Osteoporosis in Men--an Overlooked Patient Population

by David Cox, RN BSN

An Old Woman’s Disease? Not so Fast!

Osteoporosis is a chronic disease that weakens your bones and makes them much more likely to fracture, often with devastating consequences if they do. The standard assumption about osteoporosis is that it’s an old woman’s disease. But osteoporosis is surprisingly common in men. The incidence of osteoporosis-related male fractures (especially hip) is rising with aging populations. Osteoporosis in men is serious, underestimated and undertreated.

It’s still true that more women than men have osteoporosis, which shows up at an earlier average age than it does for men due to the effects of menopause. But increased age increases the incidence of osteoporosis in both men and women. An estimated 1 in 5 men over age 50 will suffer an osteoporosis-related fracture in their lifetime. Hip fractures are a major complication of osteoporosis. Patients often suffer a substantial decline in quality of life following a hip fracture. In addition, hip fractures in men are associated with higher 1-year mortality than in women, a startling 33 percent according to one study.

Why is Osteoporosis Missed in Men?

A recent article in the journal Nature Reviews--Rheumatology states that “osteoporosis in men is an area of relative neglect”, and poses an important question: Why is this serious health problem so often missed? Observational data and expert commentary argue that consistent, inclusive screening would improve detection. But the U.S. Preventive Services Task Force (USPSTF), considered by many to be the gold standard in disease treatment and healthcare screening guidance, recently concluded that the evidence is insufficient to recommend routine screening in men, thus cementing gaps in practice.

Which men should be checked for osteoporosis? Guidelines and reviews emphasize looking for contributing conditions rather than assuming primary aging alone. The long list of contributing factors includes diabetes, chronic lung or liver disease, stroke, alcohol dependence, smoking, family history of osteoporosis, and long-term use of certain drugs such as steroids and anti-seizure medications.

How is Osteoporosis Diagnosed?

People who are considered at risk for osteoporosis, or those who have already had a bone fracture possibly related to osteoporosis, should have the standard test, a Dual-energy X-ray absorptiometry (DXA) scan, which uses two types of low-level radiation to translate your bone density into pictures and graphs on a computer. It is used to diagnose osteoporosis or osteopenia (bone loss that is measurable by DXA, but not as far along as osteoporosis). Also, the patient’s risk for fracture is calculated from this data.

Preventing and Treating Osteoporosis

The most important part of treating osteoporosis is preventing broken bones. What kind of treatment options are available, for at-risk men and women with osteoporosis, osteopenia, or considered at risk for osteoporosis? The first consideration needs to be given to any lifestyle modifications that can help stop bone loss. Smoking cessation, stopping problem drinking, and keeping blood sugar under good control may be indicated. Weight-bearing exercises, most commonly walking, are emphasized. Calcium and vitamin D supplements are highly recommended for all of these groups. According to the well-known clinical decision support website UpToDate, “the Recommended Daily Allowance for total calcium intake (from diet and supplements) in men is 1000 mg per day for men aged 19 to 70 years and 1200 mg per day for men aged 71 years and older. The Recommended Daily Allowance for vitamin D is 600 international units (15 mcg) per day for men aged 19 to 70 years and 800 international units (20 mcg) per day for men aged 71 years and older.”

In addition, medications called bisphosphonates are considered first-line therapy for men with osteoporosis and men with osteopenia who have sustained a bone fracture. Two of these medications, alendronate and risendronate, are in pill form and are very affordable. People who take bisphosphonates, or other medications that also may help, will need to have DXA scans periodically in order to see if their condition is improving or at least stabilized.

How Will Men React to All of This?

How might men respond to being informed they are at risk for osteoporosis, “the disease of old women”? Although men in general are under-treated with the medications noted above, they appear to be well-motivated to follow medical advice once it’s given. In the Evidence-Based Guideline for the management of osteoporosis

in men article referenced above, a diverse working group made the recommendations highlighted here. They noted that “in the development of the recommendations presented herein, the working group included patient input, which highlighted patients’ expectations of a clinical approach to osteoporosis. With regard to the treatment of osteoporosis in men, it was emphasized by the patient representation that anti-osteoporosis therapy was desired as quickly as possible as patients want to ‘stop the clock of bone metabolism’ in order to ‘have no further fractures’.” Also, a study conducted by the Veterans Administration that proactively identified men at risk for osteoporosis and prescribed diagnostic testing and treatment as needed found a high rate of compliance with the medical advice given them.

In Summary

Although men are less likely to have osteoporosis than women and, if they do, it typically shows up at a later age, the effects of osteoporosis-related bone fractures in men all too often are catastrophic. Men benefit from the same preventive measures and medications as do women, but remain less likely to be evaluated for this potentially lethal disease, and less likely to receive treatment after an osteoporosis-related fracture.

Call to Action

Until such time as clear recommendations for screening and treatment are consistently made, it behooves primary care clinicians to add osteoporosis risk to the list of things to consider for their male patients. And it’s important as well for all men at risk for having osteoporosis to seriously consider lifestyle modifications, adding calcium and vitamin D to their list of supplements, and to proactively push for diagnosis and treatment as needed.

Assessed and Endorsed by the MedReport Medical Review Board