Bone health in transgender people: a narrative review

Abstract

Bone health in transmen and transwomen is an important issue that needs to be evaluated by clinicians. Prior to gender-affirming hormone treatment (GAHT), transwomen have lower bone mineral density (BMD) and a higher prevalence of osteopenia than cismen probably related to external factors, such as hypovitaminosis D and less physical activities. Gonadotropin-releasing hormone (GnRH) analogues in transgender youth may cause bone loss; however, the addition of GAHT restores or at least improves BMD in both transboys and transgirls. The maintenance or increase in BMD shown in short-term longitudinal studies emphasizes that GAHT does not have a negative effect on BMD in adult transwomen and transmen. Gonadectomy is not a risk factor if GAHT is taken correctly. The prevalence of fractures in the transgender population seems to be the same as in the general population but more studies are required on this aspect. To evaluate the risk of osteoporosis, it is mandatory to define the most appropriate reference group not only taking into consideration the medical aspects but also in respect of the selected gender identity of each person.

Bone mineral density in a sample of Mexican trans women

“…This is consistent with previous studies showing that TW, even before the start of any hormonal intervention, already have lower bone mass, a higher frequency of osteoporosis, and smaller bone size than cis men. [9][10][11]18,25 However, it has also been reported that the average BMD in the hip and spine of TW does not differ from that of cis men. 15 Taken together, these results suggest that spine and hip BMD can often be low in TW, which is concerning for its potential consequences.…”

“…In studies and reviews it has been reported that TW tend to have a lower BMD than cis men (whose biological sex is congruent with gender identity and expression), even before starting GAHT. [7][8][9][10][11] It has been suggested that the lower BMD in TW may be because they do less physical activity, have less muscular development, and have a higher risk of hypovitaminosis D. 7,8,10,12 In Belgium, 26% of TW presented a BMD below the expected range for their age in the spine and 2% in the hip. 13 Likewise, among TW, the density of trabecular bone was positively associated with the use of GAHT.…”

“…Some authors have suggested that it is necessary to carry out studies to identify possible risk factors related to decreased BMD in MT. 10,15,18 Taking the above into consideration, the objective of this study was to evaluate BMD and its association with health-related habits and body composition in Mexican TW.…”

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

“…Bone density in transmasculine adults appears to be similar to the general population at baseline and after taking GAHT. 64 , 65 Although testosterone initiation often leads to cessation of menses and thus a relative deficiency in estradiol, several studies, including a meta-analysis by Singh-Ospina et al , 66 have shown stable bone mineral density (BMD) in transmasculine adults on GAHT. Testosterone use by transmasculine adults alters body composition by increasing muscle mass, decreasing fat mass and also likely has direct action on the bone.…”

A response to puberty blockers for gender dysphoric youth: A lack of sound science

“…Our critical appraisal concludes these studies do not support the notion of an unacceptable risk to bone health in TGD youth, which aligns with endocrine society guidelines and others conducting high-quality reviews. 4,8 This leads to an important question: how can pharmacists mitigate any risk of negative bone health outcomes? TGD persons experience food insecurity and poor nutritional knowledge, which may lead to poor dietary intake of calcium and vitamin D. 9 Pharmacists are well-equipped to counsel patients on dietary intake, screening for deficiencies, and recommending appropriate supplementation.…”