Estrogen exposure and skeletal health: Special populations and considerations.

Estrogen is critical for bone health from puberty onwards. Various clinical scenarios in adolescence can impact skeletal exposure to estrogen during this vulnerable time. Primary ovarian insufficiency, premature menopause, and anorexia nervosa necessitate prompt evaluation, treatment, and replacement of estrogen in order to optimize accrual of peak bone mass. We have much still to learn about the skeletal impact of delaying puberty and gender affirming hormones in gender diverse individuals. While the choice of hormonal contraception in adolescence is often driven by patient preference and concerns about adherence, providers and patients much take the long-term impact on bone health into consideration. Key Concepts: (1)Delayed, diminished or absent estrogen during adolescence has a negative impact on peak bone mass accrual.(2)Hormone replacement therapy is essential for patients with primary ovarian insufficiency and premature menopause.(3)Recovery from anorexia nervosa does not lead to a complete catch-up of bone density lost/not gained.(4)Not all hormonal contraception methods are created equal for the adolescent skeleton.(5)Skeletal health of trans youth is an emerging focus.