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Severe osteoporosis in transwomen due to cessation of estrogen replacement after gender-confirming surgery

Conference contribution
Authors Ralph Decker
Jens Jacobeit
Published in 25th WPATH Symposium in Buenos Aires, Argentina
Publication year 2018
Published at Institute of Clinical Sciences, Department of Pediatrics
Language en
Keywords Gender dysphoria, cross-sex hormonal treatment, gender-confirming surgery (GCS), Estradiol replacement
Subject categories Endocrinology


Background The effect of sex steroids on the bone health of transgender individuals has been scarcely studied (1). In some male-to-female transgender, there was a lack of Estradiol treatment after gender-confirming surgery (GCS) in the 1980th and 1990th in a subgroup of patients. Lack of Estradiol is known to decrease bone mineral density (BMD) and increase the risk of fracture, especially in postmenopausal women (2). Objective & hypothesis Cessation of cross-sex hormonal treatment after GCS leads to osteoporosis. Material/ Methods A We studied prospectively a cohort of 288 transgender individuals male-to-female between 2009 - 2017. In 37 (12.8%) out of 288 patients, Dual-Energy-X-ray Absorptiometry (DXA) was performed using a DXA Luna Prodigy when hypogonadism was present (3). BMD references were used according to the original biological sex. Results In 28 cases out of 37 (76%) in whom DXA was performed, either osteopenia (BMD -1.0 to -2.5) or osteoporosis (BMD < -2.5) was detected 15.5 years after GCS without or insufficient Estradiol treatment postoperatively. Low BMD was correlated to low estradiol values before estradiol treatment was reintroduced. While lumbar osteopenia was improved after 2.3 years, osteoporosis could only be slightly enhanced, but none of the cases was fully reverted. Additionally, a significant number (23/37; 62%) of patients dropped out of further follow-up and compliance to take the Estradiol medication was moderate in the remaining. Discussion Lack of sufficient Estradiol treatment after successful gender-confirming surgery in male-to-female transgender causes osteopenia in up to 49% of these trans-women and osteoporosis in up to 38%. Both lumbar as well as femoral BMD were markedly decreased. Nevertheless, a fracture was detected solely in one case. The relationship between bone density and fracture risk, however, is a continuum, without a clear “fracture threshold” (3). The fracture risk in the future remains high in these mean 45 year old patients, ranging from 21 to 78 years. References 1. Singh-Ospina N, Maraka S, Rodriguez-Gutierrez R, Davidge-Pitts C, Nippoldt TB, Prokop LJ, Murad MH (2017) Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab, 102(11):3904–3913 2. Black DM, Rosen CJ (2016) Postmenopausal osteoporosis. N Engl J Med 374(3):254–262 3. Camacho PM et al (2016) American association of clinical endocrinologists and american college of endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2016 Sep 2;22(Suppl 4)

Page Manager: Webmaster|Last update: 9/11/2012

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