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Texto completo SciELO Uruguai
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Id: lil-538980
Autor: Rotemberg Wilf, Enrique; Smaisik Frydman, Karinna.
Título: Manifestaciones periodontales de los estados fisiológicos de la mujer / Periodontal manifestations of women's physiological states
Fonte: Odontoestomatol;11(13):[16-26], nov. 2009.
Idioma: es.
Resumo: Las hormonas sexuales esteroideas además de jugar un rol en la endocrinología reproductiva, regulan diversas funciones tisulares. En presencia de placa bacteriana asociada a cambios inflamatorios, estas hormonas influyen en la instalación y progreso de la enfermedad periodontal. Las hormonas sexuales femeninas esteoideas por sí mismas son insuficientes para producir cambios gingivales. Intervienen en la homeostasis del periodonto alterando la respuesta de los tejidos periodontales y la acción que sobre éstos ejerce la placa bacteriana, contribuyendo indirectamente a la enfermedad periodontal. Las principales hormonas sexuales femeninas esteroideas que han demostrado este efecto son los estrógenos y la progesterona.
Descritores: Ciclo Menstrual
Gravidez
Estrogênios
Gengivite
Menopausa
Progesterona
Limites: Humanos
Responsável: UY20.1 - Departamento de Documentación y Biblioteca


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Id: biblio-1283533
Autor: Sánchez Escobar, Fabio; Rueda Beltz, Camilo; Vásquez Awad, David; Moreno Escallón, Bernardo; Barón Castañeda, Germán; Gómez Tabares, Gustavo.
Título: Terapia hormonal de la menopausia en el año 2021 / Menopause hormone therapy in 2021
Fonte: Rev. colomb. menopaus;27(1):24-46, 2021.
Idioma: es.
Resumo: En enero de 2021 la Asociación Colombiana de Menopausia realizó el simposio "Terapia hormonal de la menopausia" contando con la participación de respetados profesores de la especialidad y a cada uno se le asignó un tema para ser revisado y presentado de acuerdo a la evidencia actual. En noviembre del año 2020 el Instituto de Vigilancia de Medicamentos y Alimentos (INVIMA) había lanzado una alerta sobre "Riesgo de desarrollar cáncer de mama en mujeres postmenopáusicas en manejo con terapia de reemplazo hormonal", apoyándose en una decisión del Reino Unido. Dentro de las afirmaciones de INVIMA se encontró que el uso prolongado por más de un año incrementa el riesgo de cáncer de mama sin que sea claro su soporte científico para tal afirmación. El pronunciamiento del Reino Unido se soportó en el estudio "Tipo y momento de la terapia hormonal de la menopausia y el riesgo de cáncer de mama: Meta-análisis de participantes individuales de la evidencia epidemiológica mundial, del Grupo de colaboración sobre factores hormonales en el cáncer de mama, publicado en la revista médica The Lancet el 29 de agosto de 2019. Varias asociaciones científicas se manifestaron en contra de lo enunciado y por ende la Asociación Colombiana de Menopausia consideró apropiado hacer una revisión exhaustiva del papel de la terapia hormonal en la actualidad. El resultado de dicho trabajo es presentado en esta revisión.

On January 2021 de Colombian Menopause Association did a symposium "Menopause hormonal therapy" with participation of respectable professors of the specialty, to each one previously a topic had been assigned for its review and presentation according to actual evidence. On November 2020 the Colombian Institute for Drugs and Foods Vigilance (INVIMA) had issued an alert about the "Risk of developing breast cancer in postmenopausal women under treatment with hormone replacement therapy", having support in a decision taken in the United Kingdom. One of the things affirmed by INVIMA was that prolonged use, greater than one year, increases the risk of breast cancer, without clear scientifically supporting this issue. In the United Kingdom the pronunciation was supported on the study, "Type and moment of menopausal hormone therapy and risk of breast cancer: Metanalisis of individual participants of worldwide epidemiological evidence, from the Collaborative group on hormonal factors in breast cancer published in The Lancet on August 29, 2019. Various scientific associations manifested against what was expressed and the Colombian Menopause Association considered appropriate to do an exhaustive review of the role of hormonal therapy today. The result of such work is presented in this paper.
Descritores: Terapia de Reposição Hormonal
-Neoplasias da Mama
Menopausa
Estrogênios
Fatores de Risco de Doenças Cardíacas
Limites: Humanos
Feminino
Pessoa de Meia-Idade
Tipo de Publ: Revisão
Responsável: CO5.1 - Centro de Información y Conocimiento


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Texto completo SciELO Chile
Texto completo
Id: biblio-978127
Autor: Parra, M; Lagos, N; Levancini, M; Villarroel, M; Pizarro, E; Vanhauwaert, P; Velasco, S; Fernadez, M; Gambacciani, M; Biglia, N; Cagnacci, A; Caruso, S; Cicinelli, E; De Leo, V; Di Carlo, C; Farris, M; Gambera, A; Guaschino, S; Lanzone, A; Paoletti, AM; Russo, N; Vicariotto, F; Villa, P; Volpe, A; Lavin, P; López, M; Campusano, C; Barriga, P; Brantes, S.
Título: Menopausia y terapia hormonal de la menopausia. Las recomendaciones 2018 de la Unidad de Endocrinología Ginecológica de Clínica Alemana de Santiago -Sociedad Italiana de la Menopausia y la Sociedad Chilena de Endocrinología Ginecológica / Menopause and menopausal hormone therapy. The 2018 recommendations of the Gynecological Endocrinology Unit of Clínica Alemana de Santiago -Italian Society of Menopause and the Chilean Society of Gynecological Endocrinology
Fonte: Rev. chil. obstet. ginecol. (En línea);83(5):527-550, nov. 2018. tab, graf.
Idioma: es.
Resumo: ABSTRACT In the last decade, the risk benefits ratio of MHT has been evaluated mainly in terms of cardiovascular risk. Present Consensus Statement is largely inspired by the Global Consensus on Menopausal Hormone Therapy in 2013 and 2016 by leading global menopause societies (The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society). The aim of these Recommendations is to provide a simple and updated reference on postmenopausal MHT. The term MHT typically includes estrogen replacement therapy (ERT) and estrogen-progestogen therapy (EPT). EPT can be sequential (Seq) when progestogen is added to ERT for 10-14 days a month, or continuous combined (CC) when progestogen is administered continuously every day along with a fixed amount of estrogen. MHT also includes Tibolone and the Tissue Selective Estrogen Complex (TSEC).
Descritores: Sociedades Médicas/tendências
Menopausa
Terapia de Reposição de Estrogênios
-Terapia de Reposição de Estrogênios/efeitos adversos
Fatores de Risco
Estrogênios/administração & dosagem
Limites: Humanos
Feminino
Tipo de Publ: Guia de Prática Clínica
Responsável: CL126.2 - Biblioteca Médica Dr. Profesor Hernán Alessandri R.


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Id: biblio-1116984
Autor: Castro, Viviana; Canales, Juan Pablo; Rada, Gabriel.
Título: Son efectivos los estrógenos orales en la prevención de infección del tracto urinario en mujeres posmenopáusicas / Are oral oestrogens effective in preventing urinary tract infection in postmenopausal woman
Fonte: Medwave;20(5):e7913, 2020.
Idioma: es.
Resumo: INTRODUCCIÓN: La infección del tracto urinario es una patología frecuente, con un alto riesgo de recurrencia, por lo que representa un importan-te motivo de consulta. Dentro de la población más afectada se encuentran las mujeres postmenopáusicas debido a la caída de los niveles de estrógenos, tanto locales como sistémicos, perdiéndose la barrera protectora de la vía urinaria contra agentes patógenos. Entre las variadas medidas que potencialmente disminuirían el riesgo de infección urinaria se ha planteado el uso de estrógenos, sin embargo, no está claro si realmente son efectivos. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud a nivel mundial, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis, preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos seis revisiones sistemáticas que en conjunto incluyen siete estudios primarios, de los cuales, cuatro son ensayos aleatorizados. Concluimos que no está claro si los estrógenos orales disminuyen el riesgo de desarrollar infección del tracto urinario sintomática, porque la certeza de la evidencia es muy baja.
Descritores: Infecções Urinárias/prevenção & controle
Pós-Menopausa
Estrogênios/administração & dosagem
-Ensaios Clínicos Controlados Aleatórios como Assunto
Administração Oral
Bases de Dados Factuais
Limites: Humanos
Feminino
Tipo de Publ: Metanálise
Responsável: CL1.1 - Biblioteca Central


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Id: biblio-1149830
Autor: Ocampo-Serna, Sabina; Gutiérrez-Segura, Julio César; Vallejo-González, Santiago.
Título: Disforia de género en el adulto con enfermedad coronaria. Reporte de caso y revisión de la literatura / Adult Gender Dysphoria with Coronary Disease. Case Report and Literature Review
Fonte: Rev. colomb. psiquiatr;49(3):211-215, jul.-set. 2020.
Idioma: es.
Resumo: RESUMEN Introducción: La disforia de género (DG) hace referencia a una marcada incongruencia entre la identidad de género y el sexo biológico, que genera un malestar clínico de al menos 6 meses de duración. Métodos: Reporte de caso y revisión no sistemática de la literatura. Presentación del caso: Mujer transgénero de 56 años, con historia de enfermedad coronaria y un segundo evento tromboembólico posterior a la automedicación de terapia hormonal. Después del tratamiento agudo de su afección cardiovascular, solicitó tratamiento para su DG. Discusión: La DG requiere un tratamiento multidisciplinario. La THC es el pilar del tratamiento. Se ha documentado que el uso de presentaciones orales de estrógenos puede aumentar el riesgo de eventos tromboembólicos en pacientes mayores de 40 años, principalmente cuando tienen factores de riesgo cardiovascular. Conclusiones: Se debe ofrecer un tratamiento integral a todas las personas con DG para aliviar el malestar psicológico, disminuir la comorbilidad psiquiátrica y mejorar su calidad de vida. Hasta el momento hay poca evidencia científica respecto a la THC en mujeres transgénero mayores de 40años, por lo que se recomienda una vigilancia multidisciplinaria, estrecha y rigurosa, en especial cuando hay riesgo cardiovascular.

ABSTRACT Introduction: Gender dysphoria (GD) refers to a marked incongruity between gender identity and biological sex. GD generates a significant clinical discomfort for at least six months. Methods: Case report and non-systematic literature review. Case presentation: A 56-year-old male-to-female patient, who had a history of coronary disease and a second thromboembolic event after hormone therapy (self-medicated). Once she had received acute management for the cardiovascular disease, she consulted for her GD. Discussion: GD requires multidisciplinary management. Cross-sex hormonal therapy is considered the main treatment. It has been documented that oral oestrogen preparations may increase the risk of thromboembolic events in patients over the age of 40, especially when they have cardiovascular risk factors. Conclusions: Comprehensive treatment should be offered to everyone who has GD, to relieve psychological distress, decrease psychiatric comorbidity and improve quality of life. To date, there is little scientific evidence regarding cross-sex hormonal therapy in transgender women over the age of 40; we therefore recommend multidisciplinary, close and rigorous monitoring, in particular when they have cardiovascular risk.
Descritores: Estrogênios
Disforia de Gênero
Identidade de Gênero
-Qualidade de Vida
Automedicação
Dronabinol
Doenças Cardiovasculares
Fatores de Risco
Doença das Coronárias
Angústia Psicológica
Limites: Humanos
Masculino
Feminino
Pessoa de Meia-Idade
Tipo de Publ: Relatos de Casos
Responsável: CO78 - Asociación Colombiana de Psiquiatría


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Texto completo SciELO Brasil
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Id: biblio-1278914
Autor: Barros-Oliveira, Maria da Conceição; Costa-Silva, Danylo Rafhael; dos Santos, Alesse Ribeiro; Pereira, Renato Oliveira; Soares-Júnior, José Maria; Silva, Benedito Borges da.
Título: Influence of CYP19A1 gene expression levels in women with breast cancer: a systematic review of the literature
Fonte: Clinics;76:e2846, 2021. tab, graf.
Idioma: en.
Resumo: Breast cancer is the most frequently diagnosed malignant neoplasm in women and is considered a multifactorial disease of unknown etiology. One of the major risk factors is genetic alteration. Changes in CYP19A1 gene expression levels have been associated with increased risk and increased aggressiveness of breast cancer. Increased CYP19A1 gene expression and/or aromatase activity are among the major regulatory events for intratumoral production of estrogens in breast malignant tissues. This systematic review aimed to investigate the influence of CYP19A1 gene expression levels in women with breast cancer. The research was carried out using the PubMed, Scopus, and Web of Science databases. Searches were conducted between February 2 and May 15, 2019. Inclusion criteria were studies published between 2009 and 2019, English language publications, and human studies addressing the gene expression of CYP19A1 in breast cancer. A total of 6.068 studies were identified through PubMed (n=773), Scopus (n=2,927), and the Web of Science (n=2,368). After selecting and applying the inclusion and exclusion criteria, six articles were included in this systematic review. This systematic review provides evidence that increased or decreased levels of CYP19A1 gene expression may be related to pathological clinical factors of disease, MFS, OS, DFS, WATi, markers of metabolic function, concentrations of E1, FSH, and in the use of multiple exons 1 of the CYP19A1 gene in breast cancer.
Descritores: Neoplasias da Mama/genética
-RNA Mensageiro
Aromatase/genética
Expressão Gênica
Estrogênios
Limites: Humanos
Feminino
Tipo de Publ: Revisão Sistemática
Responsável: BR1.1 - BIREME


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Texto completo SciELO Chile
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Id: biblio-838967
Autor: Da, Yun-Meng; Niu, Kai-Yu; Liu, Shu-Ya; Wang, Ke; Wang, Wen-Juan; Jia, Jing; Qin, Li-Hua; Bai, Wen-Pei.
Título: Does Cimicifuga racemosa have the effects like estrogen on the sublingual gland in ovariectomized rats?
Fonte: Biol. Res;50:11, 2017. graf.
Idioma: en.
Projeto: National Natural Science Foundation of China; . National Natural Science Foundation of China.
Resumo: BACKGROUND: Cimicifuga racemosa is one of the herbs used for the treatment of climacteric syndrome, and it has been cited as an alternative therapy to estrogen. Apart from hectic fevers, dyspareunia and so on, dry mouth also increase significantly after menopause. It has not yet been reported whether C. racemosa has any impact on the sublingual gland, which may relate to dry mouth. In an attempt to determine this, we have compared the effects of estrogen and C. racemosa on the sublingual gland of ovariectomized rats. RESULTS: HE staining showed that the acinar cell area had contracted and that the intercellular spaces were broadened in the OVX (ovariectomized rats) group, while treatment with estradiol (E2) and iCR (isopropanolic extract of C. racemosa) improved these lesions. Transmission electron microscopy showed that rough endoplasmic reticulum expansion in mucous and serous acinar epithelial cells and apoptotic cells was more commonly seen in the OVX group than in the SHAM (sham-operated rats) group. Mitochondria and plasma membrane infolding lesions in the striated ducts were also observed. These lesions were alleviated by both treatments. It is of note that, in the OVX + iCR group, the volume of mitochondria in the striated duct was larger than in other groups. Immunohistochemical staining showed that the ratio of caspase-3 positive cells was significantly increased in the acinar cells of the OVX group compared with the SHAM group (p < 0.05); and the MA (mean absorbance) of caspase-3 in the striated ducts also increased (p < 0.05). Estradiol decreased the ratio of caspase-3 positive cells and the MA of caspase-3 in striated ducts significantly (p < 0.05). ICR also reduced the ratio of caspase-3 positive cells and the MA in the striated ducts (p < 0.05), but the reduction of the MA in striated ducts was inferior to that of the OVX + E2 group (p < 0.05). CONCLUSION: Both estradiol and iCR can inhibit subcellular structural damage, and down-regulate the expression of caspase-3 caused by ovariectomy, but their effects were not identical, suggesting that both drugs confer a protective effect on the sublingual gland of ovariectomized rats, but that the specific location and mechanism of action producing these effects were different.
Descritores: Glândula Sublingual/efeitos dos fármacos
Extratos Vegetais/farmacologia
Ovariectomia
Estradiol/farmacologia
Estrogênios/farmacologia
-Fatores de Tempo
Xerostomia/prevenção & controle
Climatério/efeitos dos fármacos
Imuno-Histoquímica
Regulação para Baixo
Terapia de Reposição de Estrogênios/métodos
Reprodutibilidade dos Testes
Resultado do Tratamento
Ratos Sprague-Dawley
Apoptose/efeitos dos fármacos
Microscopia Eletrônica de Transmissão
Caspase 3/análise
Caspase 3/efeitos dos fármacos
Células Acinares/efeitos dos fármacos
Limites: Animais
Feminino
Ratos
Tipo de Publ: Estudo de Avaliação
Responsável: CL1.1 - Biblioteca Central


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Mendonça, Berenice Bilharinho de
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Id: biblio-890760
Autor: Cunha, Flávia Siqueira; Domenice, Sorahia; Sircili, Maria Helena Palma; Mendonca, Berenice Bilharinho de; Costa, Elaine Maria Frade.
Título: Low estrogen doses normalize testosterone and estradiol levels to the female range in transgender women
Fonte: Clinics;73:e86, 2018. tab.
Idioma: en.
Projeto: CNPq; . CNPq.
Resumo: OBJECTIVE: The ideal dosage of cross-sex hormones remains unknown. The aim of this study was to evaluate the luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin levels after low-dose estrogen therapy with or without cyproterone acetate in transgender women. METHODS: The serum hormone and biochemical profiles of 51 transgender women were evaluated before gonadectomy. Hormone therapy consisted of conjugated equine estrogen alone or combined with cyproterone acetate. The daily dose of conjugated equine estrogen was 0.625 mg in 41 subjects and 1.25 mg in 10 subjects, and the daily dose of cyproterone acetate was 50 mg in 42 subjects and 100 mg in one subject. RESULTS: Estrogen-only therapy reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 731.5 to 18 ng/dL, 6.3 to 1.1 U/L and 9.6 to 1.5 U/L, respectively. Estrogen plus cyproterone acetate reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 750 to 21 ng/dL, 6.8 to 0.6 U/L and 10 to 1.0 U/L, respectively. The serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin in the patients treated with estrogen alone and estrogen plus cyproterone acetate were not significantly different. The group receiving estrogen plus cyproterone acetate had significantly higher levels of gamma-glutamyltransferase than the group receiving estrogen alone. No significant differences in the other biochemical parameters were evident between the patients receiving estrogen alone and estrogen plus cyproterone acetate. CONCLUSION: In our sample of transgender women, lower estrogen doses than those usually prescribed for these subjects were able to adjust the testosterone and estradiol levels to the physiological female range, thus avoiding high estrogen doses and their multiple associated side effects.
Descritores: Testosterona/sangue
Acetato de Ciproterona/administração & dosagem
Estradiol/sangue
Estrogênios/administração & dosagem
Pessoas Transgênero
Antagonistas de Androgênios/administração & dosagem
-Prolactina/sangue
Hormônio Luteinizante/sangue
Estudos Retrospectivos
Relação Dose-Resposta a Droga
Interações Medicamentosas
Estrogênios/sangue
Hormônio Foliculoestimulante/sangue
Limites: Humanos
Masculino
Feminino
Adulto
Pessoa de Meia-Idade
Adulto Jovem
Tipo de Publ: Research Support, Non-U.S. Gov't
Ensaio Clínico
Responsável: BR1.1 - BIREME


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Id: biblio-1253931
Autor: Saraví, Fernando Daniel.
Título: Bloqueo puberal en niños con disforia de género: ¿totalmente reversible? / Pubertal block in boys with gender dysphoria: fully reversible?
Fonte: Actual. osteol;16(3):163-165, 2020.
Idioma: es.
Descritores: Disforia de Gênero/tratamento farmacológico
Disforia de Gênero/terapia
-Puberdade Precoce
Hormônio Liberador de Gonadotropina/uso terapêutico
Estrogênios/uso terapêutico
Procedimentos de Readequação Sexual
Disforia de Gênero/psicologia
Androgênios/uso terapêutico
Limites: Humanos
Masculino
Feminino
Criança
Adolescente
Tipo de Publ: Editorial
Responsável: AR2.1 - Biblioteca Central


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Id: biblio-1253780
Autor: Abdala, Rubén; Nagelberg, Alberto; Brance, M. Lorena.
Título: Salud ósea en personas transgénero / Bone health in transgender subjects
Fonte: Actual. osteol;16(3):176-186, 2020. ilus.
Idioma: es.
Resumo: Una persona transgénero es aquella en la cual el género autopercibido difiere del asignado al nacer, mientras que el término cisgénero es utilizado en aquellos individuos no trans. El tratamiento hormonal cruzado (THC) constituye una opción para lograr caracteres sexuales secundarios deseados. Es conocido que los esteroides sexuales desempeñan un rol fundamental en la adquisición de la densidad mineral ósea (DMO) durante la pubertad. Por lo tanto, el impacto del THC sobre la masa ósea se ha convertido en materia de estudio. En estadios puberales tempranos, los análogos de la hormona liberadora de gonadotrofinas (GnRH) son utilizados con un efecto reversible. Si bien la DMO parece mantenerse estable, cuando se compara con una población de referencia del mismo sexo biológico y edad, el Z-score se encuentra por debajo de lo esperado. En adultos, durante el THC no se informaron disminuciones en la DMO. Está reportado que las mujeres trans antes del inicio del TH presentan características densitométricas diferentes de los hombres cisgénero. Hasta el momento, la carga de datos para los calculadores del riesgo de fractura y el software del equipo DXA se basan en el sexo biológico y no en identidad de género. Recientemente, la International Society for Clinical Densitometry (ISCD) emitió sus recomendaciones para la evaluación de la masa ósea en personas transgénero y en aquellos individuos no conformes con el género. Si bien la ISCD sugiere realizar la evaluación únicamente en aquellos pacientes con factores de riesgo, es de importancia realizar DXA basal, sobre todo en mujeres transgénero, para determinar el riesgo inicial de dicha población. En este artículo se revisa la evidencia disponible sobre el impacto del THC en la salud ósea de personas transgénero. (AU)

Cross sex hormone therapy (CSHT) in transgender women (TW) it is an option to achieve desired secondary sexual characteristics. It is known that sex steroids play a fundamental role in the acquisition of bone mineral density during puberty, in addition to determining a different characteristic bone pattern between both biological sexes. So the impact of affirming HT on bone is it has become in subject of study. In early pubertal stages, GnRH analogs are used with a reversible effect. Although bone mineral density (BMD) seems to remain stable, when compared with a reference population of the same biological sex and age, the Z-score is lower than expected. In adults, during CSHT no decreases in BMD were reported. However, it was reported that TW prior to starting CSHT present different densitometric characteristics than cisgender men. So far, the data load for the fracture risk calculators and DXA software is based on biological sex and not gender identity. Recently the ISCD issued its recommendations for the evaluation of bone mass in transgender subjects and in those non-conforming to gender. Although the ISCD suggests performing the evaluation only in those patients with risk factors, our group recognizes that baseline DXA, especially in TW, constitutes a useful tool to determine the initial risk of this population. Our proposal arises from our own experience and from that compiled in the international literature, where it is observed that even without starting CSHT, transgender women have lower BMD. DXA. This article reviews the available evidence regarding the effect of CSHT on health bone in transgender people. (AU)
Descritores: Densidade Óssea/efeitos dos fármacos
Pessoas Cisgênero
-Hormônios Esteroides Gonadais/uso terapêutico
Testosterona/uso terapêutico
Fatores Sexuais
Fatores de Risco
Hormônio Liberador de Gonadotropina/análogos & derivados
Puberdade
Caracteres Sexuais
Densitometria
Estrogênios/uso terapêutico
Procedimentos de Readequação Sexual
Pessoas Transgênero
Antagonistas de Androgênios/uso terapêutico
Limites: Humanos
Masculino
Feminino
Tipo de Publ: Revisão
Responsável: AR2.1 - Biblioteca Central



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