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For all women, breasts are a very important and very visible aspect of their "womanhood". The display or even the indication of breasts is instinctively viewed by observers as a strong evidence that someone is female. Breasts are regarded by both men and women as a key aspect of feminine beauty - in our modern society and historically.
While ultimately most transsexual women have breast implants, the first step is always female hormone treatment to enable the growth of breasts to their maximum natural size. The resulting breast development after a few years can range from minimal to very respectable - and even in worst case, modern bra's, "push-ups" and breast enhancers can still do wonders appearance wise.
The Breast
Above, the male breast, and below the female breast
Breast
Development in the Genetic Woman Mammogenesis commences at puberty with the onset of oestrogen secretion by the ovaries - usually between the ages of 10 and 12 in a genetic girl. Oestrogen (often spelt 'Estrogen' in American English) stimulates breast growth by acting causing 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. The development occurs according to well-defined milestones called the Tanner stages:
The levels of oestrogen required to cause breast development are surprisingly low - until stage IV, the growth of the breast in a girl takes place with oestrogen levels similar to an adult male. That is why about 40% of male children also initiate "Tanner I" type mammary development during their early part of their puberty - their developing testis secrete significant quantities of oestrogens. However, as testosterone secretion also increases the breast development ceases and very few boys reach the Tanner II stage. It takes just two to three years for a girl to achieve the majority of her breast growth. Stage V is aligned with the onset of the menstrual cycle - which results in the production of progesterone for the first time. The presence of progesterone stimulates the partial development of mammary alveoli, so that by the age of 20 the mammary gland in a woman who has not been pregnant consists of a fat pad through which pass 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. These ducts are very small and contribute little to breast size - this is a key reason why many doctors consider the prescription of progesterone to be unnecessary for transwomen.
Lactogenesis (referred to as the time when the milk "comes in") starts about 40 hours after birth of a baby and is largely complete within five days. When nursing ceases the breast undergoes partial involution, losing most of its milk producing cells and structures. Most woman who have had their first child ultimately end up with slightly smaller breasts than before they became pregnant because they now have less fatty tissue, also once their breasts are no longer swollen with milk they can sag in an increasingly unsightly manner - particularly after multiple children. Innovolution completes after menopause, when most women move to a smaller bra size. However, since the 1990's hormone replacement therapy has become a very common treatment for women entering their menopause, the renewed influx of estrogen can stimulate breast tissue redevelopment and an increase in bra size.
Breast
Development in the Transsexual Woman
In the initial phase of hormone therapy subareolar nodules - which can be painful - are common. Both oestrogen and progesterone (despite the reservations of some professionals) should be taken - oestrogen stimulates cell mitosis and growth of the ductal system, whilst the growth, development and differentiation of the glandular tissue (lobules or alveoli) seems to be dependent on progesterone, and breast fat accretion seems to require both. A transwomen with well-developed breasts is thus quite able to nurse - given the right stimuli.
It's important to realise that the results of female hormone treatment eventually become obvious to everyone, whether called breasts or "man boobs". For the pre-transition woman on hormones - it becomes increasingly difficult and embarrassing to go topless - local swimming pool, the beach, or in the bedroom with a partner. It takes about two years
of hormone therapy for a transwoman to achieve maximum breast growth.
Unfortunately, even if this is quite generous, the overall appearance of
the breasts is often hampered by the transgirl having a larger chest
cage than the average average cis-woman. Even when their bra-cup
size is actually the same, a transwoman will often consider her bust
development unsatisfactory compared to that of a similarly developed
cis-female. As a result, a majority of transwomen have
augmentation mammoplasty.
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.
All transsexual women like to 'round up' the breast development they
achieve from hormones and other more uncertain methods. But
multiple studies paint a rather depressing picture.
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, of 500 transsexual women: 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. A second study published in 2017 of the breast
development of 229 European transwoman age 18 to 68 (the median
average being a surprising young 28) after a year on hormone therapy
(estrogen and anti-androgen) showed similar disappointing results.
The study used the approach of measuring the circumference of the
chest underneath the breasts and at the largest part of the breasts.
The difference between these two measurements was then used to
determine breast growth and
bra size.
The study found: Just 21 (9%) of the women had a bra size of an A cup
or larger (12+ cm difference) 14% had an AA cup (10-12 cm difference) 26% had an AAA cup (8-10 cm difference) 50% had little or no hormone induced breast
development
To compound the disappointment, the study showed
that almost all the breast growth happened during the first six
months of cross hormone therapy (CHT), and that it had tapered to
almost no growth by the final three months. I.e. it seems that
a transwoman has not achieved substantial breast growth after six
months on hormones, she is unlikely to be much better off several
years later.
The final amount
of breast development obtained by a transsexual woman on hormone
treatment is undoubtedly very variable and depends on a number of
factors: Firstly, is the fact that their body has since the foetus stage been
exposed to larger amounts of testosterone hormones than a girl.
The cumulative effect on the body is very significant - the most obvious
early differentiation is a penis rather than a vagina, but there does
seem to be a significant impact on potential breast growth as well.
Women suffering from AIS (i.e. genetically XY
male, but unaffected by androgens) are as well-endowed bust wise as
their female relatives, so the constant drizzle of testosterone in the
womb and onwards seems to have an irreversible effect on the potential
breast development of "boys". Secondly, genetics also play 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
chested sisters are a serious worry! Thirdly, breast growth seems to be very age dependent - the younger a
person and the more recent puberty the better the development will be.
But even 20-something is likely to disappointed. Finally, 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". The following chart shows the result of a study that tracked the
breast development of
125 transgender women
(varying in age from 17 to 64)
after they began female hormone treatment: The study found dramatic changes in the first 12 months of hormone
treatment, with over 90% of patients reaching at least Tanner III.
But there was only modest improvement thereafter. Although all
patients were judged to have reached at least Tanner III
after 24 months on hormones,
breast development had almost stopped at by this time, and just
8% were Tanner V. After a prolonged pause
breast tissue growth may restart - although there is usually a
trigger such as a change in the hormone regime, an orchiectomy, or SRS.
Age Matters - A Lot ... Towards the end of puberty (age 15 to 17) a genetic
"switch" in the human body seems to flick and the likely amount of
breast development rapidly falls away to a much lower level. Since
about 2001 it has become quite common for young transgirls to be
prescribed anti-androgen 'puberty blockers'. These have very
important effects such as preventing facial hair and the voice
deepening, but they don't seem to stop the clock on potential breast
development.
Empirical evidence strongly indicates that for the best possible
breast development, oestrogen hormone treatment (rather than just
puberty blockers) should begin no later than the first signs of the on-set of male puberty,
typically age 11/12 for most boys. Based on the controversial treatment of treatment of
intersex children with XY genes, beginning oestrogen hormon treatment at
this age is likely to achieve breast growth similar that to pubescent
CIS girls.
In terms of breast
volume, the final result is then likely to be only slightly less than
the girl's mother and sisters, perhaps a result of XY vs XY gentetics.
Nevertheless, it increasingly appears that beginning hormone
treatment when age 16 is already beyond the optimal age for good
breast development. Whilst most girls who start hormone
treatment at in their mid/late teens will eventually develop "B
cup" Tanner IV or V type breasts, this is by no means certain.
For example, the model
Caroline Cossey
started hormones at age 17 but owes most of her famous 36C chest
to breast implants two years later, and Caroline is far from
unique. Many young transsexuals are dissatisfied with
their breast growth as they compare themselves with other girls,
and begin to compete for boyfriends. Self-Deception
The results of the survey were very odd
finding. All seven respondents who had begun taking hormones by
age 19 or earlier were unsatisfied with their hormonal breast development (claiming
only an A or B cup), but none had yet had breast augmentation.
By comparison, a majority of the 39 respondents who started hormones age
20 or later claimed to have achieved very good breast development (C or
D cup) from hormones, however 27 had since had breast augmentation
surgery. Sadly, I just couldn't believe the survey results for the over
20's. There is undoubtedly a degree of wishful thinking and 'rounding up'
in the breast measurements and bra sizes claimed by transsexual women.
In particular, the claims often made by middle aged transwomen to have
developed large breasts after a year or two on hormone therapy are
improbable and should be treated very sceptically. My conclusion was that most adult transwomen achieve only
Tanner III "A" or small "B" cup breasts from taking estrogen hormones, although a
lucky few will get adequate
- even generous
(a very few!) - breast development.
Breast
Growth in Young Transwomen The Exceptional ...
Television star
Jazz Jennings is a "pin-up girl" for the benefits of early female
hormone treatment. She was on [male] puberty blockers for many
years - probably from age 10 - and was still flat-chested when she
turned age 15. However, she then began taking estrogens and her
breast development thereafter was remarkable. She was initially
reluctant to wear a bra, but by age 17
she was Tanner V and
had grown to a 34D/E cup!
Her
large breasts
forced her to wear a bra for comfort - "I have boobs [and] need
to wear bras". A year later. age 18, she launched her own
Jazz bra.
Even among teenage cis-girls, Jazz's breast development is well above
average, as she acknowledged herself in a YouTube video soon after
turning 17: "I did not get any surgery on my breasts, and surprisingly they
have grown to be the large size that they are today. Anyway, the
reason why my boobs have grown so large is because my mom has really
big boobs and I feel like her genetics is what caused me to ...
blossom like this. I got lucky ... I've been very fortunate to
have my breasts grow the size that they are today and it's something
unexpected. [My] endocrinologist ... said she has never really
seen anyone develop the way I have in terms of my boobs." ... and the More Likely The early prescription of
oestrogen hormones has many benefits for transgirls but guaranteed good
breast development is not one of them. In 2001 I developed a 'rule
of thumb' that a genetically XY transwoman's best possible breast
development from hormones was a bra-cup size less than her XX mother. I
soon discarded this theory in the face of supposed "evidence" that this
was a very pessimistic view, but I have now reverted to my original
supposition. 1970/80's celebrities such
as
Eva Robin's,
Roberta Close and Amanda Lear
who began hormones in their teens never reached more than a B-cup.
Fast forward to the 2010's and there is a long list of young
transgender models (e.g. Teddy Quinlivan, Ines Rau, Valentina Sampaio,
Geena Rocera ...) who started taking antiandrogens (i.e.
testosterone blockers) and female hormones whilst in their teens.
Their breast development is generally unimpressive, and several have
needed small breast implants to gain the perky nubile breasts that are
essential for a top female model. Even young transgender Youtube
stars (e.g. Blaire White, Maya Henry, Samantha Lux, Elena Genevinne,
Princess Joules, Emma Ellingsen ...) all seem to have had breast
augmentation. Another television star,
Valentijn de Hingh, is perhaps a good example to compare with Jazz as
her life was closely followed by Dutch television from age 8 to 17.
Although born physically male, her parents accepted her desire to be a
girl and she transitioned when 9. The Standards of Care
were then stretched to the limit - she started to take puberty blockers
at 12, female hormones at 16 and had her sex reassignment surgery at 18.
Since then has been working as a highly rated model, just outside a Top
100 "super-model" ranking.
Two steps forward, One step back During the 2010's I have become increasingly puzzled as to why so
many young (teenage) transgirls
seem to have so little breast development after several years on
hormones. It just doesn't align with the experience of teenage
trangirls in the 1990's and early 2000's, most soon had obviously
budding breasts, with breast growth quickly reaching at least a B cup.
After consideration of what may have changed, I think it must be the
hormone regimen. Teenage transgirls in the 1970's through to the 1990's often
self-medicated and took relatively high doses (by current standards) of
estrogen hormones dubiously and dangerously purchased without a
prescription, often from off-shore pharmacies. One of the most
popular brands was 'Premarin' - a natural conjugated estrogen extracted
from the urine of a pregnant mare. This is easily assimilated by
the human body and strongly promotes in a teenager the development of
female secondary sexual characteristics such as breasts, a feminine
pattern of fat distribution, and even (anecdotally) skeletal
characteristics such as a widening of the hips if started young enough. In the early 2000's there was a massive clamp down on off-shore
pharmacies, whilst at the same time the medical professional (guided by
the revised Standards of Care) became more willing to treat
transgirls under the age of 18, albeit with significant provisos. The prescriptions now being given to transgirls are usually for
anti-androgen puberty blockers such as Lupron (Leuprolide
Acetate) from age 14, with a relatively low dose of a synthetic estrogen
steroid hormone such as estrodial only being added when they turn 18.
The result is a very effective prevention of physical masculinisation
such as facial hair, deepening voice and muscle build up. However, the medications do little to promote feminisation and breast growth
(indeed may hinder this), with the estrogen being added too late and of
a type that breast tissue is not sensitive to. The end result of the current approach often seems to be a 21-year
old transwoman who despite (or rather, because of) years of medical
treatment still looks like a young teenage boy physically, whilst in the
same time her younger sister has transformed into a buxom woman. I suspect that the medical profession needs to become far more
aggressive in the prescription of female hormones rather than blockers
for transgender children in the 14-17 age group (accepting the risk of
the occasional mistake), and that pressure for this is building.
Indeed the instances where transgirls of age 16 or less are prescribed
estrogen by a doctor already seems to be moving from exceptional to
quite common.
The Areola of
Transwomen
A 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.
The coloured skin
surrounding the nipple rarely expands in accordance with 'normal' female
breast growth.
Unfortunately transsexual women tend to have male type arealoe,
even those lucky enough to otherwise have excellent Tanner IV or even V
breats development. This seems to be a genetic (male XY) limitation. Not only do young
transwomen who start hormone treatment in their teens often suffer from
this problem, but it is also common with AIS women (also genetically XY) whose average breast development exceeds
that of (XX) cis women.
One positive is that because the breasts of transsexual
woman rarely reach full Tanner V size and maturity, their nipples often
remain very prominent - and there are few complaints about this! Hypoplastic
Breasts Low-cost anti-androgen's such as Spironolactone, Androcur or
Finasteride are often taken as part of a transwoman's hormone
regimen. However, there is evidence that excessively high doses of these
(e.g. from self medication) can cause
incomplete breast development. The use of a "cocktail" of hormones that
includes both oestrogen and progesterone may help reduce hypoplasticy,
there is also anecdotal evidence that rubbing a progesterone cream into
the nipple area can help.
Breast Augmentation 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).
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. But if the
difference is excessive (e.g., a cup size), to the extent that one breast
has to be padded, then this can be largely eliminated by the use of
different size breast implants.
Fat Transfer The last
decade has seen the emergence of an additional solution for transwomen
who want to increase the size of their hormone induced breasts by a
modest amount without surgery.
Sadly, whilst
the immediate increase in breast volume after the injection of the fat cells into the breast
might be substantial, in the real world about 30% of the
gain is lost within a few weeks, and the long-term loss is typically 50-70%.
Nevertheless, it's a good option if a quick and confidence boosting increase in
breast size is needed, e.g. for a beach holiday, a beauty contest or even
a wedding!
For
transwomen with reasonable but not quite sufficient hormone induced
breast development, this technique can be a good alternative to
breast augmentation. It should round out their breasts and
provide a modest boost in size. Importantly there are no signs of
surgery and no implants to mare the feel of the breasts.
Whilst the temporary stretching of the skin can result in some subsequent breast
drooping - this is often desirable for middle-age transwoman seeking a natural
appearance equivalent to cis-woman of similar age.
Breast Cancer
Breast tissue means the risk of breast cancer.
Breast cancer is the primary cause of death of about 6% of cis women in
the UK, whilst it's negligible for cis-men. When this article was first written in 1999, breast
cancer was simply not considered relevant for transwomen as so few cases
had been observed. That was
despite the fact that transgender women who take high levels of estrogen
develop breast tissue similar to that of cisgender women, comprising
breast ducts, lobules, and acini. It's now clear that the lack of
cancer cases was due to the small number of transwomen, and the
fact that the vast majority of these only started taking hormones to
develop their breast tissue in their 30's or later.
Breast cancer also has to be added to the list of potential problems. It increasingly seems that a transwoman who starts hormone therapy in her teens is as likely to die from breast cancer as a ciswomen - there hasn't been enough research done to date to say if the probabity is more or less.
All transwomen taking hormones should regularly cheack their breasts. Signs of breast cancer include a lump in the breast, a change in breast shape, dimpling of the skin, fluid coming from the nipple, a newly inverted nipple, or a red or scaly patch of skin. Transwomen over 50 who have been on hormones for ten years or more should have regular mammography screening.
Summary
In 2001 I suggested in an early version of this page that a transwoman's best possible breast development from hormones was one bra-cup size less than her mother or sisters - and this was soon being widely quoted. However, this was based on taking at face value the substantial bust development claimed by many transwomen after taking hormones for even just a few months. I now realise that these claims include a considerable element of optimistic rounding up.
It's now undisputable that the earlier in life that oestrogen therapy begins the better the results will be, but some girls who began treatment as young as 16 still have have only Tanner II/III type budding years later. A substantial proportion of young transwoman starting hormones before age 18 do actually reach a breast circumference and volume of breast tissue close to the average for a natal cis women, but because their larger skeletal frame the visual appearance is still often unsatisfactory. Transsexual women starting hormone treatment over the age of 18 will be 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 a genetic cis women in Europe is actually only "C".
A Final Warning Taking hormones hoping to somehow become a closet page 3 girl - but without anyone at work or even the wife noticing - is simply unrealistic. 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.
Examples Please contact me if you have any comments. Below. A 24-year old transwoman after 30 months on oestrogen hormone therapy. Her good Tanner III breast development is typical for her age, but she was still disappointed and later had breast augmentation.
Below. Topless photos of transwoman collected from various sources such the internet, magazines and an album cover.
Below. A collection of photos sent to me by transgender women of their hormone induced breast development (several are used elsewhere on this website so apologies for the duplication)
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