Saturday, October 23, 2010

Breast Development (In Male-to-Female transsexuals)


Breast Development
(In Male-to-Female transsexuals)

Calpernia Addams
For all women, breasts are a very important and very visible aspect of their "womanhood", it is also probably fair to say that the female breast is regarded as a key aspect of feminine beauty, both in our modern society and historically - and with both men and women.
The development of breasts gives the male-to-female transsexual woman a tremendous confidence boost, and powerfully identifies her as a female to others.  It is also impossible to ignore that the fact that breasts are immensely strong sexual symbols, and secondary sexual organs whose presence can be enjoyed by both the owner and their partner.  Unlike a vagina, breasts can be easily and acceptably be publicly displayed in either part (cleavage) or full (e.g. topless sun bathing), or prominently implied underneath a skimpy top.  Bra's and [usually] breast forms/padding are essential early purchases for every transsexual woman. 
While ultimately many transsexual woman will have breast implants, the first step is always female hormone treatment, using oestrogen and anti-androgens to enable the growth of breasts to their maximum natural size - although this is somewhat less than that of close female relatives.  Breast growth can often be enhanced by use of an appropriate progesterone, causing a more natural breast shape to form with lactative and ducting tissue as well as the fatty tissue laid down by oestrogen treatment.  If the woman starts treatment already past puberty, the resulting breast development can range from respectable to very disappointing - although even in the later case it should be noted that modern bra's, "push-ups" and breast enhancers can still do wonders appearance wise.  But the final breast development may still be regarded as unsatisfactory, particularly in older patients, in which case implants may be desired.

A lovely shot of transwoman Melanie Annie communing with her breasts. 

The Breast
A breast (also known as a mammary gland) is a quite complex structure consisting of a mass of fatty tissue and nerves served by a good blood supply.  Fully developed, each breast when lactating is capable of supplying a pint or more a day of nourishment (milk) and immunoglobulins to a nursing infant.  Visible in the centre of the breast is the protruding nipple, which is surrounded by a pigmented circular area called the areola.  Small glands in and around the nipple provide lubrication and protection against infection, which is particularly important for breast-feeding mothers.  Produced by the lobules (consisting of alveoli) in the interior of the breast, milk is carried to the nipple by a collection of tubes known as ducts. 

Stages of Mammary (Breast) Development
At birth the rudiments of the functional mammary gland are in place: the nipple and areola are formed along with a rudimentary system of mammary ducts extending into a small fat pad on the chest wall.   The mammary gland remains a rudimentary system of small ducts until puberty when the advent of oestrogen secretion by the ovaries brings about the first stage of the four stages of mammary development: mammogenesis, lactogenesis, lactation and involution.

Cheryl (shown age 35) is a possible transsexual who has occasionally taken hormones since her early 20's.  The results of hormones can be embarrassing and difficult to explain for untransitioned women still living their daily life as a man.
Mammogenesis commences at puberty with the onset of oestrogen secretion by the ovaries, usually between the ages of 10 and 12 in the genetic girl.  Oestrogen (often spelt 'Estrogen' in American English) causes enlargement of the mammary fat pad, one of the most oestrogen-sensitive tissues in the human body, as well as lengthening and branching of the mammary ducts.  About 40% of male children also initiate mammary development during puberty due to the tendency of the testis to secrete significant quantities of estrogens in early phases of its development.  As testosterone secretion increases this function is lost.
Oestrogen stimulates breast growth by acting on the mammary tissue.   With the onset of the menstrual cycle the presence of progesterone stimulates the partial development of mammary alveoli, so that by the age of 20 the mammary gland in the woman who has not been pregnant consists of a fat pad through which course 10 to 15 long branching ducts, terminating in grape-like bunches of mammary alveoli.  In the absence of pregnancy the gland maintains this structure until menopause.
Mammogenesis is completed during pregnancy, with the gland becoming able to secrete milk sometime after mid-pregnancy.  Pregnancy is often considered to be the period of most extensive mammary growth.   Indeed extensive lobular and alveolar development occurs only during pregnancy.
Lactogenesis (referred to as the time when the milk "comes in") starts about 40 hours after birth of the infant and is largely complete within five days. 
When nursing has ceased the gland undergoes partial involution, losing many of its milk producing cells and structures, a process that is only completed after menopause. 

Sarah, a 24 year-old transgirl - shown after 10, 17 and 26 months on hormones.

A good example of the type of breast development that transsexual women starting female hormones post-puberty may achieve
Breast Development in the Transsexual Woman
Every person whether genetically male or female is born with milk ducts — a network of canals that transport milk through the breasts — present from birth.  In the male-to-female transsexual woman the mammary glands stay quiet until commencing female hormone treatment releases a flood of oestrogen's, causing them to grow and swell in what is effectively a female puberty and initiating the first phase of mammogenesis. 

Transsexual women must examine their breasts regularly for signs of problems
Although often only partially developed, the breast structure of a transsexual "XY" woman is basically the same as a genetically "XX" woman after the first phase of mammogenesis, indeed transsexuals with well developed breasts are quite able to nurse given the right stimuli. 
It's important to note that all the common information and rules about the female breast (including the need for regular breast self-examination and mammogram's) apply just as much to transsexual women taking oestrogen as they do to genetic women.  
Externally, breast growth and development is medically defined by "Tanner's Five Stages":
Tanner Stage
(as applies to transsexual woman)
Stage I (Pre-hormone treatment) The undeveloped "pre-adolescent" pre-hormone type breast consists of a small elevated nipple (papilla) only, with no significant underlying breast tissue.  
Stage II (Hormone treatment started) After 6-8 weeks of hormone treatment subareolar nodules can be (painfully) felt and the nipple becomes very sensitive.  After about three months breast buds will visibly start to form. There is an elevation of the nipple and surrounding breast area as a small but increasingly obvious mound, and the areola diameter may begin to enlarge (particularly in young women).  Milk ducts inside the breast begin to grow.  Elderly transwomen may not get beyond this stage.  There is a lack of material for satisfactory breast implants - any implant will be very obvious.
Stage III This stage is reached by most transwomen after between six months and a year of continuous hormone treatment. There is further enlargement and elevation of the breast and areola (with no separation of their contours).  The areola may begin to darken in colour.  The milk ducts give rise to milk glands that also begin to grow. 
Stage IV If achieved, it will take one to two years to reach this stage.  There is a projection of the areola and papilla to form a secondary "mound on a mound" above level of breast.  Many twenty-something transsexual women display this characteristic after pro-longed hormone use.  Suitable breast implants can result in an excellent Tanner V-like appearance.
Stage V Only a very few transsexual women (mostly under age 20) reach this "mature" stage, after two or three years of hormone treatment. The breast has now fully filled out and only the nipple still projects, the areola has recessed and become part of the general breast contour i.e. the secondary mound has disappeared.

Breast development, Tanner Stages I to V 
After female hormones are commenced the breast slowly evolves and gradually increases in size, often with periods of growth and periods of apparent standstill.  In the initial phase of hormone therapy subareolar nodules - which can be painful - are common.  Both oestrogen and progesterone should be taken, it's thought that oestrogen stimulates cell mitosis and growth of the ductal system, while growth, development and differentiation of the glandular tissue (called lobules or alveoli) seems to be dependent on progesterone, and breast fat accretion seems to require both.

Loira - "mid-twenties" - has been taking hormones for two years.  Her breast development amply fills a A cup or supports a padded B.  The breast size is similar to many girls in their early teens, but unfortunately on a larger rib cage.

A "30'ish" transwoman.  No further elaboration was provided but the result is consistent with 4 or 5  months of full dose hormones - with enough breast development to have a 12 year-old girl wearing a trainer bra.
It's perhaps worth emphasising here that the results of female hormone treatment eventually become obvious to everyone, whether called breasts or "man boobs" .  Indeed breast growth is often a severe embarrassment for the pre-transition woman on hormones - ranging from in bed with a partner, running, or a visit to the beach. 

Good but not generous final breast development is typical for many women starting hormones in their early 20's.
Small, pert and strangely teenage-like breasts are common for those starting hormones in their early 30's.  Many eventually have breast augmentations.

This 53 year-old trans-woman has been on hormones (0.675 mg Premarin, 10 mg Progesterone, 2 mg  Estrofem) for 7 years.
Taking hormones hoping to somehow become a closet page 3 girl - but without any one at work or even the wife noticing - is simply not realistic.  Breast growth is irreversible without reduction surgery, stop taking the hormones and the breast growth that has been stimulated will still be around ten years later, it does not melt away.
Assuming that hormones is the right route, patience is essential, it will take at least two years to achieve full growth and some imperceptible changes will continue for the rest of your life - as trying on a very old bra will reveal.
Dissatisfied girls rushing to seek breast implants after one year may then experienced complications and misshaped breasts when another spurt of breast tissue growth sets in - as is quite common after SRS or an orchidectomy.  It should also be expected that the breasts will grow unevenly, e.g. the right may become much fuller that the left.  In the long-term the differences will mostly even out, but even in mature genetic women there is often a quite visible difference in size and shape between the left and right breasts when a study is made of them.

The top photo is of a 27 years old transwoman after 18 months on hormones.  The lower picture is of a 56 year old transwoman (also shown right, age 53) after 10 years on hormones.  Comparison shows many similarities, although the younger women has greater development in far less time.
The final amount of breast development obtained by a transsexual woman on hormone treatment is quite variable, but it's known to be very age dependent - unfortunately the younger a person and the more recent puberty (which normally ends between 18 and 20), the better the development will be.  Genetics also plays a very significant role - some people are genetically predisposed to have copious amounts of fat cells in therefore large breasts, others practically none.  Thus amply endowed sisters are a promising sign that development will be good, while flat chest'ed sisters are a serious worry! 
Other smaller factors come into play in determining the size of a woman's breasts, including nutrition, exercise, health, and weight.  For example, if a woman's body weight falls below its optimum then her breasts can shrink dramatically as the fat cells in them are burnt up (or in the case of a skinny transwoman are perhaps never deposited), while if her weight is above optimum then the apparent or relative size of her breasts may diminish as they are swallowed by the surrounding "padding".    

A poor quality picture of the breasts of a 21 year old MTF transsexual who apparently secretly began taking hormones at 9!   She transitioned when 12-13 and had SRS at 17.  A 34C bra is claimed.  From the shape and position of her right breast,  augmentation is probable.
A mature post-SRS MTF transsexual - however there's a suspicion of augmentation.

The breasts of a transwoman in her 20's and 40's - although there is a hint at augmentation the appearance in the lower picture is depressingly natural.

This type of roughly Tanner III breast development is very common in transgirls who start taking hormones in their late teens or early twenties.  They often seek breast augmentation.   
The limited evidence would indicate that maximum results are obtained by starting female hormone treatment just before the on-set of male puberty, but when puberty ends (around age 18) a "switch" in the body seems to turn off and the likely amount of breast development rapidly falls away in an elongated 'reverse S-curve' to a much lower level.  Thus a 12 year old boy-to-girl will typically end up with well developed breasts not that much smaller to his sisters and mother, the same person starting hormone therapy as a 20 year-old will still have quite good results, but as a 30 year-old she will have far less satisfactory results, and this will be only slightly better than a 40 year-old who in turn will be barely better off than a 50 plus year-old. 
Anecdotal evidence (clearly there is a need for medical studies, but so far none seem to have been conducted) indicates that the best possible hormone induced breast development achievable by a transwomen - normally by young transwomen - is about one bra cup size less than the average of their close female relatives.  
Many transsexual women suffer from small or under-developed breasts.  This can be helped by  breast augmentation as shown.
It must also be emphasised that although many girls who are able to start hormone treatment while in their teens will eventually develop full Tanner IV or V, "B" or even "C cup" breasts, this is still by no means certain.  For example the model Caroline Cossey started hormones at age 17 but owes most of her famous 36C chest to implants two years later, and Caroline is far from unique.  Other young (age 16 to 18) transsexuals report having very little breast growth even after a year or two on hormones - although in these circumstance there must be a suspicion that a change of hormone regimen might have helped them.  Certainly many young transsexuals are dissatisfied with their breast growth as they compare themselves with other girls, and begin to compete for boyfriends.

After augmentation via the inframammary method, Caroline Cossey became a 36C bra size and displayed a fairly natural bust appearance in her famous Playboy spread in 1991 - the first transsexual to be knowingly featured by the magazine.
Conversely, while most of those women starting hormones when already in their mature years will achieve only slight Tanner II or III "AA cup" breast buds, a few will get adequate, even ample, breast development.
There is undoubtedly often a degree of wishful thinking and 'rounding up' in the bra sizes claimed by transsexual women.  Realistically, most adult transsexual women starting hormone treatment over the age of 20 will be very lucky if they  eventually genuinely fill a "B cup" bra from hormone use alone, and those over 30 an "A cup".  However, if letters are important it should be remembered that despite a perception created by television and the press, the average cup size of genetic women is actually only "B".

The areolae of transsexual women are  usually small compared to genetic XY women. 
One odd problem that transsexual women face is that their areala - the coloured skin surrounding the nipple - rarely expands in accordance with 'normal' female breast growth.  The areolae of a man averages about 25 mm (1 inch) in diameter, but few woman are under 30 mm and 50 mm is common, and the areola of women who have large breasts or who are lactating may be over 100 mm (4 inch) in diameter.  Unfortunately even well endowed transsexual women tend to have male type arealoe - this seems to be a genetic limitation as AIS women (who are also genetically XY) face a similar problem despite otherwise above average breast development.
Hypoplastic Breasts
Many transsexual women, particularly those starting hormones over about the age of 25, suffer from under-developed or hypoplastic breasts.  Such breasts are very small or narrow, lack normal fullness, and may seem bulbous or swollen at the tip due to an over-prominent nipple-aereolar complex - their narrow elongated appearance leads them to be termed "tubular breasts", and nicknamed "snoopy breasts".  This condition is occasionally found in genetic XX woman, but is far more prevalent in transwomen.  The shape is usually caused by a failure to sufficiently develop the glands and lobules which help fill out the breast. 

A hypoplastic tubular breast.
As a tubular breast consists primarily of just fatty tissue, milk production and breast feeding can be problematic - although of course this is rarely relevant for transsexual women.  The use of a "cocktail" of hormones that includes both oestrogen and progesterone may help reduce hypoplasticy.
In older transwomen, their small breasts are also likely to be spaced widely, and one breast is often noticeably larger than the other.  These problems make it difficult to monitor the degree of breast development in mature transsexual women using the Tanner scale.

Breast Size
Breast size can be quantified by measuring the maximum hemi-circumference over the nipple with a flexible tape.  The following table shows the results from one study of breast development, measured in the sitting position, in 500 transsexual women:

Description Breast hemi-circumference
  Average Min. Max.
After 12 months Treatment 10 cm 4 cm 22 cm
Maximum Development
(After 18-24 months Treatment)
18 cm 4 cm 28 cm
Normal "XX" Female Development 22cm 12 cm 36 cm

Julia and Bia show a breast shape common in 20-something transsexual women who start hormones after puberty (even by just a few years) but have not had breast augmentation. 
It clearly shows that the breasts of male-to-female transsexual women are considerably smaller than genetic XX women.  To make matters worse, the width of the average transsexual woman's thorax is greater than that of the average female thorax, and so the breast development is proportional to the chest size even less than the figures indicate.  Consequently, the overall effect and appearance of their hormone-only induced breasts is judged unsatisfactory by some 50-60% of MTF transsexual women, and the vast majority of these seek augmentation mammaplasty (breast implants).

Long-term breast development in an un-augmented transsexual woman who started hormones at age 23 - the picture is taken 11 years later.  This picture shows the excellent C cup breast development but perhaps rather flatters their appearance on the woman's 42" size chest.
Another characteristic of the breasts of MTF transsexual women compared with genetic women is the smaller average diameter of their areola, even if the breasts themselves are actually quite generous in size.  Only starting hormone treatment at a young age seems to avoid this tendency.  Also, because the breasts of transsexual woman rarely reach full Tanner V size and maturity, their nipples often appear very prominent - although few women object to this too much!

Two tgirls in their late twenties.  Genetics and the lottery of life have resulted in different  development, but both girls have the small areola common for transwomen.
The Future
The advent of the first, very expensive, female hormone treatments in the 1950's was a massive advance for transsexual women seeking 'natural' breasts.  Since then there have been improvements in potency, delivery and cost - but no fundamental progress in the likely final result.  This may soon change with stem cell injections becoming a possibility in the next few years.  Named Celution, the procedure involves injecting a stem cells into the breast tissue.
Fat is taken through liposuction from the woman's belly or bottom.  The stem cells are filtered out from the extract and then put into a cartridge for injection into her breasts maybe an hour later under local anaesthetic.  While the initial change is small, it is claimed that the breasts will gradually 'inflate' over a six-month period and the eventual result will be an increase in two cup sizes (e.g. a B- cup to a D).   For many transsexuals this technique could represent a wonderful alternative to breast augmentation.
Madis - a 30-something transsexual woman with exceptionally good breast Tanner V development, large areola and appropriate veins - it's unlikely that one in a hundred MTF women are this lucky.  No indication of secret augmentation is apparent.

A follow-up from the header picture.  Diversity is the spice of life.
The following ladies are all believed to be transsexual women with natural breasts developed from hormone use.  I have attempted to classify using the Tanner stage, this system can be hard to apply to the breasts of transsexual women and my grading can be debated in several cases.  Notice the small areali, a feature so common with transsexual women, even if hormones were started early and the overall breast development is good.
Please contact me if you have any comments.
Early Tanner II budding Tanner II Tanner III - typical final type
breast development when
starting hormones in 40's
Tanner III, started hormones
age 25
, after 18 months use
Arguably a Tanner III, but the
scale doesn't apply well to some
Small Tanner V, started
hormones about age 19
Possible Tanner V, started
hormones age 13 but may have
had implants
And a few more examples sent to me by transwomen of their breast development:

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1 Response to Breast Development (In Male-to-Female transsexuals)

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