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What Transgender People Need to Know About Bone Health

Taking care of your bones now can reduce your risk of fractures later on.

Two young friends having a discussion while walking through the city.

Medically reviewed in August 2021

More than 43 percent of people over the age of 50 have low bone mass, which is a precursor to osteoporosis, a condition that involves a weakening of bone structure and strength. Having osteoporosis increases one's risk of fractures, which can be painful and debilitating.

But bone health isn't a concern only for older people. In fact, it's something you should bear in mind throughout your life.

Given the interplay between the body's hormones and the growth and regeneration of bones over a lifetime, bone health is a topic of particular significance to people who are transgender, gender nonconforming or nonbinary who have had gender-affirming hormone therapy (GAHT) or other gender-affirming treatment, or who used puberty blockers before starting hormone therapy.

Here’s what you need to know about bone health, from the effects of GAHT and gender-affirming surgery to making sense of recommended screening guidelines

Risk factors for low bone density
The older you are, the greater your risk of osteoporosis. But regardless of one's age, there are a number of risk factors for low bone density that you should be aware of:

  • Tobacco use
  • Excessive alcohol consumption 
  • Low levels of physical activity
  • Not getting enough calcium and vitamin D
  • Use of certain medications, such as glucocorticoids (a type of steroid)
  • Certain medical conditions, like rheumatoid arthritis
  • Insufficient levels of estrogen or testosterone (also known as sex steroid hormones)
  • Low body mass index (BMI) or small body frame size
  • Having an eating disorder that results in severely restricted food intake and being underweight

Having low levels of sex steroid hormones is a risk factor that’s relevant for anyone on GAHT or who has had gender-affirming surgery. That's because sex steroids, particularly estrogen, play an important role in the development and maintenance of bone density in all people. Your levels of hormones may vary depending on your body’s production of hormones (also called endogenous hormones), as well as hormone therapy and surgical history.

For example, having a gonadectomy (removal of the testes or ovaries) affects your body's ability to produce endogenous estrogen or testosterone. And even if you haven’t had any kind of gonadectomy, hormone levels that are inconsistent or below a specific range can be harmful to your bone health. That means if you are taking GAHT, you’ll want to make sure to take your medication as directed and follow up with your healthcare provider (HCP) to ensure your hormones are at the appropriate level.

"It's important to keep in mind you need to maintain yourself on some sex steroid, because both testosterone and estrogen prevent bone loss. So, if you're lacking one of those, you're going to lose bone," explains Vin Tangpricha, MD, PhD, board-certified endocrinologist at Emory University School of Medicine and former president of the World Professional Association for Transgender Health.

For a variety of reasons that are still being explored, transgender women appear to have lower bone density relative to cisgender men and transgender men. This suggests that it’s especially important for transgender women or those on feminizing hormones to maintain bone health by following a bone-healthy lifestyle (the tips below can help) and staying in close touch with their HCP about screening recommendations.

Screening for bone health
The screening recommendations for osteoporosis are confusing enough for cisgender people, let alone for gender-diverse people who have historically been left out of the research that informs these guidelines. For instance, the U.S. Preventive Services Task Force (USPSTF) recommends bone density screening for cisgender women age 65 and older as well as postmenopausal people younger than that. The USPSTF doesn’t, however, offer a screening recommendation for cisgender men, due to a lack of sufficient evidence.

The National Osteoporosis Foundation, on the other hand, recommends screening for all cisgender women 65 and older as well as cisgender men 70 and older, plus younger adults with certain risk factors.

Guidelines specific to gender-diverse folks also differ across various medical organizations:

UCSF’s Transgender Care and Treatment guidelines suggest that all transgender individuals get bone density screening starting at age 65, or as early as age 50, depending on one’s risk factors. They also suggest screening in anyone who has had a gonadectomy and has gone at least five years without hormone therapy.

The Endocrine Society's Clinical Practice Guidelines, last updated in 2017, recommend bone density screening for any transgender individual with risk factors for osteoporosis, particularly people who have stopped taking hormone therapy after gonadectomy.

The International Society for Clinical Densitometry recommends baseline bone density screening for any transgender individual who:

  • Has had a gonadectomy
  • Has received therapy to suppress their sex steroid levels before starting GAHT
  • Has impaired production of endogenous hormones and who don't plan to start hormone therapy, or
  • Have any risk factors that warrant screening.

"If there's someone who has been missing dosages or had periods of time they were off hormones, they would probably get screened earlier with bone density testing," says Dr. Tangpricha.

That's a lot to take in, but one of the most helpful things you can do is talk with a knowledgeable and trusted HCP about your bone health, particularly if you've had a gonadectomy and/or your hormone levels have previously been inconsistent. Your HCP can help you navigate the maze of screening recommendations.

Doctors can test your bone mineral density (BMD) with a special X-ray of your hip and spine called a dual energy X-ray absorptiometry scan, or DEXA for short. You'll most likely need a referral for the test, which is why it's best to start by talking to your HCP about your risk factors and making sure your hormone levels are in the appropriate range. 

Keeping your bones healthy
In the meantime, there are a number of steps you can take in your daily life to help maintain your bone density now and into the future:

  • Getting your daily calcium... This important bone-building mineral comes from foods like low-fat dairy or leafy green vegetables. If you don’t get enough calcium from the foods you eat, your HCP may recommend you take a supplement.
  • ...and enough vitamin D. Vitamin D helps your body absorb calcium. You can get some from certain foods—including fish like salmon and trout, and fortified milk and juices—and your body also makes some naturally when you expose your skin to the sun. If you’re deficient in vitamin D, you may also need to take a supplement.
  • Eating a well-rounded balanced diet. This includes plenty of fresh fruits and vegetables, whole grains, lean proteins and healthy fats, while reducing excessive intake of salt, caffeine and alcohol.
  • Staying physically active. Weight-bearing exercises—those that require your body to push against gravity, like walking, running or dancing—are great for your bones, while muscle-strengthening moves help keep your entire skeletal system in shape.
  • Maintaining a healthy weight. Some research suggests that obesity increases one’s risk of facture, while having a low BMI is associated with low bone density. Work with your HCP to identify a weight that’s right for you and strategies to get there.
Article sources open article sources

Neda Sarafrazi, Ph.D., Edwina A. Wambogo, Ph.D., M.S., M.P.H., R.D., and John A. Shepherd, Ph.D. Osteoporosis or Low Bone Mass in Older Adults: United States, 2017–2018. Centers for Disease Control and Prevention. National Center for Health Statistics. NCHS Data Brief No. 405, March 2021.
Compston JE. Sex steroids and bone. Physiol Rev. 2001;81(1):419-447.
U.S. Preventive Services Task Force. Final Recommendation Statement. Osteoporosis to Prevent Fractures: Screening. June 26, 2018.
National Osteoporosis Foundation. Bone Density Exam/Testing.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Bone health and osteoporosis. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.
Rosen HN, Hamnvik O-PR, Jaisamrarn U, et al. Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position. J Clin Densitom. 2019;22(4):544-553.
National Osteoporosis Foundation. Hormones and Healthy Bones. 2009.

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