Mammography and breast sonography in transsexual women
Introduction
Gender identity disorder is a condition in which a person has been assigned one gender but identifies as belonging to another gender and feels significant discomfort about this or is unable to deal with this condition.
Transsexualism is the most extreme form of gender identity disorder (GID) and will typically require sex reassignment surgery (SRS). In transsexual women SRS consists of removal of the male reproductive organs (testes and penis), creation of a neovagina and -clitoris and, since hormonal breast development is usually insufficient, in most patients implantation of breast prostheses. Surgery however is always preceded by extensive counselling by a psychiatrist and long-term hormonal therapy. Moreover gender dysphoric patients are only allowed to undergo definitive SRS after succeeding the ‘real-life experience’: the patient has to live for at least 1 year in his new sex identity.
In male-to-female transsexual individuals (transsexual women) endocrinological feminization is achieved by suppression of androgen effects followed by induction of female physical characteristics [1]. In our centre, suppression of androgenic effects is achieved by the anti-androgen cyproterone acetate, while estrogen is the principal agent used to induce female characteristics [2]. One of the desired effects of estrogen therapy is gradual growth of breast tissue. The latter effect is however highly variable, this is some patients will hardly develop some breast buds even after years of estrogen therapy while others have full breast development after 1–2 years.
Data on the necessity of performing screening mammographies in transsexual women are lacking. In one publication, mammography is recommended after 10 years of hormonal therapy for women older than 40 [3]. Another report advises screening mammography from the age of 50 in the presence of additional risk factors [4], but evidence from prospective studies is lacking.
In this study a follow-up investigation of 50 patients post-SRS was carried out. The primary objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women. Secondary objectives were the following: to describe any clinical, radiologic and/or ultrasonographic abnormalities, to analyse the expected and experienced discomfort of mammography and to assess the acceptance of breast exams by transsexual women.
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Patient population
Since the inception of the gender team at Ghent University Hospital, we performed SRS in over 300 male-to-female transsexuals, the last 5 years at an average rate of 30 cases a year. For the present study, Dutch-speaking transsexual women who had a minimal interval of 6 months since SRS and who consulted one of the members of the gender team for treatment or follow-up during the past 12 months were invited to participate (n = 70). After 4 weeks a participation rate of 50/70 (71%) was reached and
Study population characteristics
The main characteristics are summarized in Table 1. Two patients had no augmentative breast surgery since hormonally induced breast development was satisfactory (Fig. 1). Although in most women breast and genital surgery was combined in the same operative time, this was not the case in 15/48 (31.3%). The vast majority of transsexual women were on estrogen replacement therapy, the three women not taking any estrogens had important contra-indications (history of thrombosis). Only 2 patients were
Discussion
Breast cancer is uncommon in men, accounting for <1% of all male malignancies. Unlike female breast cancer, for which incidence rates are rising throughout the world, the comparative incidence of male breast cancer has remained relatively stable in most countries [7]. It is not unlikely however that in transsexual women, which for the most part receive life-long estrogen therapy, the risk of developing breast cancer will prove to be higher than for their male counterparts. So far, reports of
Conclusion
Our study shows that mammography as well as breast sonography is technically feasible and well accepted in transsexual women. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. As a result of these findings and since there is uncertainty about the long-term effects of estrogens on the male breast and about the real breast cancer risk of transsexual women, we think that breast screening habits in this population should not
Competing interests
Steven Weyers was supported by an unrestricted grant donated by Besins-Healthcare® (Brussels, Belgium).
Conflict of interest
All authors declare that there are no conflicts of interest.
Acknowledgements
The authors would like to thank the other members of the gender team for referral of participants, especially Prof. Dr. P. Hoebeke, Dr. G. De Cuypere, Dr. G. Heylens, Prof. P. De Sutter and Dr. G. T'Sjoen. We also thank all volunteers who participated as study subjects.
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