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Bone health of transgender adults: what the radiologist needs to know

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Abstract

Sex steroids are important regulators of bone development before puberty and of bone homeostasis throughout adulthood. Gender-affirming therapies with sex steroids are used in transgender and gender diverse persons for treatment of gender dysphoria, which may have profound impacts on their bone metabolism. Many studies have described variable changes in bone density and geometry in transgender cohorts. In order to provide informed guidance on the effect of gender-affirming therapy, the International Society of Clinical Densitometry issued official position statements in 2019 for the performance and interpretation of dual-energy x-ray absorptiometry in transgender and gender-diverse patients. We review the effects of gender-affirming hormone therapy on bone physiology and the changes in bone modulation that have been reported in the literature in transgender patients who have received gender-affirming therapy. We also summarize the recent guidelines for interpretation of dual energy x-ray absorptiometry as an update for the radiologist.

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Notes

  1. Previous studies in TGD persons have used the term osteoporosis to indicate low bone density in their study populations [10,11,12,13, 16, 17, 25, 34]. However, the ISCD 2019 Position Statement reserves the term osteoporosis for all TGD persons over the age of 50 with a T-score of <2.5 [37]. Therefore, we use the phrase “low bone density” in place of osteoporosis for this review.

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Authors and Affiliations

Authors

Contributions

Justin T. Stowell, M.D.: conception and design, acquisition of data/literature review, analysis and summary of data into Tables 1, 2, 3, and 4; drafting and revision of article for final approval; accountable for all aspects of the work.

Hillary W. Garner, M.D.: analysis and summary of data into Tables 1, 2, and 3; drafting and revision of article for final approval; accountable for all aspects of the work.

Stephen Herrmann, M.D., Ph.D.: analysis and summary of data into Tables 1, 2, and 3; drafting and revision of article for final approval; accountable for all aspects of the work.

Kimberly Tilson, R.N., B.S.N.: literature review and analysis; drafting and revision of article for final approval; accountable for all aspects of the work.

Rupert O. Stanborough, M.D.: analysis and summary of data into Tables 1, 2, and 3; drafting and revision of article for final approval; accountable for all aspects of the work.

Corresponding author

Correspondence to Justin T. Stowell.

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Additional information

Key Points for the Radiologist

Notable changes in bone mineral density and bone geometry are known to occur among transgender and gender diverse people who receive gender-affirming therapies.

Transfeminine persons may have low bone mineral density and small bone size prior to the initiation of gender-affirming therapies. Although feminizing hormones seem to improve bone mineral density initially, long-term data show bone mineral density and cortical size to be lower than that of genotypic male controls. This difference may be a consequence of non-hormonal lifestyle factors.

Transmasculine persons who receive gender-affirming therapies are typically able to maintain or increase their bone mineral density, especially at sites with a higher proportion of cortical bone.

Although gender-affirming therapies are considered safe when administered appropriately, the implications on long-term fracture risks are still unknown.

Radiologists should refer to the recently issued guidelines from the International Society for Clinical Densitometry in their performance, interpretation, and reporting of DXA in transgender and gender diverse patients.

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Stowell, J.T., Garner, H.W., Herrmann, S. et al. Bone health of transgender adults: what the radiologist needs to know. Skeletal Radiol 49, 1525–1537 (2020). https://doi.org/10.1007/s00256-020-03511-y

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