Breast cancer screening recommendations for transgender people

There is a lack of information about transgender people and risk for breast cancer. This is likely due, in part, to health disparities experienced by gender non-conforming and transgender people. Another reason why there is insufficient research on transgender people and breast cancer is that gender identity, as something different than sex assigned at birth, is not included in medical records.

Still, there are now more resources for transgender people than there have been in the past. In fact, the American College of Radiology (ACR) offers breast cancer screening guidelines for transgender people based on age; sex (female or male) assigned at birth; risk factors; and use of hormone therapy, surgery, or both that may be used in the transitioning process. Based on these guidelines, it is important to talk to your doctor about when and how often to get screened.

How risk in transgender people determines screening guidelines

The ACR provides definitions for three categories of breast cancer risk that is more than average: higher than average, intermediate, and high. These categories are determined by factors such as personal history of breast cancer or other breast conditions, and known or unknown risk of breast cancer.

Whether a person has had hormone therapy, top surgery, or both also can affect the screening recommendations.

What do higher-than-average, intermediate, and high risk mean?

Higher-than-average risk, as defined by ACR, means a person has all of the following:

• Personal history of breast cancer or chest irradiation at 10 to 30 years of age
• Genetic predisposition to breast cancer
• Family history of breast cancer or ovarian cancer

A person who has not been tested for an inherited high-risk breast cancer gene mutation but has a first-degree relative with genetic predisposition to breast cancer is also at higher-than-average risk.

Intermediate risk, as defined by ACR, means a person has at least one of the following:

• Personal history of breast cancer
• Lobular neoplasia (a non-cancerous, or benign, breast condition of the lobular or milk-producing glands, which increases breast cancer risk)
• Atypical ductal hyperplasia (a non-cancerous, or benign, breast condition of the ducts, tubes that carry milk from the lobules, which increases breast cancer risk)
• A 15% to 20% lifetime risk for breast cancer (as determined with your doctor or using a risk calculator such as the Gail Model)

High risk, as defined by ACR, means a person has one of the following:

• Genetic predisposition for breast cancer, or is untested with a first-degree relative with a genetic predisposition to breast cancer
• History of chest irradiation at 10 to 30 years of age
• 20% or greater lifetime risk for breast cancer (as determined with your doctor or using a risk calculator such as the Gail model)

Hormone therapy and breast cancer risk

For people assigned male at birth (AMAB) who are transitioning to female (transfeminine), estrogen and anti-androgens are often taken to help with feminization, which includes breast development. Research suggests that transfeminine people using hormone therapy have an increased risk for breast cancer compared with cisgender men.

For people assigned female at birth (AFAB) who are transitioning to male (transmasculine), testosterone is often used to help with virilization, which includes suppression of breast development and other feminine secondary sex traits. Transmasculine people have a lower risk of breast cancer compared with cisgender women.

Top surgery and breast cancer risk

People AMAB who are transfeminine may decide to have top surgery to create breasts. This surgery is called breast augmentation mammoplasty.

One year of hormone therapy is strongly recommended before undergoing transfeminine breast augmentation mammoplasty. In fact, insurance often requires this before breast augmentation can be done. In this situation, there is an increased risk of breast cancer.

It’s rare that transfeminine breast augmentation mammoplasty would be performed without hormone therapy, but when it is, breast cancer risk is the same as risk in cisgender men: .01%, or one in 100.

People AFAB who are transmasculine may decide to have top surgery to remove both breasts, also called bilateral mastectomy, or breast reduction mammoplasty to make breasts smaller. In both surgeries, some breast tissue is left behind, so there is still some breast cancer risk.

Breast cancer screening guidelines for cisgender people and gender non-conforming people (regardless of sexual orientation) who have not taken hormones or had top surgery, as well as more information about mammograms—the best screening technique available—can be found on the Mammogram page.

ACR’s breast cancer screening guidelines for transfeminine (male-to-female) people

• For transfeminine people ages 40 and older with past or current hormone use equal to or greater than five years, 3D mammography (also known as digital breast tomosynthesis, or DBT) or standard 2D mammography may be appropriate if you are at average risk.
• For transfeminine people ages 25 to 30 and older with past or current hormone use equal to or greater than five years, annual 3D mammography (DBT) or standard 2D mammography is usually appropriate if you are at higher-than-average risk.
• For transfeminine people who have not used hormones or have used hormones for less than five years, breast cancer screening is usually not appropriate if you are at average risk.
• For transfeminine people ages 25 to 30 and older with no hormone use, 3D mammography (DBT) or standard 2D mammography may be appropriate if you are at higher-than-average risk.

Different organizations have developed different guidelines on the age at which and frequency with which transgender women should be screened. The Endocrine Society recommends that transgender women screen at the same frequency as cisgender women, starting at age 40. Talk with your doctor about what’s right for you based on your individual risk factors. If it’s determined that your risk is higher than average, it may be recommended that you start screening earlier than age 40. You can learn more about cisgender risk and screening on the Mammogram page.

ACR’s breast cancer screening guidelines for transmasculine (female-to-male) people

• For transmasculine people who have had bilateral mastectomies, screening is usually not appropriate.
• For transmasculine people ages 40 and older who have had reduction mammoplasty or no chest surgery, annual 3D mammography (DBT) or standard 2D mammography is usually appropriate if you are at average risk.
• For transmasculine people ages 30 and older who have had reduction mammoplasty or no chest surgery, annual 3D mammography (DBT) or standard 2D mammography is usually appropriate if you are at intermediate risk. Breast ultrasound or MRI (without and with IV contrast) may be appropriate.
• For transmasculine people ages 25 to 30 and older who have had reduction mammoplasty or no chest surgery, annual 3D mammography (DBT) or standard 2D mammography is usually appropriate if you are at high risk. Breast MRI (without and with IV contrast) is recommended in addition to DBT or mammography. Breast ultrasound may also be appropriate.

A complete guide to ACR Appropriateness Criteria: Transgender Breast Cancer Screening is available on the organization's web site.

Exceptions to ACR’s guidelines

Just as not all organizations’ guidelines and recommendations are the same for breast cancer screening of cisgender people, not all groups agree with some of the transgender screening guidelines proposed by the ACR. The most significant differences are related to addressing the needs of people who have had top surgery.

The World Professional Association for Transgender Health, or WPATH, suggests in Standards of Care for the Health of Transgender and Gender Diverse People that MRI or ultrasound may be appropriate for transmasculine people who have had both breasts removed who have a family history of breast cancer or have tested positive for a BRCA gene mutation. The reason for this is that some breast tissue may remain even after surgery to remove the breasts.

The Endocrine Society recommends that transgender people who are considering top surgery—whether mammoplasty or bilateral mastectomy—have a breast cancer risk assessment before surgery and follow the screening guidelines for the cisgender community.

Paying for MRI/ultrasound screening

While screening mammograms are usually covered by insurance, and MRI screening is sometimes covered if you are at high risk, check with your insurance company before having an MRI or an ultrasound, if that’s what your doctor recommends.

MRI tests are expensive if you are paying out of pocket. If you have trouble getting approved by your insurance company for an MRI or ultrasound, you may want to talk to your healthcare team and ask for help with getting insurance approval or finding financial assistance resources.

Visit the Testing section to learn more about mammogram, breast MRI, ultrasound, and other imaging tests.