What are the current guideline recommendations for osteoporosis screening and treatment in men and transgender patients?
Executive summary
Major U.S. guideline panels diverge on routine screening for osteoporosis in men: the USPSTF finds evidence insufficient to recommend population-wide screening for men, while specialty societies (Endocrine Society, ACP and international groups) advise targeted DXA testing for older or at‑risk men—typically men ≥70 years or men 50–69 with risk factors [1] [2] [3] [4]. For transgender patients, guidance is fragmented: institutional and review guidance recommend individualized screening based on age, gonadal status, hormone therapy and other risk factors, with some centers advising routine screening at age 65 and earlier testing for those with risks [5] [6] [7] [8].
1. Screening recommendations for men: conflicting national vs specialty guidance
The U.S. Preventive Services Task Force (USPSTF) states evidence is insufficient to assess benefits and harms of population screening for osteoporosis in men, leaving the decision individualized (I statement) and emphasizing that most trial evidence and screening thresholds derive from studies in women [1] [9]. By contrast, endocrinology and international societies recommend active case-finding: central DXA of the hip and spine is advised for men aged ≥70 and for men 50–69 who have risk factors such as low body weight, prior adult fracture, glucocorticoid use, or other secondary causes of bone loss [2] [3] [4]. This split reflects different interpretations of limited male-specific fracture prevention trial data and competing priorities between population-level evidence review (USPSTF) and specialty-driven clinical practice needs [1] [2].
2. How to test and diagnose: modalities and reference standards
Dual-energy x‑ray absorptiometry (DXA) of lumbar spine and hip remains the recommended diagnostic test for men and transgender patients when screening is indicated, and clinicians generally use the WHO-derived T‑score reference standard (originally based on young White women) that most guidelines continue to apply across sexes while recognizing limitations [6] [8] [2]. Vertebral fracture assessment and opportunistic CT measures are discussed in endocrinology and clinical guidelines for patients with height loss, kyphosis, long‑term steroids, or acute back pain, and specialist groups urge assessment for secondary causes when low BMD or fragility fracture is found [10] [2].
3. Screening and management for transgender patients: individualized care amid evidence gaps
Systematic reviews and clinical practice guidance emphasize that gender‑affirming hormones often maintain or increase bone mineral density, but long‑term fracture data are sparse; therefore screening decisions should be based on clinical factors—age, removal of gonads, adherence to hormone therapy, and traditional osteoporosis risks—with some centers (e.g., UCSF Transgender Care) advising routine DXA at age 65 and earlier testing (50–64) for those with established risk factors [6] [7] [5]. The USPSTF explicitly flags transgender bone‑health research as a need and notes that transgender persons who have not received gender‑affirming hormones likely have risks aligned with their sex assigned at birth, recommending shared clinician–patient decision‑making [8] [11].
4. Treatment: largely the same pharmacologic and nonpharmacologic approaches, with some nuance
Available reviews and guidelines indicate that pharmacologic management of osteoporosis in transgender people generally follows the same evidence‑based treatments as for cisgender patients when osteoporosis is diagnosed, while nonpharmacologic measures—adequate calcium and vitamin D, weight‑bearing exercise, and fall‑prevention—are universally recommended [7] [6] [8]. For men at very high fracture risk, newer international guidance names agents such as abaloparatide as appropriate first‑line options in select cases, reflecting recent updates aimed at closing a perceived care gap in men [12]. Harms and benefits of specific drugs vary by agent and must be weighed individually [1] [10].
5. Where uncertainties remain and what clinicians should do now
Consensus exists on using clinical risk factors and DXA to guide diagnosis, but authoritative prevention guidance differs: USPSTF’s population‑level caution for men contrasts with specialty recommendations for proactive screening of older and at‑risk men, and transgender guidance centers on individualized assessment because of sparse long‑term fracture data—points explicitly noted as research gaps by the USPSTF and multiple reviews [1] [8] [7]. Clinicians and policy makers therefore must balance the risk of missed diagnoses in underrecognized groups (an explicit concern of international bodies) against limited trial evidence for population screening in men, and transgender patients require explicit discussion of gonadal status, hormone therapy adherence and shared decision‑making [12] [13] [5].