Boobs! Breast development is a hot topic in gender affirming care, and there are a lot of unknowns about optimizing breast development.
We believe that there is no one way to be trans, and that includes each person’s body goals. For people who want breast development, we believe that adding progesterone to the medication regiment supports fuller breast development. Here’s Dr. Beal talking about it in a QueerCME tiktok – please remember that Queer CME is directed at clinicians and prescribers, and not patients, so the language is often a little different than how we would discuss breast development in an appointment with a patient.
Other QueerDoc Info On Progesterone and Breast Development:
- Progesterone – The Big Debate
- Progesterone- Why’s it Missing?
- Gettin’ Nerdy on Gettin’ Curvy: Estradiol, Progesterone, and SERMs
- 12/16 “The Beal Method” Optimizing Breast Development in Trans and Gender Diverse People
QueerCME tiktok on Breast Development:
originally posted 12/3/2023
Video Transcript
let’s talk about uh
the timeline for breast development
I’ll talk more about progesterone this upcoming week um
but someone asked uh
timeline questions
and I wanna take some time to go over this
cause I think clinicians
setting realistic expectations for patients seeking gender affirming care
is one of the most important jobs or roles we have um remember
gender affirming care is a little different than a lot of the rest of healthcare
um because gender diversity is not a disease or pathology um right
it’s an identity
and we’re supporting people being who they are and so uh
this is less about being the paternalistic expert and more about supporting um
people having the information to make the right choices for themselves
and so I think expectation setting is a very important part of that and so
timeline for breast development and expectations around breast development
your patient should start to experience breast budding
typically within three to six months of gender affirming hormone therapy
starting with estrogen um
and we expect to see the bulk of breast development completed within two years
um a lot of times you’ll see you know
the vast majority of it in the first 18 months
and the changes after that
are more subtle
and after two years
you can continue to see subtle changes
particularly if your body changes size right
weight gain definitely affects breast size
but it’s gonna be much more subtle than what you saw in the first 18
months to two years in that patient
there is a lot that is unknown about breast development
and trans and gender diverse patients um
and there tends to be a
a fair amount of dissatisfaction
when we look at the literature with breast development
which is interesting because breast size is actually fairly similar um
to average breast size in ciswomen
um I think part of the issue is um
the same size breasts are sitting on a larger chest
right so chest width, rib cage size are larger in patients who are
in people who have had a testosterone based puberty first
and so um even though the amount of breast tissue present
is similar to what we see in ciswomen
um it looks proportionally smaller because of the size chest it’s on
um also because of that chest width
it tends to set a little further apart um
and so you don’t get the same kind of cleavage response um
that two years is actually kind of important
if patients are interested in breast augmentation
if patients are interested in breast augmentation
and are considering estrogen therapy or gonna do estrogen therapy
the general recommendation is to wait for two years of estrogen therapy
um so that the implants can be placed appropriately
according to how the breast develop
um right if we put them in sooner than that
the surgeon can’t account for that uh
upcoming breast tissue development
and so the aesthetics might long term might not be quite as ideal um
as far as like
the one best approach in gender affirming care for breast development
as far as we know
that doesn’t exist
we don’t have any peer reviewed literatures or studies saying that um
estrogen done this way or estrogen with this anti androgen is better
um there is some literature that suggests patients who take spironolactone
are more likely to seek breast augmentation later
um so that might be associated with like um
potentially earlier breastbud fusion
there’s also um
evidence that suggests uh
too high of an estrogen dose too fast can lead to um
earlier breastfed fusion as well
and thus stunted or a decrease development or growth um
this kind of circles to around some of Powers like approaches
cause he kind of has this idea
this recipe maybe that is like there’s one best approach for everyone
I don’t think that’s true
I think the best approach for gender affirming care is individualized
off of many many issues
but primarily pre existing health conditions
um goals for care um
values and access um
that being said
my clinicians at my clinic sometimes joke
about something they called the Beal method and
I’m not the only clinician who thought of this right
but testosterone has a stunting effect on breast development as well and
and we know that a too high dose of estrogen too fast
stunts breast development in
so theoretically
if we could really successfully block testosterone
and do a much more gradual approach with estrogen dosing
much more similar to what we see in a cis-based ovarian puberty um
there’s some thoughts that we might have
like matter better or more predominant breast development
and so that you know
really looks like trying to access a GnRH agonist um
or orchiectomy um
which isn’t necessarily accessible for most people
a lot of patients aren’t necessarily at a point
and their experience with their want to access orchectomy
like before they start estrogen um
and GnRH agonists
a lot of times are cost inaccessible for patients um
a lot of times you have to fail uh
you know oral anti antigens before an insurance will prior auth GnRH agonists
um and for patients without insurance
they’re you know
not accessible at all except from international pharmacies
typically because they’re thousands of dollars um
I have heard FQHC
so nonprofit pharmacies have them for a cheaper
and so that’s like 100 bucks a month instead of thousands of bucks a month
so that’s something to consider
um yeah to be clear
all of this is theory
none of this is proven
um and frankly
the way we would try to prove things like this would potentially be twin studies
um which obviously have a lot of barriers
issues and ethics around them um
but based off of what we currently know
that is like how I would think about
theoretically trying to optimize breast development
I would also incorporate progesterone um
I think it’s absolutely essential for the development of a mature breast
and what we do see in the literature about um
breasts on trans people taking estrogen is that they rarely reach Tanner stage 5
and I think that’s because progesterone
has been left out of gender affirming care
um so much and
and so I do think it’s an essential component
um the other thing you know
we see in the literature is that breast development varies widely
um in a few studies have actually said it’s independent of the estrogen dose
um which again
harkens back to this idea that like
if there is one best way
to approach gender affirming care with estrogen for breast development
we certainly don’t know what it is yet um
yeah so to answer that question
um breast budding starts within the first three to six months
of taking estrogen um
and like you know
kind of the maturation or completion of breast development on estrogen
is mostly gonna happen within the first two years
you’ll see more subtle changes after that um
and I think for optimizing breast development
progesterone is really important
um most of my patients are not on spironolactone
I have had more lately on spironolactone
cause I’m getting a lot of transfers of care um
because everything is happening in Florida um um
I clinicians am not a big fan of spironolactone um
not necessarily because of that literature about breast development
although if a patient has um
breast development and physical expression as some of their big goals
I’m always gonna be talking about that with them
um I’m less a fan of it because it’s a diuretic and um
being a trans person
trying to use public restrooms um
even in like
really urban areas that are like
generally more affirming
even there it’s hard
um and so anywhere outside of that fucking sucks
and I just don’t wanna give um
patient something
that’s gonna have to make them access public restrooms more often
if I can avoid it um yeah
thoughts about breast development
and hopefully that answered your question
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