Inclusion Criteria:

• Adult transgender women and men, ≥ 18 years of age. 
• Diagnosis of gender dysphoria according to DSM-V.
• Able and willing to provide informed consent.

Exclusion Criteria:

• Previous use of cross sex hormone therapy:
  • Estrogen;
  • Testosterone;
  • Progesterone;
  • Spironolactone;
  • 5-Alpha Reductase Inhibitor (Finasteride, Dutasteride);
  • Anti-Androgen (such as Leuprolide, Bicalutamide, Cyproterone Acetate).
• Previous fracture within 12 months of study.
• Tobacco users.
• Presence of clinical diagnosis of any of the following:
  • Significant liver or renal disease;
  • Malignancy (including myeloma);
  • Malabsorption (as defined by clinical diagnosis);
  • Hypoparathyroidism;
  • Hyperparathyroidism;
  • Acromegaly;
  • Cushing’s Syndrome;
  • Hypopituitarism;
  • Severe Chronic Obstructive Pulmonary Disease.
• Heart failure history.
• Use of medications affecting bone turnover:
  • Oral or systemic glucocorticoids ≥ 3 Months;
  • Anticonvulsant therapy for seizures in past year;
  • Thiazolidinediones;
  • Thyroid Hormone (causing suppression of thyroid stimulating hormone below normal).
• Use of previous and current bone modulating therapy:
  • Bisphosphonates;
  • Denosumab;
  • Teriparatide;
  • Abloparatide;
  • Selective Estrogen Receptor Modulators;
  • Romosozumab.