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. 2019 Mar;34(3):447-454.
doi: 10.1002/jbmr.3612. Epub 2018 Dec 7.

Bone Safety During the First Ten Years of Gender-Affirming Hormonal Treatment in Transwomen and Transmen

Chantal M Wiepjes  1   2 , Renate T de Jongh  1 , Christel Jm de Blok  1   2 , Mariska C Vlot  1 , Paul Lips  1 , Jos Wr Twisk  3 , Martin den Heijer  1   2
Affiliations

Bone Safety During the First Ten Years of Gender-Affirming Hormonal Treatment in Transwomen and Transmen

Chantal M Wiepjes et al. J Bone Miner Res. 2019 Mar.

Abstract

Concerns about the effects of gender-affirming hormonal treatment (HT) on bone mineral density (BMD) in transgender people exist, particularly regarding the decrease in estrogen concentrations in transmen. Although it is known that HT is safe for BMD in the short term, long-term follow-up studies are lacking. Therefore this study aimed to investigate the change in BMD during the first 10 years of HT, to determine whether HT is safe and if assessing BMD during HT is necessary. A follow-up study was performed in adult transgender people receiving HT at the VU University Medical Center Amsterdam between 1998 and 2016. People were included if they were HT naive and had a dual-energy X-ray absorptiometry (DXA) scan at the start of HT. Follow-up DXA scans performed after 2, 5, and/or 10 years of HT were used for analyses. The course of BMD of the lumbar spine during the first 10 years of HT was analyzed using multilevel analyses. A total of 711 transwomen (median age 35 years; IQR, 26 to 46 years) and 543 transmen (median age 25 years; IQR, 21 to 34 years) were included. Prior to the start of HT, 21.9% of transwomen and 4.3% of transmen had low BMD for age (Z-score < -2.0). In transwomen lumbar spine BMD did not change (+0.006; 95% CI, -0.005 to +0.017), but lumbar spine Z-score increased by +0.22 (95% CI, +0.12 to +0.32) after 10 years of HT. Also in transmen lumbar spine BMD did not change (+0.008; 95% CI, -0.004 to +0.019), but lumbar spine Z-score increased by +0.34 (95% CI, +0.23 to +0.45) after 10 years of HT. This study showed that HT does not have negative effects on BMD, indicating that regularly assessing BMD during HT is not necessary. However, a high percentage of low BMD was found prior to HT, especially in transwomen. Therefore, evaluation of BMD before start of HT may be considered. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.

Keywords: BONE; DXA; GENDER-AFFIRMING HORMONAL TREATMENT; OSTEOPOROSIS; TRANSGENDER.

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Figures

Figure 1
Figure 1
Flowchart of inclusion of study population. DXA not within time frame: more than 1 year before start of gender‐affirming hormonal treatment or more than 4 months after start of HT. The reported percentages are the percentages of transwomen or transmen with a DXA scan at that time point compared with the total included transwomen or transmen, respectively. DXA = dual‐energy X‐ray absorptiometry; HT = gender‐affirming hormonal treatment; VUmc = VU University medical center.
Figure 2
Figure 2
Change in absolute BMD and Z‐score in transwomen and transmen during the first 10 years of gender‐affirming hormonal treatment. CI = confidence interval; BMD = bone mineral density; yr = year.
Figure 3
Figure 3
Change in BMD during the first 10 years of gender‐affirming hormonal treatment in transwomen and transmen, stratified for age groups, concentrations of estradiol, testosterone, and LH. For each group, the mean change with 95% CI is reported below the graphs. Age is defined as age at start of HT. Estradiol, testosterone, and LH concentrations were assessed during HT and are shown as mean (range). BMD = bone mineral density; CI = confidence interval; LH = luteinizing hormone.
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