Osteoporosis in Men

Osteoporosis (or porous bone) is a disease in which bones become weak and are more likely to break. Without prevention or treatment, osteoporosis can progress without pain or symptoms until a bone breaks (fractures). Fractures commonly occur in the hip, spine, and wrist. Osteoporosis is the underlying cause of more than 1.5 million fractures annually (300,000 hip fractures, approximately 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 fractures in other areas). The estimated national cost (hospitals and nursing homes) for osteoporosis and related injuries is $14 billion each year in the United States. 
 
Although women are more likely to get osteoporosis, it is not just a disease of elderly women. Osteoporosis is more common in white or Asian women older than 50 years, but osteoporosis can occur in almost any person at any age. In fact, more than 2 million American men have osteoporosis and 3 million are at risk. Many people who have osteoporosis and risk factors for osteoporosis often do not know they have thin or weak bones. This is because osteoporosis has no symptoms, so many people do not know they have weak bones until they have an unexpected fracture. For example, a simple everyday movement such as picking up a grocery bag causes a broken bone or a slip and fall in a parking lot causes a broken hip, and that is the first “symptom.” 
 
Osteoporosis is often not recognized in men. There are many reasons for underdiagnosis in men. Identifying risk factors is important because osteoporosis is more or less preventable for most people. Identifying men with osteoporosis is also important because, while there is no cure for osteoporosis, there are treatments.

Greater bone mass

Osteoporosis is more commonly diagnosed in women, and women are at greater risk than men. However, men really have only temporary protection against osteoporosis. The temporary protection is related to the size of men’s skeletons, which are generally larger than women’s bones. This means that men have larger reserves of bone mass to draw from as they age, so their bone loss progresses more slowly. Also, men do not experience the same rapid bone loss that occurs in women during and after menopause. See What is Bone Loss? for more information.

Because bone loss is delayed and osteoporosis does not have any symptoms, men do not usually know they have osteoporosis until a fracture occurs. Increasing awareness about the true frequency of osteoporosis in men is essential for prevention and long-term health.

Screening standards for osteoporosis

Osteoporosis is diagnosed using bone mineral density (BMD) tests to measure the solidness and mass (bone density) usually in the spine, hip, and/or wrist (the most common sites of fractures due to osteoporosis). These tests are performed like x-rays, and they are the only reliable way to determine loss of bone mass. They are painless, noninvasive, and safe. See Bone Mineral Density Tests for more information.

The results of a bone mineral density test are compared to standards, or norms, determined from a large average population. One of the problems with measuring the bone mineral density of men is that many of the standards used for comparison are from young women rather than men. The average bone mass in healthy young women is always lower than that observed in healthy young men. This means that a man may have low bone mass (osteopenia) compared to healthy men, but the comparison with the norm (from young women) will not show that they are at risk for osteoporosis. Consequently, few men are classified as osteoporotic based on the normal data from young women.

Even though bone loss in men usually occurs later in life compared with women, men can still be at high risk for osteoporosis. By age 65, men catch up to women and lose bone mass at the same rate. Additional risk factors such as a small body frame, long-term use of corticosteroids (medications prescribed for a wide range of diseases, including arthritis, asthma, Crohn disease, lupus, and other diseases), or low testosterone (or sex hormone) levels can increase the risk of osteoporosis in men.

It is estimated that by 2025, the total number of hip fractures in men will be similar to the current number reported in women. Perhaps because men are generally older than women are when they have a fracture, men are often more severely disabled. As with women, the hips, spine, and wrists are the most common sites of fracture. The complications and death caused by hip fractures is 3 times higher in men than women. 

Risk factors for bone loss and fractures include:

• Certain drugs (corticosteroids, anticonvulsants, heparin, excessive thyroid replacement, certain cancer therapies)



• Chronic disease that affects the kidneys, lungs, stomach, and intestines and alters hormone levels



• Undiagnosed low levels of the sex hormone testosterone



• Lifestyle habits
  
  
  • Smoking
  
  
  
  • Low calcium intake (see Osteoporosis and Calcium)
  
  
  
  • Inadequate physical exercise
  
  
  
• Increasing age



• Heredity



• Race (Of all men, white men appear to be at greatest risk for osteoporosis. However, men from all ethnic groups develop osteoporosis.)

Early detection of low bone mass (osteopenia) or osteoporosis is the most important step for prevention and treatment. Even after osteopenia or osteoporosis has occurred, actions can be taken to stop the progression of bone loss. Remember, effective treatment or prevention cannot take place if a man does not know he has osteoporosis or is at risk.

The only way to accurately test the strength and solidness of the bones is with bone mineral density tests, which are performed like x-rays and measure the solidness and mass (bone density) of bones (see Bone Mineral Density Tests). 
 
The doctor should take a medical history, asking questions to identify risk factors. The doctor should conduct a complete physical exam, including measuring height and weight, obtaining x-rays, and testing urine and blood. Inform the doctor at once if a loss of height, change in posture, or sudden back pain is noticed because this can indicate a fracture of the spine (vertebral fracture).

Building strong bones and reaching peak bone density (maximum strength and solidness), especially before the age of 30, can be the best defense against developing osteoporosis. Also, a healthy lifestyle can keep bones strong, especially for people older than 30 years. See Prevention of Osteoporosis for more details. 

Medical research on osteoporosis in men is limited. However, experts agree that all persons should take the following steps to preserve bone health.

• Any underlying medical conditions that affect bone health should be recognized and treated. Also, use of medications that are known to cause bone loss should be identified and monitored.



• Change unhealthy habits, such as smoking. Begin an exercise program.



• Ensure a daily calcium intake of 1000 mg/day to age 50 and 1200 mg/day for people 51 and older (see Osteoporosis and Calcium).



• Ensure adequate vitamin D intake. Vitamin D comes from 2 sources. It is made in the skin through direct exposure to sunlight, and it comes from the diet. Many people get enough vitamin D naturally. It is also found in fortified dairy products, egg yolks, saltwater fish, and liver. However, vitamin D production decreases in older and elderly people, in people who are housebound, and during the winter. These people may need vitamin D supplements to ensure a daily intake of 400-800 IU of vitamin D.

Exercise

Exercise is important to prevent osteoporosis. Although bones may seem like hard and lifeless structures, bones are more like muscle; bones are living tissue that responds to exercise by becoming stronger. Physical activity during childhood and adolescence increases bone density and strength, which means that children who get exercise are more likely to reach their peak bone density (maximum strength and solidness). People who reach their peak bone density, which usually occurs by age 30 years, are less likely to develop osteoporosis.

The best exercise to prevent osteoporosis is weight-bearing exercise that works against gravity. Exercises include walking, hiking, jogging, climbing stairs, playing tennis, and dancing. The second type of exercise is resistance exercise. Resistance exercises include activities that use muscle strength to build muscle mass and strengthen bone. These activities include weight lifting, such as using free weights and weight machines found at gyms and health clubs. Exercise has additional benefits in older people as well because exercising increases muscle strength, coordination, and balance and leads to better overall health (see Fall Prevention and Osteoporosis).

Elderly people, people with osteoporosis, and people who have not exercised for most of adulthood should check with their healthcare provider before beginning any exercise program.

Once a diagnosis of osteoporosis or osteopenia is determined, the doctor may talk about medications available to treat bone loss. The goal of treatment is to prevent the development of osteoporosis (if decreased bone mass or other risk factors are present) and to prevent further bone loss (especially if osteoporosis has already been diagnosed). The bottom line is to preserve the bone mass and density present to decrease the risk of broken bones (osteoporotic fractures) and disability. The many treatments available today have been shown to work quickly (within 1 year), and they reduce the risk of fracture by up to 50%. The choice of treatment should fit a person's specific medical needs and lifestyle, so talking to the doctor is important. See Understanding Osteoporosis Medications for more information.

• Alendronate (Fosamax) is approved as a treatment for osteoporosis in men. Alendronate and risedronate (Actonel) are approved for use in steroid-induced osteoporosis that occurs in men and women as a result of long-term use of steroids such as prednisone or cortisone.   



• Although many medications are prescribed to treat osteoporosis in women, currently they are not approved by the Food and Drug Administration (FDA) for use in men, but investigational studies in men are in progress.



• To help men with osteoporosis and low testosterone, doctors may recommend testosterone replacement therapy. In men, testosterone results in a small, but significant increase in bone density. Calcitonin is another medication that slows or stops bone loss and may relieve the pain of fractures in some patients. Calcitonin is approved by the FDA for the treatment of osteoporosis in postmenopausal women. It has not been studied in men, but evidence suggests that it may work the same in men as in women. Calcitonin is available as an injection and as a nasal spray.



• Teriparatide (Forteo) contains a portion of the parathyroid hormone (PTH) molecule and has been shown to increase bone density of the spine in men. It is administered as a daily injection that is approved for men with hypogonadal (low testosterone) osteoporosis.



• Sodium fluoride is a medication still under investigation (recommended for approval by an FDA committee)

National Osteoporosis Foundation
1232 22nd Street NW
Washington, DC 20037-1292
(202) 223-2226

International Osteoporosis Foundation
info@osteofound.org

National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center
2 AMS Circle
Bethesda, MD 20892-3676
(800) 624-Bone
niamsboneinfo@mail.nih.gov

|Web Links|

National Osteoporosis Foundation, Osteoporosis, Men

Food and Drug Administration, Osteoporosis and Men

National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center, Osteoporosis in Men

National Institutes of Health, Word on Health, Men Can Get Osteoporosis Too

Media file 1: The image on the left shows decreased bone density in osteoporosis. The image on the right shows normal bone density.

Media type:  Illustration

Media file 2: Arrow indicates vertebral fractures.

Media type:  Illustration

Media file 3: A. Normal spine, B. Moderately osteoporotic spine, C. Severely osteoporotic spine.

Media type:  Illustration

osteopenia, weak bones, porous bones, bone loss, bone density loss, bone mineral density loss, BMD, bone mineral density tests, dual-energy x-ray absorptiometry, DXA, calcium, hunchback, hump back, broken hip, Fosamax, weight-bearing exercise, osteoporosis in men

Author: Mythili Seetharaman, MD, Consulting Staff, Department of Rheumatology, Albert Einstein Medical Center.

Coauthor(s): Jessica B Johnson, Medical Writer, .com, Inc.

Editors: Kristine M Lohr, MD, Associate Chief, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology, University of Tennessee School of Medicine; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, .com, Inc; Rick Kulkarni, MD, Assistant Professor of Medicine, David Geffen UCLA School of Medicine; Director of Informatics, Department of Emergency Medicine, UCLA/Olive View-UCLA Medical Center.