Women with very large breasts face health system ‘discrimination’

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Going through life with breasts that required a G-sized bra cup presented many, painful, realities for Lili Pingiaro.

Like many women living with breasts so large they cause functional difficulties, Pingiaro had a constant ache in her neck and back, and battled with self-esteem.

Lili Pingiaro, 22, feels like she can “take on the world” now she has had breast reduction surgery that has ended her neck and back pain and allowed her to exercise normally.Credit: Joe Armao

Exercise was difficult. “I would try to go for runs, but I would have to wear two sports bras at a time, it was still a struggle”, she said.

Especially in her teens, “I would get a lot of unwanted male attention”. Pingiaro also had a mass of axillary, or extra, breast tissue under one armpit. “It made me feel very insecure,” she said.

Life transformed for the better, though, about eight weeks ago, when the 22-year-old had “about a Coke can’s worth” of tissue removed from each breast, in a bilateral breast reduction surgery performed in the private hospital system.

Now pain-free and more able to move freely, “I feel like I can take on the world”.

Though the operation is recognised as a legitimate medical procedure on the Medicare Benefits Schedule, like the increasing number of women who need it, Pingiaro may have had to wait years in the public system.

In Victoria, bilateral breast reduction is considered “cosmetic”, and in New South Wales, as an “aesthetic” procedure.

This is discrimination against women, prominent surgeons say. They are campaigning for states where it is restricted, or considered cosmetic, to review elective surgery policies and restrictions on breast reduction, based on health evidence.

Associate Professor Nicola Dean, president of the Australian Society of Plastic Surgeons, said Medicare data shows demand has tripled in 20 years, but public hospital provision of breast reduction is declining.

This amounts to “arbitrary discrimination” by state health systems, she said.

“It’s one thing to have elective surgeries restricted by the available resources, but it’s a different thing to have it restricted by a specific policy which seems to embed a level of discrimination,” she said.

Breast reduction is as potentially life and health-changing as other elective surgeries, including bariatric surgery (also known as a gastric bypass), or hip replacement, said Dean, and to limit its availability is “neither fair nor evidence based”.

Restrictions on its provision leave women who cannot afford the $10,000 cost of private surgery in pain, and often experiencing poorer mental health. Recent Australian research also showed the surgery to be highly cost-effective, Dean said.

The push comes after Flinders University research, published this week, found women with very large cup sizes were less likely to do high-intensity or group exercise, but those who had undergone breast reduction were able to participate in healthier lifestyle practises.

Reduction has “direct and indirect benefits on improving people’s health; pain levels improve almost straight after the surgery, but it also has the indirect effect of improving people’s fitness and health generally,” she said.

“It probably also indirectly affects cardiovascular health because if you can’t exercise, you’re not going to have good cardiac health.”

David Morgan, specialist plastic surgeon and head of the Alfred Hospital’s Maxillofacial Surgery Unit, said breast reduction surgery was considered cosmetic in the public system, meaning women have been “largely precluded from even getting on waiting lists, let alone getting off waiting lists for it”.

“We know it is not a cosmetic procedure, it is eminently functional, with significant psycho-social benefits,” said Morgan, who also performs reduction surgeries.

“It is included on the MBS, which by definition means it’s functional.”

That some states impose body mass index requirements before they will allow women to queue for it is also a harmful barrier, Morgan said, because giving them the ability to move more easily helps them exercise.

Lili Pingiaro said her neck and back pain vanished, and her confidence and quality of life increased, after she had breast reduction surgery about eight weeks ago.Credit: Joe Armao

“It can be a self-perpetuating cycle: they can’t lose the weight because of their heavy bust, so they’re not going to qualify on a weight issue alone … if you do it [the surgery] at the beginning or early on in their weight loss journey, it encourages them continue,” Morgan said.

He agreed that state policies should be reviewed quickly, “to improve fairness in the long term”. Dean said she recognised backlogs due to the pandemic meant changes would take time to implement.

Flinders University senior medical scientist Dr Tamara Crittenden said high-quality data showed the health improvements of bilateral breast reduction in women with hypertrophy (excessive breast tissue growth), as the condition carried “a significant health burden across all areas”.

These included physical function, bodily pain, general health and mental health and social function.

‘We know it is not a cosmetic procedure, it is eminently functional.’

“We found surgery was so effective it had removed the health deficits associated with this condition, and [after it] levels of quality of life were equivalent to women in the general population in all areas,” she said.

“It showed the clinical effectiveness in removing often chronic pain also meant because the improvements were so dramatic, it was very cost-effective.”

Kate Johnston-Ataata, policy manager at Women’s Health Victoria, said the Flinders University research supported other findings that women who undergo breast reduction report improved psychosocial wellbeing post-operatively.

“Increasing access to breast reduction surgery will have important implications for improving the quality of life and mental health and wellbeing of women with larger breasts,” she said.

“The findings regarding the impact of large breast size on exercise may be of particular importance for mature-aged women, as only half of women at this age are reported to be sufficiently active.”

The organisation supports Nicola Dean’s call for an immediate policy review in states where breast reduction is considered cosmetic or aesthetic, including Victoria.

A spokesperson for the Victorian Department of Health said: “We know that women’s health has been under-diagnosed for too long – it’s why we’re providing significant funding to overhaul the way women’s health issues are treated in Victoria.”

The department is building 20 women’s health clinics across the state to “give women’s health issues the attention they deserve”.

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