that once their ovaries and breasts are gone, they're gone forever -- we can't reverse this procedure."

Indeed, one of the major impacts of removing the ovaries is sterility, meaning women can no longer bear children. Perhaps for this reason, the Lancet study found that most of those who opted for gene testing and ovarian removal were young women who already had children.

Even with all of the drawbacks, for many women removal of their breasts and sometimes their ovaries is well worth it. It reduces their fear of getting breast cancer. A recent study from the Mayo Clinic, published in the July 19, 2000 issue of the Journal of the American Medical Association found that of 572 women who'd had double preventive mastectomies between 1960 and 1993, nearly 70% felt good about their decisions. And nearly 75% said they worried less about breast cancer.

Small, for one, says she's still happy with the choice she made three years ago. "When you get cancer, you have to go through a period where you don't feel good and don't know what is wrong with you. And then you have radiation and chemotherapy," she says. "It's better to have the surgery and to avoid having cancer."

Linda Carroll is the women's health columnist for MSNBC. Her health stories have also appeared in a variety of publications, including The New York Times, Newsday, The Los Angeles Times, The Chicago Sun Times, and The Detroit Free Press.