Mammography and breast sonography in transsexual women

https://doi.org/10.1016/j.ejrad.2009.03.018Get rights and content

Abstract

Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women.

Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities.

Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0–10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain.

Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological 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.

Section snippets

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.

References (19)

  • S. Weyers et al.

    Long-term assessment of the physical, mental, and sexual health among transsexual women

    J Sex Med

    (2009)
  • F. Ravandi-Kashani et al.

    Male breast cancer: a review of the literature

    Eur J Cancer

    (1998)
  • S.A. Mc Intosh et al.

    Augmentation mammoplasty: effect on diagnosis of breast cancer

    J Plast Reconstr Aesthet Surg

    (2008)
  • W. Meyer et al.

    The standards of care for gender identity disorder—sixth version

    Int J Transgenderism

    (2001)
  • E. Moore et al.

    Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects

    J Clin Endocrinol Metab

    (2003)
  • K.A. Oriel

    Medical care of transsexual patients

    J Gay Lesbian Med Assoc

    (2000)
  • Feldman J, Goldberg J. Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia 2006....
  • G.W. Eklund et al.

    Improved imaging of the augmented breast

    Am J Roentgenol

    (1988)
  • W. Symmers

    Carcinoma of breast in transsexual individuals after surgical and hormonal interference with the primary and secondary sex characteristics

    Br Med J

    (1968)
There are more references available in the full text version of this article.

Cited by (44)

  • Gynecologic Care for Sexual and Gender Minority Patients

    2024, Obstetrics and Gynecology Clinics of North America
  • Breast imaging in transgender women: a review

    2021, Clinical Imaging
    Citation Excerpt :

    On ultrasonography, the breasts were judged “fatty” in 36% of women, “slightly dense” in 26%, “dense” in 36%, and “very echodense” in 2%. There was a significant correlation between the breast density at mammography and ultrasonography [11]. As in cisgender women and men, benign breast lesions will be encountered more frequently than malignancy on screening and diagnostic evaluation in transgender women.

  • ACR Appropriateness Criteria® Transgender Breast Cancer Screening

    2021, Journal of the American College of Radiology
  • Triple Negative Breast Cancer in a Male to Female Transgender Patient: A Case Report and Literature Review

    2020, Advances in Radiation Oncology
    Citation Excerpt :

    Additional data in the transgender population supports improvement in breast satisfaction, sexual well-being, and psychologic health after undergoing breast augmentation when using the widely validated Breast-Q scoring system.32,33 Thus, special attention should be paid to optimizing cosmetic outcomes by focusing on details such as reducing dose inhomogeneity (minimizing the maximum dose and the volume of breast tissue receiving >105% of the dose), which can be affected by the presence of an implant and possibly even by the increased breast tissue density seen in transgender female patients.21,34,35 Although cisgender women appear to be largely satisfied with their choice of surgical management of their breast cancer, data are lacking for transgender female patients.36,37

View all citing articles on Scopus
1

All other authors can be reached via their own department at the same address.

View full text