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Mehta JM, Kanell S, Borowicz CEA, Fisher MA. Transgender patients and gender-affirming hormone therapy through the mid-life. Maturitas 2024; 189:108093. [PMID: 39178607 DOI: 10.1016/j.maturitas.2024.108093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 08/07/2024] [Accepted: 08/17/2024] [Indexed: 08/26/2024]
Abstract
The menopause transition and post-menopause period marks a time of dynamic physiological and hormonal change. Cisgender women commonly experience vasomotor symptoms, genitourinary symptoms, and changes in bone health. The transgender population, including those assigned female at birth (AFAB) and those assigned male at birth (AMAB), has been understudied in terms of experiences through the menopause transition and midlife. Additionally, there is no formal recommendation or guidance on continuation of gender-affirming hormone therapy (GAHT) through midlife. While gender-affirming therapies for transgender patients are well defined and supported by organizational guidelines, including from the World Professional Association for TGD Health (WPATH) (Standards of Care 8, SOC8) and from the Endocrine Society (2017), evidence on continuation of therapy and dose adjustments into mid-life are lacking. Data from a few large cohort studies and small cross-sectional studies suggest increased risk of venous thromboembolism (VTE), stroke and myocardial infarction in those AMAB on GAHT. For those AFAB on testosterone therapy, risks of cardiovascular disease and stroke and to bone health are not well defined, given inconsistent findings from large cohort studies. Currently, the decision to continue GAHT for transgender patients is guided by patient preference along with clinician guidance. Further research is warranted regarding risks of continuing GAHT into mid-life for both AMAB and AFAB patients. Given the significant benefit of GAHT in this population, however, this data would be most helpful for counseling on risks along with appropriate monitoring and prevention for related morbidities during mid-life in the setting of GAHT use.
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Affiliation(s)
- Jaya M Mehta
- Primary Care Institute, Allegheny Health Network, Pittsburgh, PA, United States of America; Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America.
| | - Sarah Kanell
- Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Charlie E A Borowicz
- Center for Inclusion Health, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Molly Ainsman Fisher
- Primary Care Institute, Allegheny Health Network, Pittsburgh, PA, United States of America; Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
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2
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Edwardson S, Flower L, Fawcett E, Medlock R, Cheung AS, Kamaruddin K, McCormack VL, Agarwal S. Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments. Anaesthesia 2024; 79:1102-1116. [PMID: 39043129 DOI: 10.1111/anae.16378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients. METHODS A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken. RESULTS The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes. CONCLUSIONS This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.
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Affiliation(s)
- Stuart Edwardson
- Department of Anaesthesia and Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Luke Flower
- Department of Medicine, Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Intensive Care Medicine, London School of Intensive Care Medicine, London, UK
| | - Erik Fawcett
- Department of Anaesthesia, Queen Elizabeth Hospital, Woolwich, UK
| | - Rebecca Medlock
- Department of Anaesthetics and Critical Care Hospital, Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ada S Cheung
- Trans Health Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Melbourne, Australia
| | - Kamilla Kamaruddin
- General Practitioner in Transgender Health Care and Clinical Lead East of England Gender Service, Cambridge, UK
| | - Victoria L McCormack
- Department of Anaesthesia and Critical Care Medicine, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - Seema Agarwal
- Department of Anaesthesia and Critical Care Medicine, Wythenshawe Hospital, Manchester Foundation Trust, Manchester, UK
- Manchester University, Manchester, UK
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Hayes-Lattin M, Krivicich LM, Bragg JT, Rogerson A, Salzler MJ. Considerations for the care of transgender patients in orthopaedics and sports medicine: a narrative review. Br J Sports Med 2024; 58:1075-1082. [PMID: 38997148 DOI: 10.1136/bjsports-2023-107703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
Orthopaedic and sports medicine clinicians can improve outcomes for transgender patients by understanding the physiological effects of gender-affirming hormone therapy (GAHT). This narrative review investigated the role of GAHT on bone mineral density, fracture risk, thromboembolic risk, cardiovascular health and ligament/tendon injury in this population. A search from the PubMed database using relevant terms was performed. Studies were included if they were levels 1-3 evidence. Due to the paucity of studies on ligament and tendon injury risk in transgender patients, levels 1-3 evidence on the effects of sex hormones in cisgender patients as well as basic science studies were included for these two topics. This review found that transgender patients on GAHT have an elevated fracture risk, but GAHT has beneficial effects on bone mineral density in transgender women. Transgender women on GAHT also have an increased risk of venous thromboembolism, stroke and myocardial infarction compared with cisgender women. Despite these elevated risks, studies have found it is safe to continue GAHT perioperatively for both transgender women and men undergoing low-risk operations. Orthopaedic and sports medicine clinicians should understand these unique health considerations for equitable patient care.
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Affiliation(s)
| | - Laura M Krivicich
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jack T Bragg
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ashley Rogerson
- Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Matthew J Salzler
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
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Venkatesh VS, Nie T, Golub S, Stok KS, Hemmatian H, Desai R, Handelsman DJ, Zajac JD, Grossmann M, Davey RA. High circulating concentrations of estradiol are anabolic for bone mass and strength in an adult male to female transgender mouse model. Bone 2024; 186:117143. [PMID: 38866125 DOI: 10.1016/j.bone.2024.117143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
The effects of gender affirming hormone therapy (GAHT) on bone microarchitecture and fracture risk in adult transgender women is unclear. To investigate the concept that skeletal integrity and strength in trans women may be improved by treatment with a higher dose of GAHT than commonly prescribed, we treated adult male mice with a sustained, high dose of estradiol. Adult male mice at 16 weeks of age were administered ~1.3 mg estradiol by silastic implant, implanted intraperitoneally, for 12 weeks. Controls included vehicle treated intact females and males. High-dose estradiol treatment in males stimulated the endocortical deposition of bone at the femoral mid-diaphysis, increasing cortical thickness and bone area. This led to higher stiffness, maximum force, and the work required to fracture the bone compared to male controls, while post-yield displacement was unaffected. Assessment of the material properties of the bone showed an increase in both elastic modulus and ultimate stress in the estradiol treated males. Treatment of male mice with high dose estradiol was also anabolic for trabecular bone, markedly increasing trabecular bone volume, number and thickness in the distal metaphysis which was accompanied by an increase in the histomorphometric markers of bone remodelling, mineralizing surface/bone surface, bone formation rate and osteoclast number. In conclusion, a high dose of estradiol is anabolic for cortical and trabecular bone in a male to female transgender mouse model, increasing both stiffness and strength. These findings suggest that increasing the current dose of GAHT administered to trans women, while considering other potential adverse effects, may be beneficial to preserving their bone microstructure and strength.
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Affiliation(s)
- Varun S Venkatesh
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia; Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.
| | - Tian Nie
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Suzanne Golub
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Kathryn S Stok
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria 3010, Australia.
| | - Haniyeh Hemmatian
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Reena Desai
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, New South Wales 2137, Australia.
| | - David J Handelsman
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, New South Wales 2137, Australia.
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Mathis Grossmann
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia; Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.
| | - Rachel A Davey
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
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Ceolin C, Papa MV, Scala A, Sergi G, Garolla A. Getting old in the desired gender: a systematic review on aging diseases in transgender people. J Endocrinol Invest 2024; 47:1851-1862. [PMID: 38904914 PMCID: PMC11266207 DOI: 10.1007/s40618-024-02353-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/28/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The growing demographic presence of the transgender (TGD) population has sparked an increase in clinical investigations focusing on the impacts of gender-affirming hormone therapy (GAHT) in adults with gender dysphoria. Despite this surge in studies, there remains a significant gap in the literature regarding the health status of older TGD individuals. This review aims to assess prevalent pathological conditions within the TGD population, specifically concentrating on aging-related diseases investigated to date. METHODS A systematic search across Embase Ovid, Scopus, PubMed, Cochrane Library, and Web of Science databases was conducted to identify articles reporting on the aging process in TGD individuals. Methodological quality was evaluated using Newcastle-Ottawa Scale (NOS) scores. RESULTS Initial database searches yielded 12,688 studies, which were refined to 18 through elimination of duplicates and title/abstract review. Following a comprehensive appraisal, nine studies were included in the systematic review. These articles, published between 2017 and 2023, involved a total of 5403 participants. The evidence indicates a noteworthy percentage of the TGD population being at risk for cardiovascular diseases, experiencing depression or disability, and demonstrating hesitancy toward major recommended screening programs. CONCLUSIONS Limited studies on older TGD individuals highlight not only an organic risk of chronic diseases but also a cognitive/psychiatric risk that should not be underestimated. Further research is imperative to deepen our understanding of the pathophysiological mechanisms involved in the health challenges faced by older TGD individuals.
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Affiliation(s)
- C Ceolin
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy.
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy.
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Aging Research Center, Stockholm, Sweden.
| | - M V Papa
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy
| | - A Scala
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - G Sergi
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
| | - A Garolla
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
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Yang KJ, Kerr C, Rumps MV, Mulcahey M. Musculoskeletal and cardiovascular considerations for transgender athletes. PHYSICIAN SPORTSMED 2024:1-7. [PMID: 38605534 DOI: 10.1080/00913847.2024.2342230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/09/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Participation in athletics is essential for the overall well-being of transgender athletes and should be included as part of gender-affirming care. Surveys show physicians and athletic trainers want to provide appropriate care for transgender athletes but lack the proper knowledge and training to do so. Gender Affirming Hormone Therapy (GAHT) is part of gender-affirming care, yet the effects of GAHT on the cardiovascular and musculoskeletal health of transgender athletes is not well-understood. The purpose of this review was to discuss important musculoskeletal and cardiovascular considerations unique to transgender athletes and improve physician understanding in caring for transgender athletes. METHODS A representative selection of literature on the effects of GAHT on cardiovascular and musculoskeletal health was included in this review. RESULTS Estrogen therapy may increase the risk of venous thromboembolism (VTE) and stroke, and decrease blood pressure levels among transgender women, while studies on lipid profile are inconsistent among both transgender men and women. Transgender women receiving GAHT may also be at greater risk for bone fracture and ligamentous injuries. CONCLUSION Exercise is essential for the well-being of transgender individuals and special considerations regarding the cardiovascular and musculoskeletal health of transgender athletes should be incorporated into standard medical education. Educational programs for transgender patients and their support team should focus on preventative measures that can be taken to reduce the risk of adverse musculoskeletal and cardiovascular events. The PPE is an invaluable tool available to physicians to monitor the health and safety of transgender athletes and should be regularly updated as research on the health of transgender individuals continues to grow. Longitudinal and prospective studies should examine the effects of GAHT on the musculoskeletal and cardiovascular health of transgender athletes. Lastly, health care providers play an important role in the advancement of gender-neutral policies.
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Affiliation(s)
- Kailynn J Yang
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Canaan Kerr
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Mia V Rumps
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Mary Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Iwamoto SJ, Rothman MS, T’Sjoen G, Defreyne J. Approach to the Patient: Hormonal Therapy in Transgender Adults With Complex Medical Histories. J Clin Endocrinol Metab 2024; 109:592-602. [PMID: 37683089 PMCID: PMC10795931 DOI: 10.1210/clinem/dgad536] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/10/2023]
Abstract
While endocrinologists continue to initiate gender-affirming hormone therapy (GAHT) in healthy transgender and gender diverse (TGD) patients, they may also encounter more TGD patients in their clinics with complex medical histories that influence the patient-provider shared decision-making process for initiating or continuing GAHT. The purpose of this Approach to the Patient article is to describe management considerations in 2 adults with thromboembolic disease and 2 adults with low bone mineral density in the setting of feminizing and masculinizing GAHT.
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Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Micol S Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Guy T’Sjoen
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Justine Defreyne
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
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8
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Cheung AS, Zwickl S, Miller K, Nolan BJ, Wong AFQ, Jones P, Eynon N. The Impact of Gender-Affirming Hormone Therapy on Physical Performance. J Clin Endocrinol Metab 2024; 109:e455-e465. [PMID: 37437247 PMCID: PMC10795902 DOI: 10.1210/clinem/dgad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance. EVIDENCE ACQUISITION MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes. EVIDENCE SYNTHESIS Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women. CONCLUSION Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | | | - Brendan J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Alex Fang Qi Wong
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
- Australian Regenerative Medicine Institute, Monash University, Clayton 3800, Australia
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Venkatesh VS, Nie T, Zajac JD, Grossmann M, Davey RA. The Utility of Preclinical Models in Understanding the Bone Health of Transgender Individuals Undergoing Gender-Affirming Hormone Therapy. Curr Osteoporos Rep 2023; 21:825-841. [PMID: 37707757 PMCID: PMC10724092 DOI: 10.1007/s11914-023-00818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE OF REVIEW To summarise the evidence regarding the effects of gender-affirming hormone therapy (GAHT) on bone health in transgender people, to identify key knowledge gaps and how these gaps can be addressed using preclinical rodent models. RECENT FINDINGS Sex hormones play a critical role in bone physiology, yet there is a paucity of research regarding the effects of GAHT on bone microstructure and fracture risk in transgender individuals. The controlled clinical studies required to yield fracture data are unethical to conduct making clinically translatable preclinical research of the utmost importance. Novel genetic and surgical preclinical models have yielded significant mechanistic insight into the roles of sex steroids on skeletal integrity. Preclinical models of GAHT have the potential inform clinical approaches to preserve skeletal integrity and prevent fractures in transgender people undergoing GAHT. This review highlights the key considerations required to ensure the information gained from preclinical models of GAHT are informative.
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Affiliation(s)
- Varun S Venkatesh
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
| | - Tian Nie
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, 3084, Australia
| | - Rachel A Davey
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia.
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10
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Cheung AS. Reversible Effects of Puberty Suppression on Bone Strength, Mass, and Body Composition in Adolescent Mice After Testosterone Therapy. J Bone Miner Res 2023; 38:1389-1390. [PMID: 37701985 DOI: 10.1002/jbmr.4906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, The University of Melbourne, Heidelberg, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
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11
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Goodrich E, Walcott Q, Dallman J, Crow H, Templeton K. Bone Health in the Transgender Population. JBJS Rev 2023; 11:01874474-202310000-00013. [PMID: 37883596 DOI: 10.2106/jbjs.rvw.23.00123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
» Transgender women are more susceptible to low bone mineral density (BMD) before initiating gender-affirming hormone therapy (GAHT), and while bone density initially improves with GAHT, it gradually declines while still remaining above baseline. Transgender women older than 50 years have a comparable fracture risk as age-matched cisgender women. Transgender men typically have normal or increased BMD before initiating and while receiving GAHT and are not at increased risk of fractures.» Transgender youth who receive puberty-blocking medications experience either no change or a slight decrease in BMD that returns to baseline after initiating GAHT.» It is important to abide by the International Society for Clinical Densitometry guidelines whenever ordering, performing, or reading a BMD scan for a gender-diverse patient.» There are no specific guidelines concerning vitamin D and calcium supplementation or the use of bisphosphonates in the transgender population, so the current recommendation is to abide by the guidelines for cisgender individuals.
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Affiliation(s)
| | | | | | - Hanna Crow
- Ascension Saint Thomas, Nashville, Tennessee
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12
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McGovern MM, Lowenstein NA, Matzkin EG. Sports Medicine Considerations When Caring for the Transgender Athlete. Arthrosc Sports Med Rehabil 2023; 5:100736. [PMID: 37645385 PMCID: PMC10461145 DOI: 10.1016/j.asmr.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/13/2023] [Indexed: 08/31/2023] Open
Abstract
Orthopaedic surgeons and other orthopaedic care providers have expressed a desire to care for transgender patients but have a self-perceived knowledge deficit. Transgender athletes experience many psychosocial barriers to sport that are useful for clinicians to understand. Medical and surgical gender-affirming care can impact musculoskeletal physiology and pathophysiology. Transgender women (TW) have demonstrated an increased risk of insufficiency fractures and thromboembolism in patients receiving exogenous estrogen therapy. The impact of gender-affirming care on sex-based differences in athletic injuries is less well studied.
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Affiliation(s)
- Madeline M. McGovern
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie A. Lowenstein
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth G. Matzkin
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Moreland E, Cheung AS, Hiam D, Nolan BJ, Landen S, Jacques M, Eynon N, Jones P. Implications of gender-affirming endocrine care for sports participation. Ther Adv Endocrinol Metab 2023; 14:20420188231178373. [PMID: 37323162 PMCID: PMC10262668 DOI: 10.1177/20420188231178373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Many transgender (trans) individuals utilize gender-affirming hormone therapy (GAHT) to promote changes in secondary sex characteristics to affirm their gender. Participation rates of trans people in sport are exceedingly low, yet given high rates of depression and increased cardiovascular risk, the potential benefits of sports participation are great. In this review, we provide an overview of the evidence surrounding the effects of GAHT on multiple performance-related phenotypes, as well as current limitations. Whilst data is clear that there are differences between males and females, there is a lack of quality evidence assessing the impact of GAHT on athletic performance. Twelve months of GAHT leads to testosterone concentrations that align with reference ranges of the affirmed gender. Feminizing GAHT in trans women increases fat mass and decreases lean mass, with opposite effects observed in trans men with masculinizing GAHT. In trans men, an increase in muscle strength and athletic performance is observed. In trans women, muscle strength is shown to decrease or not change following 12 months of GAHT. Haemoglobin, a measure of oxygen transport, changes to that of the affirmed gender within 6 months of GAHT, with very limited data to suggest possible reductions in maximal oxygen uptake as a result of feminizing GAHT. Current limitations of this field include a lack of long-term studies, adequate group comparisons and adjustment for confounding factors (e.g. height and lean body mass), and small sample sizes. There also remains limited data on endurance, cardiac or respiratory function, with further longitudinal studies on GAHT needed to address current limitations and provide more robust data to inform inclusive and fair sporting programmes, policies and guidelines.
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Affiliation(s)
- Ethan Moreland
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Ada S. Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Danielle Hiam
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Brendan J. Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Shanie Landen
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Macsue Jacques
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Ballarat Road, Footscray, VIC 3011, Australia
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14
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Iwamoto SJ, Defreyne J, Kaoutzanis C, Davies RD, Moreau KL, Rothman MS. Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults. Ther Adv Endocrinol Metab 2023; 14:20420188231166494. [PMID: 37113210 PMCID: PMC10126651 DOI: 10.1177/20420188231166494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.
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Affiliation(s)
- Sean J. Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Avenue, Aurora, CO 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Robert D. Davies
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- CUMedicine LGBTQ Mental Health Clinic, University of Colorado Hospital, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Kerrie L. Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
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15
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Cheung AS, Nolan BJ, Zwickl S. Transgender health and the impact of aging and menopause. Climacteric 2023; 26:256-262. [PMID: 37011669 DOI: 10.1080/13697137.2023.2176217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Gender affirming hormone therapy (GAHT) is used by many transgender people to reduce gender incongruence and improve psychological functioning. As GAHT shares many similarities with menopausal hormone therapy, clinicians supporting people through menopause are ideally placed to manage GAHT. This narrative review provides an overview of transgender health and discusses long-term effects of GAHT to consider when managing transgender individuals across the lifespan. Menopause is less relevant for transgender individuals who take GAHT (often given lifelong) to achieve sex steroid concentrations generally in the range of the affirmed gender. For people using feminizing hormone therapy, there is an elevated risk of venous thromboembolism, myocardial infarction, stroke and osteoporosis relative to cisgender individuals. For trans people using masculinizing hormone therapy, there is an increased risk of polycythemia, probable higher risk of myocardial infarction and pelvic pain which is poorly understood. Proactive mitigation of cardiovascular risk factors is important for all transgender people and optimization of bone health is important for those using feminizing hormones. With a lack of research to guide GAHT in older age, a shared decision-making approach is recommended for the provision of GAHT to achieve individual goals whilst minimizing potential adverse effects.
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Affiliation(s)
- A S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - B J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - S Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
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16
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David K, Narinx N, Antonio L, Evenepoel P, Claessens F, Decallonne B, Vanderschueren D. Bone health in ageing men. Rev Endocr Metab Disord 2022; 23:1173-1208. [PMID: 35841491 DOI: 10.1007/s11154-022-09738-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 01/11/2023]
Abstract
Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.
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Affiliation(s)
- Karel David
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Nick Narinx
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Leen Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Frank Claessens
- Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Brigitte Decallonne
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Vanderschueren
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium.
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.
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17
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Sirufo MM, Magnanimi LM, Ginaldi L, De Martinis M. Early monitoring of bone health in transgender individuals. Bone 2022; 163:116486. [PMID: 35843484 DOI: 10.1016/j.bone.2022.116486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy; Technical Group for the Coordination of Gender Medicine, AUSL 04 Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy; Technical Group for the Coordination of Gender Medicine, Regione Abruzzo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy; Technical Group for the Coordination of Gender Medicine, Regione Abruzzo, Italy.
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18
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Giacomelli G, Meriggiola MC. Bone health in transgender people: a narrative review. Ther Adv Endocrinol Metab 2022; 13:20420188221099346. [PMID: 35651988 PMCID: PMC9150228 DOI: 10.1177/20420188221099346] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/21/2022] [Indexed: 12/29/2022] Open
Abstract
Bone health in transmen and transwomen is an important issue that needs to be evaluated by clinicians. Prior to gender-affirming hormone treatment (GAHT), transwomen have lower bone mineral density (BMD) and a higher prevalence of osteopenia than cismen probably related to external factors, such as hypovitaminosis D and less physical activities. Gonadotropin-releasing hormone (GnRH) analogues in transgender youth may cause bone loss; however, the addition of GAHT restores or at least improves BMD in both transboys and transgirls. The maintenance or increase in BMD shown in short-term longitudinal studies emphasizes that GAHT does not have a negative effect on BMD in adult transwomen and transmen. Gonadectomy is not a risk factor if GAHT is taken correctly. The prevalence of fractures in the transgender population seems to be the same as in the general population but more studies are required on this aspect. To evaluate the risk of osteoporosis, it is mandatory to define the most appropriate reference group not only taking into consideration the medical aspects but also in respect of the selected gender identity of each person.
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Affiliation(s)
- Giulia Giacomelli
- Division of Gynecology and Physiopathology of Human Reproduction, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Universitaria Di Bologna. S. Orsola Hospital, University of Bologna, Bologna, Italy
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19
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Ali D, Tencerova M, Figeac F, Kassem M, Jafari A. The pathophysiology of osteoporosis in obesity and type 2 diabetes in aging women and men: The mechanisms and roles of increased bone marrow adiposity. Front Endocrinol (Lausanne) 2022; 13:981487. [PMID: 36187112 PMCID: PMC9520254 DOI: 10.3389/fendo.2022.981487] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Osteoporosis is defined as a systemic skeletal disease characterized by decreased bone mass and micro-architectural deterioration leading to increased fracture risk. Osteoporosis incidence increases with age in both post-menopausal women and aging men. Among other important contributing factors to bone fragility observed in osteoporosis, that also affect the elderly population, are metabolic disturbances observed in obesity and Type 2 Diabetes (T2D). These metabolic complications are associated with impaired bone homeostasis and a higher fracture risk. Expansion of the Bone Marrow Adipose Tissue (BMAT), at the expense of decreased bone formation, is thought to be one of the key pathogenic mechanisms underlying osteoporosis and bone fragility in obesity and T2D. Our review provides a summary of mechanisms behind increased Bone Marrow Adiposity (BMA) during aging and highlights the pre-clinical and clinical studies connecting obesity and T2D, to BMA and bone fragility in aging osteoporotic women and men.
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Affiliation(s)
- Dalia Ali
- Department of Molecular Endocrinology, KMEB, University of Southern Denmark and Odense University Hospital, Odense, Denmark
- *Correspondence: Dalia Ali, ; Abbas Jafari,
| | - Michaela Tencerova
- Laboratory of Molecular Physiology of Bone, Institute of Physiology of the Czech Academy of Sciences, Prague, Czechia
| | - Florence Figeac
- Department of Molecular Endocrinology, KMEB, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Moustapha Kassem
- Department of Molecular Endocrinology, KMEB, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Abbas Jafari
- Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Dalia Ali, ; Abbas Jafari,
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