The research team, led by Emma Hansson with Catrin Wessman and Anna Paganini, recruited 276 women who were referred for breast reduction within Sweden’s publicly financed health care system. All participants met the Swedish national guidelines for the procedure, which specify criteria such as a body mass index under 30 and a minimum breast volume of more than 800 millilitres per breast, adjusted upward for higher BMI ranges. Each woman completed the HADS questionnaire before surgery, and a subset of 52 patients filled it in a second time two weeks later to test how stable the scores were over time. Another 52 patients completed the questionnaire again twelve months after their operation, allowing the researchers to see whether the instrument could detect the change in psychological symptoms that surgery is expected to produce.

The choice of HADS was deliberate and scientifically motivated. Many familiar depression measures, including the Beck Depression Inventory and the Hamilton rating scales, were originally developed for psychiatric populations. Women seeking breast reduction, by contrast, typically do not have primary psychiatric disorders; their distress is linked to a somatic condition. HADS was designed precisely for medically ill patients. Its fourteen items, split evenly between an anxiety subscale and a depression subscale, deliberately exclude symptoms that could be confused with physical illness, such as fatigue and dizziness, and it omits items on suicidal ideation. Each item is scored on a four-point scale, giving subscale scores from 0 to 21, where 0 to 7 suggests no significant symptoms, 8 to 10 indicates possible cases, and above 10 suggests probable cases. Despite its validation for breast cancer reconstruction, HADS had never been validated for benign breast conditions such as macromastia, a distinction the authors argued warrants separate testing.

The technical heart of the study was a battery of psychometric analyses reported according to the COSMIN checklist, an international standard for studies of patient-reported outcome measures. Confirmatory factor analysis was used to test whether the questionnaire’s underlying structure held up in this specific population. The researchers compared the classic two-factor model, with separate anxiety and depression factors, against a three-factor model that adds a dimension of negative affectivity, reflecting the theoretical overlap between anxiety and depression. Both models showed satisfactory or near-acceptable fit across standard indices, including the comparative fit index, the nonnormal fit index, the root mean square error of approximation and the standardised root mean squared residual. All factor loadings were statistically significant and above 0.30. Because both structures fit comparably well, the team judged the models using the Akaike information criterion and, weighing clinical usefulness and comparability with prior research, proceeded with the original two-factor structure.

The reliability results were reassuring. Internal consistency, measured by Cronbach’s alpha, came out at 0.85 for the anxiety subscale and 0.87 for the depression subscale, comfortably within the accepted range of 0.70 to 0.95 and short of the level that would suggest redundant items. Every item correlated sufficiently with the total score of its subscale, with corrected item-total correlations ranging from 0.45 to 0.73, all above the recommended threshold of 0.3. Inter-item correlations fell between 0.2 and 0.8 for both subscales, indicating that the questions hang together without duplicating one another. In plain terms, the questionnaire measures what it claims to measure consistently, without wasted or contradictory questions.

Stability over time, known as test-retest reliability, was assessed in the 52 women who repeated the questionnaire after two weeks. The intraclass correlation coefficient was 0.81 for anxiety and 0.75 for depression, values classified as good reliability under widely used benchmarks. Bland-Altman plots showed mean differences between the two time points close to zero, and the limits of agreement stayed within the seven-point margin the researchers had prespecified, corresponding to the clinical cut-off between non-cases and probable cases. This matters because a screening tool that gives wildly different answers on consecutive occasions cannot be trusted to guide individual treatment decisions.

Construct validity was tested by comparing HADS against instruments that should, in theory, produce related results. The depression subscale correlated strongly with the Beck Depression Inventory and the anxiety subscale correlated strongly with the Beck Anxiety Inventory, both at a Spearman coefficient of about 0.7, exactly matching the researchers’ pre-registered hypotheses. The team also compared HADS with the psychosocial well-being domain of the BREAST-Q, the most widely used quality-of-life instrument in breast surgery, which asks about feelings such as self-confidence and happiness with one’s body. Here the correlation was moderate and negative, around minus 0.5, meaning that higher breast-related psychosocial well-being goes hand in hand with fewer symptoms of anxiety and depression. Importantly, the authors note, this moderate relationship shows that the two instruments capture related but distinct constructs, supporting the case for measuring depression and anxiety separately rather than assuming a breast-specific quality-of-life questionnaire covers them adequately.

The questionnaire also proved responsive, meaning it could detect real change over time. Twelve months after surgery, patients reported significantly fewer symptoms on both subscales, with mean decreases of 1.1 points for anxiety and 1.2 points for depression, each statistically significant. No floor or ceiling effects were observed, so the scale retains its ability to distinguish between patients at both the healthy and severely symptomatic ends of the spectrum. Together, these findings paint a picture of an instrument that is valid, reliable and sensitive enough to serve both halves of the clinical workflow: pre-operative evaluation and post-operative outcome assessment.

The authors are candid about the limits of generalisability. Their sample comprised women treated in the Swedish public system, excluding patients with a BMI over 30, a group that is operated on in some countries, particularly the United States, and one in which obesity and comorbidity are known to influence HADS scores. The post-operative sample was relatively small, and cultural factors can affect questionnaire scores, although the authors argue this matters most when creating norm data rather than when validating an instrument for a specific condition. They also caution that because both the two-factor and three-factor structures fit the data acceptably, and because anxiety and depression symptoms clinically overlap, HADS should be used carefully when attempting to differentiate the two conditions in individual patients.

Even with those caveats, the study delivers something the field has lacked: a validated, reliability-tested standard for measuring depression and anxiety in women with breast hypertrophy undergoing reduction. Because different clinics and countries have historically used a patchwork of unvalidated instruments, comparisons between studies and meta-analyses have been difficult, slowing the accumulation of evidence about the psychological benefits of the surgery. A common, psychometrically sound yardstick changes that. It gives clinicians a defensible tool for documenting the emotional indications for surgery and for demonstrating, with patient-reported data, that the operation relieved psychological as well as physical suffering. For a procedure that has often had to justify itself against perceptions of being cosmetic, that standard may prove as consequential as any surgical technique.

Subject of Research: Validation of the Hospital Anxiety and Depression Scale for assessing depression and anxiety symptoms in women undergoing breast reduction surgery

Article Title: Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS

Article References: Hansson, E., Wessman, C., & Paganini, A. (2025). Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS. BMC Plastic and Reconstructive Surgery, 1(1), Article 2. https://doi.org/10.1186/s44452-025-00001-9

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00001-9

Keywords: breast reduction, breast hypertrophy, HADS, depression, anxiety, patient-reported outcomes, psychometric validation, plastic surgery, macromastia, questionnaire reliability, BREAST-Q, Sweden

The research team, led by Dr. Kristyn Pocock, assistant professor of neurology at Wake Forest University School of Medicine, drew on a medical record database covering women treated between 2017 and 2024 at clinics affiliated with Stanford Medical Center. The analysis included 687 women in total: 347 diagnosed with macromastia and 340 without the condition. To isolate the effect of enlarged breast tissue itself, the investigators statistically adjusted for several potential confounders, including age, body mass index, depression and anxiety. These factors matter because each is independently associated with headache disorders, musculoskeletal pain and sleep-disordered breathing, so failing to control for them could have exaggerated the apparent link between breast size and the studied outcomes.

After those adjustments, the associations remained striking. Women with macromastia were roughly 40 percent more likely to have chronic migraine, defined as experiencing headache on 15 or more days per month for at least three months. They were about twice as likely to report neck pain, approximately 50 percent more likely to have obstructive sleep apnea, and more than twice as likely to be diagnosed with cervical radiculopathy compared with women without the condition. The magnitude of these increases is notable for conditions that each impose substantial individual burdens on quality of life, work productivity and health care utilization, and the fact that all four clustered together in the same patient group strengthens the case that the pattern is not a statistical accident.

Many people think of enlarged breast tissue primarily as a cosmetic issue, but our findings suggest it may be associated with a broader range of women’s health concerns, including chronic migraine, neck pain and sleep-related breathing disorders, Pocock said. By better understanding these connections, we can help ensure women receive more comprehensive evaluations and care for symptoms that may affect their daily lives. Her comments reflect a recurring theme in macromastia research: patients frequently bring complaints of headache, neck and back pain, and shoulder discomfort to their physicians, and many seek breast reduction surgery specifically to relieve these symptoms rather than for aesthetic reasons.

The symptom profile described by patients has long been recognized in clinical practice, and some insurers already acknowledge headaches as a qualifying symptom when evaluating coverage requests for reduction mammaplasty. However, the researchers point out that relatively little rigorous epidemiological work has examined how enlarged breast tissue relates to specific headache disorders, rather than to undifferentiated head pain, or to neurological conditions affecting the cervical spine. By using structured diagnostic codes from electronic health records, the new study moves beyond anecdote and provides quantified associations for individually named conditions, including the distinction between episodic and chronic migraine, a difference with major implications for treatment planning and prognosis.

One of the more provocative secondary findings concerned breast reduction surgery. When the investigators examined which factors were associated with undergoing reduction procedures among the women with macromastia, neck pain emerged as the only condition linked to a significantly greater likelihood of surgery. This suggests that the musculoskeletal consequences of carrying excess breast tissue, rather than headaches or sleep apnea, may weigh most heavily in decisions by patients and clinicians to pursue operative treatment. It also hints that the full spectrum of associated conditions may be under-recognized during preoperative evaluation, and that some women could experience broader symptomatic benefits from surgery than current documentation captures.

From a mechanistic standpoint, several plausible biological pathways could explain the observed associations. Excess anterior chest wall mass alters head and neck posture, shifting the center of gravity forward and increasing sustained contraction of cervical paraspinal and trapezius muscles, a known trigger for cervicogenic pain and potentially for migraine exacerbation through heightened nociceptive input to the trigeminocervical complex. Chronic muscular strain and poor sleep posture may also worsen sleep quality, while increased soft tissue and altered thoracic mechanics could contribute to airway compromise during sleep, raising the likelihood of obstructive sleep apnea. Nerve root compression in the neck, meanwhile, could arise from compensatory spinal loading and degenerative changes accelerated by altered posture. None of these pathways has yet been definitively demonstrated, and the authors are careful to frame their results as associative rather than causal.

Indeed, the study design carries important limitations that shape how the findings should be interpreted. Because the research was a cross-sectional review of existing medical records, it captures associations at a single point in time and cannot establish whether macromastia causes migraine, neck pain or sleep apnea, whether these conditions share common risk factors, or whether reverse causation plays a role. The cohort was drawn from headache and neurology clinics, a setting that may overrepresent patients with severe symptoms and limit generalizability to the broader population of women with macromastia. Residual confounding is also possible despite the statistical adjustments, particularly for factors such as physical activity, occupational demands and detailed measures of body fat distribution that may not be fully captured in routine clinical records.

Additional research is needed to determine the mechanisms through which macromastia influences migraine, neck pain or sleep apnea, the researchers note, and longitudinal studies could clarify whether treating macromastia, surgically or otherwise, leads to measurable improvement in these conditions. If such benefits are confirmed, macromastia treatment could enter the conversation around comprehensive management of chronic headache and sleep disorders in women, and insurers could be prompted to re-evaluate the criteria used to authorize reduction surgery. These findings raise important questions about how enlarged breast tissue may contribute to painful symptoms for women, Pocock said. More research is needed to determine whether treating macromastia could help certain women find relief and enhance quality of life.

For now, the study offers clinicians a concrete evidence base for taking patient-reported symptoms of headache, neck pain and sleep disturbance seriously when evaluating women with enlarged breast tissue, and it offers patients validation that their complaints may reflect a recognizable clinical pattern rather than isolated grievances. Published in Headache: The Journal of Head and Face Pain, the analysis adds macromastia to the growing list of physical factors that neurologists and sleep specialists may need to consider when assessing women with chronic migraine, cervical nerve disorders or sleep-disordered breathing. As the authors emphasize, the next step is to determine whether relieving the mechanical burden of enlarged breast tissue translates into durable relief from the neurological and sleep conditions that so often accompany it.

Subject of Research: Associations between macromastia in women and chronic migraine, neck pain, cervical radiculopathy and obstructive sleep apnea

Article Title: Women with enlarged breast tissue more likely to experience chronic migraine, neck pain and sleep apnea, study finds

Article References: Women with enlarged breast tissue more likely to experience chronic migraine, neck pain and sleep apnea, study finds. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: macromastia, chronic migraine, neck pain, obstructive sleep apnea, cervical radiculopathy, breast reduction surgery, Wake Forest University School of Medicine, women's health, neurology, electronic health records, Headache journal, Women