Men and Osteoporosis
Osteoporosis is commonly thought of as a women’s disease, even among medical professionals. But many men get it. It is estimated that 2 million men in the United States have osteoporosis. Millions more have osteopenia or are thought to be at risk for developing osteoporosis. Experts estimate that a 60-year-old man has about a 25% chance of having a bone fracture some time in his life. Hip and spinal fractures are about one-third as common in elderly men as in women. The mortality rate for people past age 75 who have had hip fractures is higher for men than for women.
As men get older, they can lose 20 to 30 percent of their bone mass, with cortical bone lasting longer than trabecular bone. Both estrogens and androgens influence bone density and as these hormone levels change with age, bone demineralization occurs. Higher estrogen levels are associated with higher bone density in men, no matter what the androgen levels. Testosterone (an androgen) levels decline with age, and study results differ on whether this decline is associated with decreased bone density.
Obesity is known to be a risk factor for osteoporosis, new findings show that belly fat - the kind more typical in overweight men - is particularly detrimental when it comes to raising the risk for osteoporosis. Researchers at Harvard Medical School found visceral (deep belly) obesity is the worst type of body fat, as it increases the risk for heart disease and diabetes as well as for osteoporosis.
One obstacle is diagnosis. Women are much more likely to be given bone density tests than men. Doctors often don’t find male osteoporosis until the patient comes in for pain, often back pain. If small fractures are detected, that’s a clue for osteoporosis. The diagnostic techniques are the same as those used for women.
The National Health and Nutrition Examination Survey found that only 1 percent of men past age 65 reported they had osteoporosis, even though 2 percent of men in this age range had suffered a hip fracture. So even men with a history of fractures did not know, or want to admit, that they had osteoporosis. By contrast, 11 percent of women said they had osteoporosis, more than the 6 percent with a history of fractures. Women seem much more willing to admit to themselves and others they have osteoporosis. This may be misplaced male pride or a genuine failure to understand that men can get osteoporosis. Further, it seems about half of male osteoporosis cases are secondary osteoporosis with an obvious cause such as corticosteroids. Secondary osteoporosis is more commen in men than in women.
The standard definition of osteoporosis relies on a deviation from a statistical mean in bone density. This poses a little bit of a problem for osteoporosis in men as the bone densitometry numbers are not as well defined in men as they are in women. There is sexual dimorphism when it comes to bones in young adults. Bone mineral density measurements are useful for predicting fractures in men, although men have a lower absolute risk for fracture than women at any bone density T-score. The World Health Organization (WHO) recommends using the same classification of BMD. (2.5 standard deviations below the mean being osteoporosis, and between 1.0 and 2.5 standard deviations below the mean being osteopenia.) Doctors pay less attention to osteopenia in men than in women and are less likely to prescribe bisphosphonates for it.
Younger adult men tend to break bones more often than women, because they tend to be more active. Among older adults, fractures are more common in women, because osteoporosis is more common in women. It should be noted, however, that when older men do suffer hip fractures, those fractures are more likely to lead to death than the same fractures in women. (Both mortality and morbidity are higher for men following fractures than for women of the same age.) When men suffer fractures in the wrist bones, there is a a greater chance they will be followed by hip or spine fractures than is true for women with the same wrist fracture.
Should men get bone density mineral tests even if they have not had fractures? Authorities differ on this question. The U.S. Preventive Services Task Force (federal government) says routine screening is not called for if men show no signs of risk. The National Osteoporosis Foundation (NOF), International Society for Clinical Densitometry (ISCD), and the Endocrine Society recommend BMD testing for all men older than 70 years, and in men 50 to 70 years when risk factors are present. Obvious symptoms or indications that might suggest osteoporosis include a loss of height (over an inch), several fractures due to low trauma, and visible osteopenia showing up on an X-ray. Long-term glucocorticoid (GC) therapy is known to induce osteoporosis. People with hyperparathyroidism are often checked as the two disorders are correlated.
The initial evaluation includes blood and urine tests to rule out kidney or liver disease, a complete blood count, serum testosterone, calcium, alkaline phosphatase, and 25-hydroxyvitamin D (calcidiol).
One reason men (and their doctors) need to be careful is that the mortality rate for men who get bone fractures (hips, vertebrae) is higher than the rate for women. Morbidity and mortality rates are higher for men with hip fractures than for women.
Treating Men With Osteoporosis
The treatment for men is largely the same as for women: bisphosphonates are considered the standard first-line therapy. Men are sometimes given testosterone replacement therapy, although the results for stopping osteoporosis with this method have been disappointing. Androgens (which include testosterone) stop the loss of cancellous bone. It might sound like a paradox, but the prostate drugs pamidronate and zoledronic acid are given as part of androgen deprivation therapy and they have a side effect of preventing bone loss.
Related: Juvenile osteoporosis
Sources for information on this page: National Health Service of Scotland, National Osteoporosis Foundation, National Library of Medicine, MedPageToday, NIH Osteoporosis and Related Bone Diseases National Resource Center
The Boneporosis book is now available on Amazon.com.Click here