I got my bi-annual mammogram this week. My third ever.

I am low risk (no family history, no lifestyle risk factors) but I have small, dense breasts. So every single time, the technician has to perform what I can only describe as a heroic feat of engineering to get my tissue into the machine. She pulls. She coaxes. She compresses. By the time the plate clicks down, I am painfully flattened and smashed. 

It is fast. It is clean. The techs are skilled and kind. And it still feels like a medieval torture device.

After I posted a quick story about this on Instagram, my inbox exploded. Women asking: Why are we still doing this? Can't I just get an ultrasound instead? What about those new AI ultrasound companies I keep seeing ads for? When does breast MRI actually make sense?

So this week, I'm breaking down the honest state of breast screening — what mammograms actually do well (and where they fall apart), what's coming next, and exactly what you should be doing right now.

Not sure which screening option is right for your breast density and risk level? Let's figure it out together →

Half of women over 40 have dense breast tissue. Most of them don't know that a "normal" mammogram may have missed something hiding inside that tissue.

The Dense Breast Action Plan:

❌ The old assumption: A normal mammogram means no cancer.

✅ The new reality: For women with extremely dense breasts, mammography sensitivity drops to 30–50% (RadioGraphics, 2023). That's essentially a coin flip.

They do reduce breast cancer mortality — approximately 30% when used consistently across all breast densities (ScienceDirect, 2025). The problem isn't that they're useless. It's that they're insufficient for a large percentage of women, and we've been using them as if they're the complete answer.

Also worth knowing: yes, they involve radiation. A single mammogram is equivalent to about 26 days of natural background radiation (ACR). Small — but not zero.

Ultrasound is radiation-free, painless, and much better at seeing through dense tissue. It's commonly used as a follow-up when a mammogram flags something. It catches cancers mammography misses.

But traditional ultrasound has real limitations: it's highly operator-dependent (the skill of the sonographer matters enormously), and it's not approved as a standalone screening replacement for mammography. Insurance typically covers it only when there's already an indication — not for routine screening.

This is what's generating all those ads in your feed. Several companies are now offering automated, AI-powered 3D breast ultrasound — radiation-free, compression-free, and operator-independent. Two worth knowing about:

BeSound — Advanced ultrasound technology in a standalone clinic setting. 20-minute pain-free scan, no radiation, no contrast dye, AI-powered detection, results in 24–48 hours. Currently available in Los Angeles with waitlists opening in other cities. Their technology is clinically shown to detect 35.7% more breast cancers than mammograms alone. Out-of-pocket cost (not covered by insurance).

PerfeQTion Imaging — Founded by Dr. Jenn Simmons, breast oncologist. Uses QT Imaging's FDA-cleared Breast Acoustic CT scanner — 3D ultrasound tomography that reconstructs detailed breast images without radiation or compression. Located in Haverford, PA. Pairs scanning with hormonal wellness programs.

These are not replacements for your mammogram - at least not yet. They don't yet have insurance coverage and they are not proven as mammogram replacements. But for women with dense breasts who want additional detection beyond what mammography offers — and can pay out of pocket — they represent a genuinely new, and to me exciting, category.

Breast MRI is the gold standard for sensitivity — over 90% for detecting malignant lesions (PMC, 2025). It sees through dense tissue entirely.

The 2025 BRAID trial — the first large-scale RCT directly comparing supplemental screening options — found abbreviated MRI detected 17.4 cancers per 1,000 women, versus 4.2 per 1,000 for automated ultrasound (PMC, 2025). The detection advantage is substantial.

The tradeoffs: higher false-positive rate, requires contrast dye injection, takes up to 45 minutes, and is expensive. Traditional breast MRI is typically covered only for high-risk women (BRCA mutation, lifetime risk >20%). Abbreviated fast MRI runs roughly $250–400 out of pocket and isn't yet routinely covered — though some states are legislating to change this.

1️⃣ Get your annual mammogram starting at age 40. ACOG updated its guidelines in late 2024: screening every 1–2 years starting at age 40 is now recommended for all average-risk women (Obstetrics & Gynecology, January 2025). The "enhanced" 3D tomosynthesis (digital) version of the mammogram is preferred when available — and is usually covered by insurance.

2️⃣ Ask your density category and advocate for supplemental screening. Since September 2024, all mammography centers must notify you of your breast density by federal law. If you're in category C (heterogeneously dense) or D (extremely dense):

3️⃣ Consider AI-enhanced ultrasound if you want more insight now. If you have dense breasts and want additional peace of mind beyond your mammogram — and can pay out of pocket — BeSound (LA) and PerfeQTion Imaging (Philadelphia area) are examples of companies doing this today. Not a replacement for mammography. Additive to it.

4️⃣ Do a monthly self-exam and know your breasts. Once a month, 3–5 days after your period ends:

5️⃣ Reduce your actual biological risk. Screening finds cancer. Prevention lowers the odds.

The goal: You're not choosing between mammograms and something better. You're layering — mammogram as the baseline, supplemental imaging based on your density and risk.

My mammogram experience this week reminded me why some forms of self-care are painful but worth it. I would love to skip it, honestly. I still can't believe we subject women to this experience. If men had to have their testicles compressed and radiated on a regular basis to detect disease, I guarantee we would have had new technology decades ago.

But I'm encouraged that change is coming. A lot of times, innovation in medicine starts with consumer products — think full-body MRIs, out-of-pocket breast ultrasounds, at-home genetics tests — and then makes its way into conventional care. I think we're in the awkward teenage years of these technologies. Over time, like everything, they'll get cheaper, faster, and eventually — as the evidence base mounts — covered by insurance.

The downside of paying out of pocket for screening is the concern about false positives. But conventional tests find false positives too. And when it comes to my health, I would rather know more — and be able to do something about it — than less.

That's a personal decision, of course. Not everyone has the mental, emotional, practical, or financial bandwidth for this level of testing and the action steps that follow. Knowing yourself — your capacity to handle extra information, your tendency toward anxiety or action — matters as much as the data itself. So does having a doctor who knows you and can help you make sense of what you find.

For women especially, longevity is about trade-offs. We only have so much time and money to invest in fitness, food, testing, and supplements before we also have to live our lives, have fun, and not sweat every data point. I'm finding my own balance — imperfectly — as I approach 45. I see my friends and patients doing the same.

Wherever you're starting from: some of this is a little painful, like mammograms. But if we do the basics, we give ourselves a meaningfully better shot at the long, healthy, full lives we're working toward. That's worth it.

Knowing your breast density is step one. Understanding your full hormonal picture, risk factors, and labs is step two. At Parsley, we look at everything together — not just whether your mammogram was "normal." Sign up now!

Stay strong, stay curious, and breathe,

Robin

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As always, this newsletter is for informational and educational purposes only and is not intended as medical advice. Always consult your healthcare provider before making any health decisions or changes to your treatment plan.