What transgender people need to know about bone health

In the United States, more than 4 in 10 people ages 50 or older have low bone mass. This can lead to osteoporosis, a condition that causes bone to become weaker and more fragile. Having osteoporosis increases the 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.

The way bones grow and regrow over a lifetime is closely related to the body's hormones. Bone health is therefore a topic of 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, including the effects of GAHT and gender-affirming surgery, as well as making sense of recommended screening guidelines.

Risk factors for low bone density

The older you are, the greater your risk of osteoporosis. Other risk factors for low bone density include:

• 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
• Low body mass index (BMI) or small body frame size
• Having an eating disorder that results in severely restricted food intake and being underweight
• Insufficient levels of estrogen or testosterone (also known as sex steroid hormones)

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)
• Any hormone therapy you may take, as well as 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 that 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 (see the tips below) 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 (whose gender identity corresponds with the sex they were identified as having at birth). They can be even more confusing 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 cisgender women younger than that who are at increased risk of osteoporosis. 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 years and older as well as cisgender men 70 and older, plus younger adults with certain risk factors.

Guidelines specific to gender-diverse people 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 for anyone who has had a gonadectomy and has gone at least five years without hormone therapy.

The Endocrine Society's Clinical Practice Guidelines for transgender people, last updated in 2017, recommend bone density screening for any transgender person with risk factors for osteoporosis, particularly people who have stopped taking hormone therapy after gonadectomy. In particular, transgender women at low risk of osteoporosis should begin screening at age 60 or if they have not been consistent with taking hormone therapy. Transgender men should have osteoporosis screening if they have stopped or have been inconsistent with hormone therapy or if they have otherwise developed risks for bone loss.

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
• Has 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.

HCPs 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 steps you can take in your daily life to help maintain your bone density now and into the future:

Get 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.

Remember vitamin D

Vitamin D helps your body absorb calcium. You can get some from certain foods—including fish such as salmon and trout, as well as 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.

Eat a well-rounded diet

This includes plenty of fresh fruits and vegetables, whole grains, lean proteins, and healthy fats, while reducing excessive intake of saturated fat, added sugars, added salt, caffeine, and alcohol.

Stay physically active

Weight-bearing exercises—those that require your body to push against gravity, like walking, running, or dancing—are great for your bones. Muscle-strengthening moves help keep your entire skeletal system in shape.

Maintain a healthy weight

Some research suggests that obesity increases one’s risk of bone fracture, 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.

Avoid smoking

Among its many drawbacks, smoking can contribute to lower bone mass and higher risks of fracture and developing osteoporosis. If you smoke, speak to an HCP about the best ways to quit for you.