Pain-Free Living

Male Osteoporosis: Underdiagnosed & Undertreated

By Kurt Ullman

Despite the fact that most discussion of osteoporosis centers on women, studies suggest one out of every 20 men will have osteoporosis during his lifetime. Yet a recent survey from the International Osteoporosis Foundation found 93% of men are not aware of how common osteoporotic fractures are in males.

Osteoporosis is a disease that causes the skeleton to weaken and bones to break. Fractures most often occur in the hip, spine and wrist.

20% of Men over 50 Have Fractures
“Around 20% of men over 50 will have a fracture due to osteoporosis during their lifetime,” said Robert Recker, M.D., director of the Osteoporosis Research Center at Creighton University in Omaha, Nebraska. “The concern is due to the fact that when men have hip fractures, they are more likely to die, have greater disability or have a lower quality of life compared to when women have hip fractures.”

Each year, about 80,000 men will break hips in falls related to their osteoporosis. Of these, one third will die within the following year, and another third will have a second fall.

“When men have hip fractures, they tend to have more lung and heart disease and cancers at the time of the break,” said Linda Russell, MD, director of the Osteoporosis Center at the Hospital for Special Surgery in New York City. “In general, they have decreased functional status and just aren’t in as good physical shape compared to  women. This explains some of the differences in mortality between the genders.”

Declining Bone Density
A person’s bones constantly are changing as old bone is removed and new bone takes its place. As a person ages, changes in levels of sex hormones (specifically estrogen in women and testosterone in men) affect the amount of bone that is deposited in the skeleton. In some cases, lower levels of these chemicals can result in minerals being removed from the bone faster than they are being replaced. This causes the density and strength of the bones to decline.

“The big difference is that men tend not to go through menopause or, more accurately, andropause,” said Howard Heller, M.D., an endocrinologist at the Baylor University Medical Center in Dallas. “They lose testosterone gradually over their entire life starting around 50. There is no single event signaling the onset of higher risk in men.”

Other reasons  women are more likely to have osteoporosis than men include their tendency to live longer and, thus, to lose bone density over a longer period of time. In addition, men tend to have greater bone density at their peak, around 30 years of age.

Two Types of Osteoporosis
The two main types of osteoporosis are primary and secondary. Primary either is caused by age-related bone loss (senile osteoporosis) or has an unknown cause (idiopathic osteoporosis).

In secondary osteoporosis,  the loss of bone mass is caused by lifestyle, diseases or medications. Most men will have at least one, and often more than one, secondary cause.

“There are certain things that are very bad for your bones,” said Russell. “Drinking  alcohol to excess can have a very detrimental impact on bone density. Medications such as steroids have been shown to cause bone loss. Although the science isn’t as well established, many doctors think a class of drugs called proton pump inhibitors used to treat heartburn also could  be a concern.”

Secondary osteoporosis also can  be seen in those who:

• have chronic diseases such as rheumatoid arthritis; chronic obstructive pulmonary disorder (COPD); gastrointestinal disorders including malabsorption syndrome; too much calcium, thyroid or parathyroid hormone; or low levels of sex hormones (specifically testosterone);
• have poor nutrition such as low vitamin D and/or calcium levels in the blood;
• smoke; and/or
• get insufficient exercise.

Another indicator is age: the older you are, the greater the risk. Various guidelines have been released by national and international associations. However, most suggest increased vigilance for men over 70 years of age, or over 65 if they have other risk factors.

“It is very reasonable for a man to discuss with his primary health-care provider if he is at risk for osteoporosis and then what to do,” said Russell. “Patients should absolutely be proactive.”

Making the Diagnosis
Osteoporosis in men is diagnosed by taking a complete medical history, obtaining x-rays and running urine and blood tests to help rule out the causes of secondary osteoporosis. There also is a test for bone mineral density—a dual-energy X-ray absorptiometry (DXA) test.

DXA produces two X-ray beams, one high frequency and one low frequency. The amount of the X-ray passing through the bone and soft tissue is measured for each, and the difference is used to calculate a person’s bone density.

Depending on the amount of bone loss, the diagnosis may be either osteopenia or osteoporosis. Osteopenia occurs when bone density is lower than normal but not yet at the critical loss level seen in osteoporosis. It is considered by many doctors to be a precursor to osteoporosis, but not every person diagnosed with osteopenia will go on to develop osteoporosis.

DXA tests are important because they can often identify osteoporosis in early stages before fractures are likely. Treatments now in place can be used to stop or reverse bone loss and greatly reduce the likelihood bones will break.

When to Test?
“One of the difficulties of male osteoporosis is telling when they should be tested,” said Recker of Creighton University. “The only external sign is a family history of male osteoporosis. Additionally, the criteria that Medicare and insurance programs use to decide if they will pay for bone density testing almost exclusively relates to women. In men, the only time Medicare will pay for this is after a fracture already has occurred. We prefer to identify a patient long before that happens to help prevent it in the first place.”

Heller does note that payment for a DXA test often is approved if an X-ray for another concern, such as arthritis, shows evidence of possible bone density problems. He suggests patients remind their physicians to look for indicators if they are having X-rays done for another reason.

Prevention is the Best Treatment
As with almost all diseases, the best treatment is prevention. While there have been fewer research studies on men, most experts agree men should take these steps to preserve their bones.

Start and continue regular weight-bearing exercises, preferably early in life. When the bones and muscles work against gravity, bone density increases, depending on how vigorous the exercise. These exercises could include walking, jogging, tennis, lifting weights or using a resistance machine. As with all such programs, check with your doctor to see if you are healthy enough to tolerate them.

“Another important consideration is diet,” said Heller. “Many people don’t get the 1,200 milligram minimum daily recommended requirement for calcium in their diet. I suggest three servings of dairy products a day. That would be a cup of any dairy product per serving, except for cheese, which is 1.5 ounces.” He also notes that almond milk, calcium fortified juices and soymilk can be used if you can’t tolerate cow’s milk or just prefer those options. Most have calcium added, so check the labels to make sure.

Some doctors will suggest you use dietary supplements available over the counter in pharmacies, groceries and other stores.

Vitamin D is another dietary consideration. The vitamin helps calcium get into the bones. Normally your body will make enough as long as you are exposed to the sun for 10 minutes or more per day. When that isn’t possible—if you have fair skin, are taking medications that might make you burn easier or you live in northern areas during the winter—you can get enough vitamin D from milk or dairy products, salmon, tuna, sole, fortified cereals or most multivitamins.

Treating Osteoporosis
The treatment for loss of bone in men is largely the same as in women. The main goal is to preserve bone density and lessen the risk for fractures, disability and early death.

Many medications are available to stabilize and possibly reverse the loss of bone. They can work in as little as one year to reduce the risk of breaking a bone. Which one your doctor prescribes will be based on your specific needs. Your doctor will try to find a medication that will have as little impact on your lifestyle as possible.

Alendronate (Fosamax), ibandronate (Boniva) and risedronate (Actonel) all are members of a group of medicines called bisphosphonates. They alter the cycle of bone formation and breakdown in the body. This slows bone loss while increasing bone mass, which may prevent bone fractures.

These medications can cause serious problems in the stomach and esophagus, so you will need to sit or stand for at least 30 minutes after taking them. You should take these medications at least a half hour before you eat, drink or use another medication. If you are taking Boniva, you should wait a full hour. Each dose should be taken with at least six to eight ounces of water.

Zoledronic acid (Reclast) is another medication approved for use in men. Unlike the others, it can be given only intravenously. It often is administered in your doctor’s office over 15 minutes. A major advantage is that it is taken only once a year.

Teriparatide (Forteo) had been shown to increase bone density in men. This is a daily medication given subcutaneously, or right under the skin, instead of into a muscle or a vein. It is not a bisphosphonate and stimulates bone formation.

All these medications can cause significant side effects and drug interactions, and there are times when they cannot safely be used. Talk to your doctor about these concerns and make sure you completely understand them.

Since secondary osteoporosis often is seen in men, you may be prescribed additional medication to treat the other underlying problem. Treatments in this case will be very individualized, depending on what is found.

“Everyone thinks of osteoporosis as a female disease, but it isn’t,” said Russell. “Men need to be more aware that they, too, can have osteoporosis and should make sure they discuss this with their doctors.” 

Last Reviewed September 15, 2015

Kurt Ullman, RN, is an Indiana-based medical writer whose career spans 30 years.

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