Osteoporosis and Bone Health in Transgender Individuals

This review discusses the changes in bone mass, structure, and metabolism that occur upon gender-affirming hormonal treatment (GAHT) in transgender adults and adolescents, as well as their clinical relevance. In general, available evidence shows that GAHT in transgender adults is not associated with major bone loss. In transgender adolescents, pubertal suppression with gonadotropin-releasing hormone agonist monotherapy impairs bone development, but at least partial recovery is observed after GAHT initiation. Nevertheless, a research gap remains concerning fracture risk and determinants of bone strength other than bone mineral density. Attention for bone health is warranted especially in adult as well as adolescent trans women, given the relatively high prevalence of low bone mass both before the start of treatment and after long-term GAHT in this population. Strategies to optimize bone health include monitoring of treatment compliance and ensuring adequate exposure to administered sex steroids, in addition to general bone health measures such as adequate physical activity, adequate vitamin D and calcium intake, and a healthy lifestyle. When risk factors for osteoporosis exist the threshold to perform DXA should be low, and treatment decisions should be based on the same guidelines as the general population.

Automated summary

This review discusses the impact of gender-affirming hormonal treatment (GAHT) on bone mass, structure, and metabolism in transgender adults and adolescents. It suggests that GAHT in transgender adults does not result in significant bone loss, while pubertal suppression in transgender adolescents affects bone development, with partial recovery observed after GAHT initiation. However, there is still a research gap in understanding fracture risk and other determinants of bone strength. Attention to bone health is especially important for adult and adolescent trans women, who have a relatively high prevalence of low bone mass before and after long-term GAHT. Strategies to optimize bone health include monitoring treatment compliance, ensuring adequate exposure to sex steroids, physical activity, sufficient vitamin D and calcium intake, and a healthy lifestyle. When risk factors for osteoporosis are present, DXA screening should be conducted with a low threshold, and treatment decisions should follow the same guidelines as the general population.