If you are 50 or older, you have a 25% chance of breaking a bone due to osteoporosis. According to the Bone Health & Osteoporosis Foundation, approximately two million American men have osteoporosis, and about 12 million more are at risk.
Risk factors for developing osteoporosis include:
- Family history.
- Taking steroid medications.
- Physical inactivity
- Previous fragility fracture.
- Vitamin D deficiency.
- Low calcium intake.
- Smoking.
- Alcohol consumption of > 2 drinks per day.
- Chronic diseases such as diabetes.
- Prostate cancer.
- Autoimmune disorders such as rheumatoid arthritis.
- Low testosterone.
- Low estrogen.
- Body weight < 70 kg.
- Age 70 or older.
Medication-related risk factors for male osteoporosis include:
- Oral glucocorticoids.
- Androgen-deprivation therapy.
- Antiepileptics.
- Chemotherapeutic agents.
- Nicotine.
- Opioids.
- Proton-pump inhibitors.
- Thiazolidinedione.
Meaning “porous bone,” osteoporosis is a common disease that causes bones to become more porous and susceptible to fracture. Osteoporosis develops when bone mineral density (BMD) and bone mass decrease or when the quality or structure of bone changes. Loss in bone density or mass causes the bone to have an abnormal tissue structure.
Hypogonadism (testosterone deficiency) is a known risk factor for decreased BMD and increased risk of bone fractures in men. Hypogonadism involves clinical symptoms such as sexual dysfunction, depression, reduced muscle mass and strength, visceral obesity, and decreased BMD.
The relationship between hypogonadism and decreased BMD, particularly in young adult men with severe hypogonadism, has been well established. Several recent studies support the benefit of TRT on BMD in hypogonadal men with osteoporosis.
In a study of 211 participants, testosterone treatment for one year in men with low testosterone was associated with significantly greater volumetric bone mineral density and bone strength than in men not treated with testosterone.
Osteoporosis in men is a growing problem in the US and worldwide. Reasons for this growth include multiple factors, such as the aging of the population, more sedentary lifestyles, and decreased testosterone in men. Additionally, osteoporosis in men is commonly overlooked due to cultural factors that associate osteoporosis with post-menopausal women. As such, diagnosis and treatment in men are essential, as men experience higher mortality and morbidity following bone fractures.
Bone Mass Changes with Age
Bone is made of living tissue: older bone is broken down while new bone forms in its place in a process called remodeling. Virtually all adult bone is remodeled every ten years. During your 20s, bone mass peaks and begins to decrease with age.
Bone mass is lost when more bone is broken down than is formed, an imbalance that happens with aging or due to medications or disease.
Men with testosterone deficiency have an accelerated bone turnover rate and an increased fracture risk. Fractures due to osteoporosis most commonly occur in the hip, wrist, and spine. If osteoporosis affects the bones of the spine, it frequently results in a hunched-over appearance. Moreover, osteoporosis may result in loss of mobility, isolation, and depression.
Diagnosis of Osteoporosis
Central dual-energy x-ray absorptiometry (DXA or DEXA) is the most common test to measure bone mineral density and diagnose osteoporosis. DXA emits a small amount of radiation (x-ray) to measure the amount of calcium and other minerals in a specific area of bone. For men younger than 50, a diagnosis should not be made based solely on BMD.
While screening for hypogonadism in the general population is not recommended, men aged 50 and older diagnosed with hypogonadism should undergo BMD testing.
Screening for osteoporosis should include the following:
- All men aged 70 and older.
- Men aged 50 to 69 if risk factors are present.
- Assessment for adequate calcium and vitamin D intake.
- A scan of the spine and hip for men at risk for osteoporosis.
- Assessment of risk factors for falls.
- Laboratory evaluation, including serum calcium, phosphate, liver function, and total testosterone.
Causes of Osteoporosis in Men
There are many causes of osteoporosis in men, including:
- Chronic diseases such as diabetes or rheumatoid arthritis.
- Regular use of medications such as glucocorticoids.
- Parkinson’s disease and other neurological conditions.
- Lifestyle habits such as smoking or excess alcohol.
- Being age 70 or older.
- Low levels of the sex hormones testosterone and estrogen.
- Weak muscles.
Osteoporosis treatments include:
- Improved nutrition.
- Calcium and vitamin D supplementation.
- Adoption of healthy lifestyle habits.
- Anti-osteoporotic drugs such as bisphosphonates, denosumab, and teriparatide.
- Testosterone replacement therapy (TRT) in hypogonadal men.
While TRT is not currently recommended solely to enhance BMD, it should be considered a treatment option when there are additional symptoms of hypogonadism. In hypogonadal men, testosterone administration inhibits bone resorption, maintains bone mass, and may prevent osteoporosis.
Guidelines
The Endocrine Society Male Osteoporosis Guideline recommends osteoporosis-specific medications and testosterone replacement therapy for older men with symptomatic hypogonadism at risk for bone fracture.
- Men with low testosterone levels risk losing bone density more than men with normal testosterone levels.
- There is no way to cure osteoporosis and its symptoms, which can impact mobility, comfort level, mood, and overall quality of life.
- Prevention of decreased BMD and osteoporosis is critical and can help to slow or stop the loss of bone density and reduce the risk of bone fractures.
- Diet changes, exercise, and medications, including testosterone replacement therapy, may prevent osteoporosis and improve bone health.
- Testosterone replacement therapy should be considered a treatment option to improve low testosterone and BMD symptoms in symptomatic hypogonadal men with osteopenia.
