Osteoporosis: Underdiagnosed in men

Osteoporosis is more common in women than in men, so it is often thought of as a women’s disease. Subsequently, it is underdiagnosed and undertreated in men, especially men age 65 and older, who are at risk for developing osteoporosis. In addition, the number of fractures caused by fragile bones in men has increased in recent years.

A fracture after age 50 is an important signal that a person may have osteoporosis. Unfortunately, men are less likely than women to be evaluated for osteoporosis after a fracture. Men also are less likely to get osteoporosis treatment.

“Although women are at greater risk, men get osteoporosis too. In fact, up to one in four men over age 50 will break a bone due to osteoporosis,” said Carina May, who is with the Bone Health and Osteoporosis Foundation in Arlington, Virginia. “Approximately two million American men already have osteoporosis. About 12 million more are at risk.”

Increased risks

Osteoporosis develops because bone mineral density and bone mass decrease or the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures. These fractures can occur in any bone. However, they are most common in bones of the hip, vertebrae in the spine, and wrist.

Bone is made up of living tissue that is constantly changing, with older bone being broken down and new bone formed in its place. This is called remodeling. Almost all bone in adults is remodeled every 10 years. Bone mass is lost when there is an imbalance between bone breakdown and bone formation. That imbalance occurs with aging and other conditions.

Bone mass is gained during growth and typically peaks in one’s 20s. Peak bone mass is generally higher in men than in women. Having lower bone density and bone strength is a major risk factor for fracture in both men and women.

“Men older than 50 are more likely to break a bone due to osteoporosis than they are to get prostate cancer. Each year, about 80,000 men will break a hip,” said May. “Men are more likely than women to die within a year after breaking a hip. This is due to problems related to the break.”

In men, risk factors for osteoporosis include chronic diseases such as diabetes or rheumatoid arthritis and regular use of certain medications, such as glucocorticoids. “Many of the risk factors that put women at risk for osteoporosis apply to men as well. For example, a family history, use of steroid medications, sedentary lifestyle, smoking, and excessive alcohol consumption,” said May. “Low testosterone levels can elevate the risk in men and evidence also suggests that low estrogen levels in men can lead to bone loss.”

Testing and diagnosis

The most common test used to measure bone mineral density and diagnose osteoporosis is a central dual energy x-ray absorptiometry (DXA or DEXA). DXA uses a small amount of x-ray to measure how much calcium and other minerals are in a specific area of your bone.

The U.S. Preventive Services Task Force recommends annual DXA testing in women by age 65. But the Task Force says that not enough evidence is available to recommend routine DXA testing in men.

If you are 50 or older, your bone mineral density test result will be a T-score. A T‑score is the difference between your bone mineral density and the average bone mineral density of a healthy young adult. A T-score less than -2.5 is usually considered to indicate osteoporosis.

Your doctor might use the Fracture Risk Assessment Tool (FRAX) along with the T‑score to estimate your risk for fracture. This score uses your age, sex, medical history, country and other factors.

Worldwide, it is estimated that one in five men over the age of 50 will experience an osteoporotic fracture in their remaining lifetime, and the number of hip fractures in men is expected to rise by approximately 310% between 1990 and 2050.

The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) just recently issued GRADE-assessed recommendations for the diagnosis, monitoring and treatment of osteoporosis in men. The Working Group recommendations cover approaches to fracture risk assessment in men, including appropriate interpretation of bone densitometry and absolute fracture risk.

Trabecular bone score, used with bone mineral density and FRAX probability, provides useful information for fracture risk assessment in men. All men with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications. The anti-osteoporosis treatment regimen in men should be adapted to an individual’s baseline fracture risk.

“Some of the most important things people can do to protect their bone health are to get enough calcium and vitamin D and eat a well-balanced diet, engage in regular exercise that is weight-bearing and muscle strengthening, avoid smoking, and limit alcohol intake,” said May.

The guidelines state that men 65 and older should be screened to make sure they have adequate levels of vitamin D and calcium. Oral bisphosphonates (alendronate or risedronate) are first-line treatments for men at a high risk of fracture. Denosumab or zoledronate are considered second-line treatments for men at a high risk of fracture.