Osteoporosis in Men

Abstract

Osteoporosis in men remains underdiagnosed and underappreciated, despite the fact that at age 50, 13–25 men per 100 can expect to suffer an osteoporotic fracture before they die. In older men, hip fracture carries a high mortality rate, twice that of women. While vertebral fractures are occasionally noted in middle-aged men, the risk for fracture rises markedly after age 80. Screening of older men and those with important risk factors may lead to fewer fractures. Evaluation requires history/physical examination, a modest list of laboratory tests, and bone mineral density by dual energy X-ray absorptiometry (DXA). Most expert groups advocate use of the white female normative database for calculation of the DXA T-score in men, but it is important to note that fractures can occur in men with normal bone mineral density. Osteoporosis risk factors magnify the predicted fracture risk of DXA testing. Secondary causes of osteoporosis are important in men, and diagnostic testing may be helpful. Although bone density and serum testosterone decline in parallel with aging, bioavailable estradiol is better correlated with bone density. In younger men, testosterone replacement increases bone density. In older men, testosterone has been shown to increase bone strength, but larger studies are needed to demonstrate fracture risk reduction. Approved medications that lower fracture risk in women appear to work equally well in men: oral and intravenous bisphosphonates, denosumab, and teriparatide. However, long-term management decisions rely on studies in women.