What is Osteoporosis in Males?
Osteoporosis, often a silent condition, is marked by weakened bones with lower density. It makes bones fragile and more likely to fracture. This condition is often associated with women after menopause because a decrease in estrogen, a female hormone, can lead to a decrease in bone mass. But in recent years, it’s been recognized that men also face a significant risk of osteoporosis. This increased awareness is due to a rise in fractures linked to frail bone condition, which is associated with longer lifespans, less active lifestyles, and more prevalent risk factors globally.
Groups like the World Health Organization (WHO) and the International Society for Clinical Densitometry (ISCD) have set diagnostic guidelines for low bone mass (also known as osteopenia) and osteoporosis. These are based on bone mineral density (BMD) measurements taken from a DEXA (dual-energy x-ray absorptiometry) scan. For these measurements, men are compared to a reference population, using the same thresholds as females. However, these standards are not as well established in men as they are in women after menopause.
While osteoporosis is more common in women, fractures caused by this condition can be more dangerous in men, often leading to a higher risk of death. This remains true for fractures in different parts of the body. Despite the high risk and serious consequences in men, most clinical trials for osteoporosis treatment focus on women after menopause, presenting a challenge when it comes to managing osteoporosis in men.
What Causes Osteoporosis in Males?
Even though men have hormonal and physical advantages, about a third of them might still suffer from one or more bone fractures caused by osteoporosis in their lifetime. Osteoporosis in men falls into two categories: primary and secondary. Half of the cases in men are due to secondary factors. However, primary causes are often overlooked, especially in patients without risk factors.
Primary osteoporosis is split into two kinds. The first is involutional osteoporosis, which affects men over 70 and is not tied to any other risk. The second is idiopathic osteoporosis, which affects men under 70 and doesn’t have a clear risk factor.
Idiopathic osteoporosis occurs in men younger than 70 without an obvious reason. However, the cause can be multi-layered, including issues like not reaching peak bone mass, hidden genetic issues, being physically inactive, or other unknown health problems. These patients might also have a slight defect in aromatization, a process that helps to convert male hormones to female hormones.
Secondary osteoporosis can be attributed to a variety of health conditions and behaviors such as low levels of male hormones (including men receiving treatment for prostate cancer), excessive alcohol consumption, too much corticosteroid hormone (naturally occurring or from medication), malabsorption issues related to inflammatory bowel disease, primary biliary cirrhosis (a liver disease), post-weight loss surgery, chronic kidney disease, overactive parathyroid glands, overactive thyroid, systemic illnesses like various cancers and chronic obstructive pulmonary disease, HIV, inflammatory rheumatic diseases, anticonvulsant drugs, chemotherapy, and diabetes (type 1 and type 2).
Increased bone fragility in diabetes is caused by multiple factors that weaken bones, such as damage to small vessels, oxidative stress, products resulting from glucose reaction that damage collagen type I, increased inflammatory factors and adipokines. Some diabetes medications like thiazolidinediones and canagliflozin and an increased risk of falls due to low sugar levels may also contribute to this.
Apart from these conditions, certain unchangeable factors can also lead to secondary osteoporosis in men like age (more than 70), white ethnicity, and late puberty. However, some risk factors are controllable like excessive alcohol consumption, smoking, low body mass index (BMI), and a sedentary lifestyle.
Risk Factors and Frequency for Osteoporosis in Males
In 2010, it was estimated that over 10 million people in the U.S. had osteoporosis, with more women diagnosed than men. On top of that, around 43 million people were dealing with osteopenia. While women are more likely to be diagnosed with osteoporosis, a good chunk of fractures related to osteoporosis happen in men. Around 30-40% to be exact.
Men also face higher risks of death after a fracture. An observational study in Australia supported this fact. It showed different death ratios for major fractures in women and men. These include fractures of the upper leg bone, spine, and other major fractures. Basically, me are more likely to die from these types of fractures compared to women.
- Fractures in men typically have two peak periods: 15-45 years and after the age of 70.
- The first peak is usually due to accidents causing breaks, while the second peak is mostly due to osteoporosis or osteopenia.
- Men generally experience hip fractures 10 years later than women on average.
- These facts are particularly important as both men and women are now living longer.
- Indeed, a 50-year old man has a 13-25% chance of experiencing osteoporotic fractures in his lifetime.
- The likelihood can, however, be influenced by various factors like race, ethnicity, and geographic location.
- It’s worth noting that males in Northern Europe and North America have a higher prevalence compared to black, Asians, and Hispanics.
Signs and Symptoms of Osteoporosis in Males
When doctors see men with osteoporosis, they ask important questions about their diet (particularly calcium and vitamin D intake), exposure to the sun, history of breaks or fractures, any changes in height, and how those fractures occurred. Doctors also conduct a physical examination, which usually doesn’t show anything unusual unless the osteoporosis is advanced. At this stage, patients may have a curved spine (kyphosis) and noticeable height loss from previous fractures in the spine. A general physical exam should also include checking how well the patient can walk, balance, and move around, as well as their overall frailness and muscle mass.
In order to find out whether the osteoporosis could be caused or made worse by something else, doctors systematically look for specific pieces of information and physical signs that might suggest the following medical conditions:
- Use of certain medicines, including epilepsy drugs, chemotherapy, glucocorticoids, some drugs for organ transplants, hormone therapies for cancer, thyroid hormone replacement (particularly after thyroid cancer), HIV drugs, and long-term use of the blood thinner heparin. Long term use of opioid painkillers can also indirectly cause osteoporosis by reducing hormone levels.
- Endocrine problems, such as overactive thyroid, too much cortisol, overactive parathyroid glands, low sex hormone levels, diabetes, vitamin D deficiency, delayed puberty, problems with testosterone, and growth hormone deficiency.
- Malabsorption problems, like celiac disease, having had weight-loss surgery, and inflammatory bowel disease
- Blood disorders, such as multiple myeloma, systemic mastocytosis, and chronic blood diseases that break down red blood cells
- Connective tissue diseases, like osteogenesis imperfecta, Marfan Syndrome, Ehlers-Danlos syndrome, and hereditary phosphorus and vitamin D metabolism disorders
- Other causes, like chronic liver disease, chronic kidney disease, excess urinary calcium excretion, anorexia nervosa, chronic obstructive pulmonary disease, rheumatoid arthritis, cancer, and having had an organ transplant.
Lastly, it is essential for the doctor to learn about the patient’s lifestyle, including smoking, excessive drinking, and lack of physical activity.
Testing for Osteoporosis in Males
The Endocrine Society in 2012 released guidelines that are still updated for checking men for osteoporosis using a DEXA scan. It advises checking men who are 70 years or older as well as men aged 50 to 69 years if they show signs that they might get osteoporosis. A DEXA scan looks at the spine and hip in men who are at risk for osteoporosis. It can also look at the forearm if the doctors can’t interpret the spine or hip results well, or for men with a condition where the body produces too much parathyroid hormone or men receiving androgen deprivation therapy. The International Society for Clinical Densitometry (ISCD), the National Osteoporosis Foundation (NOF), and the United States Preventative Services Task Force all agree with these recommendations.
DEXA scans give a score that helps doctors diagnose osteoporosis. In anyone who is 50 years or older, a T-score (the number that shows you how much your bone density is higher or lower than the bone density of a healthy 30-year-old adult) that is less than or equal to -2.5 means you may have osteoporosis. A T-score between -1.0 and -2.5 may mean you have osteopenia, which is a condition where you are losing bone mass and may lead to osteoporosis.
In anyone younger than 50 years old, doctors use a Z-score instead of a T-score. A Z-score that is less than or equal to -2.5 may mean you have osteoporosis. A Z-score between -1.0 and -2.5 may mean you have osteopenia.
Younger patients should not be diagnosed with osteoporosis based on bone density alone. Also, people with osteopenia without a history of osteoporotic fractures should use the FRAX calculator to figure out if they need treatment. If you are 50 years or older with osteopenia, and the FRAX calculator shows you have a 10-year risk of hip fracture that is 3% or higher or a 10-year risk of major fracture that is 20% or higher, then you should consider treatment.
Doctors may also use imaging of the thoracic and lumbar spine using Vertebral Fracture Assessment (VFA) for people with osteopenia or osteoporosis. VFA uses less radiation than regular x-rays and can be done at the same time as the DEXA scan. If VFA isn’t available, they use lateral spine radiographs. Patients should get lateral spine radiographs if they are 80 years or older with a T-score of less than or equal to -1.0, or if they are aged 70 to 79 with a T-score of less than or equal to -1.5, or if they are 50 years or older with specific risk factors like a history of fracture, significant height loss, or current long-term treatment with certain drugs.
Another part of diagnosing osteoporosis in men would be doing various lab tests. Doctors might check their levels of calcium, phosphate, creatinine, alkaline phosphatase, liver function, 25(OH)vitamin D, testosterone, as well as complete blood count, and 24-hour urine calcium. If the doctor suspects a specific cause of the osteoporosis based on the patient’s medical history and physical exam, they might do more tests.
Biochemical markers of bone turnover can also help to assess risk and check how well treatment is working. However, their role in managing individual patient care is not very clear so far.
Treatment Options for Osteoporosis in Males
If you’re over 70 with a T-score of -2.5 or lower on a bone density test at your hip or spine, you should consider treatment for osteoporosis, a condition that weakens your bones. Similarly, if you’re at a 3 percent or higher risk of breaking your hip in the next 10 years, or a 20 percent or higher risk of any fracture due to osteoporosis (calculated by your doctor depending on the country), treatment may be necessary. Also, if you’ve already had a fracture from osteoporosis, you may need treatment to prevent future fractures.
When managing osteoporosis, your doctor will first suggest lifestyle changes, similar to those recommended for women to maintain bone strength. A well-balanced diet with enough protein and dairy is essential, along with regular physical activity. Be sure to limit your alcohol and avoid smoking. Doctors recommend at least 30-40 minutes of weight-bearing exercise 3-4 times a week.
Your doctor will also consider fall precautions to reduce your chance of breaking bones, such as making your home safer, physical therapy, addressing vitamin D levels, and reducing medication that makes you feel unsteady. They might also recommend correcting your vision if necessary.
Supplements such as calcium and vitamin D can also help reduce the risk of fractures. However, calcium supplements might increase the risk of heart disease. For this reason, the National Osteoporosis Foundation (NOF) recommends getting enough calcium from your diet (around 1000 mg/day for men aged 50–70 and 1200 mg/day for men 71 and older) and only adding supplements if your diet lacks calcium. For vitamin D, they recommend a daily intake of 800–1000 IU to keep levels at 30 ng/ml or above. Higher doses may be needed if you’re deficient in vitamin D.
Approved drugs such as bisphosphonates, which help prevent bone loss, and denosumab, an antibody that inhibits bone destruction, can also be used in treatment. These drugs have been shown to reduce fractures and increase bone density. The FDA has approved them for the treatment of osteoporosis in men and post-menopausal women. However, they come with potential side effects like gastrointestinal issues, hypocalcemia (low calcium in the blood), and rare cases of bone death in the jaw, among others.
Other types of drugs, such as teriparatide (an artificial form of a hormone that regulates calcium in the body), can stimulate bone growth rather than just preventing bone loss. This drug is typically recommended for individuals who have a high fracture risk. As with all medications, doctors will weigh the benefits against possible side effects, such as leg cramps, nausea, and dizziness.
Another treatment option includes hormone therapy, which is mainly used for men with low testosterone levels. This can improve bone density and reduce the risk of fractures. If you can’t use testosterone therapy or have high fracture risk, your doctor might recommend adding non-hormonal treatments as well.
Your doctor might suggest using a combination of these therapies over time for long-term management of osteoporosis. The goal is to provide effective protection against fractures without increasing the risk of side effects.
Remember, no treatment is indefinite, and your doctor will monitor your progress and adjust your treatment as necessary. Some medications can have lingering effects after you stop taking them, so your doctor might suggest a “drug holiday” after a certain period of treatment to minimize any potential risks.
What else can Osteoporosis in Males be?
When a patient experiences a spontaneous fracture or injury after a minor impact, the doctor should consider several different potential diagnoses:
- Vitamin D deficiency or insufficiency: If the patient’s vitamin D levels are low, they could be at risk of developing osteomalacia, which can increase the likelihood of hip fractures. This condition can be reversed with cholecalciferol treatment.
- Solid tumors with bone metastasis: These types of tumors are often linked to fractures. The types of solid tumors most commonly associated with bone metastasis are those of the lung, breast, and prostate.
- Hematologic malignancies: Blood-related cancers often cause bone fractures, with multiple myeloma being the most common primary malignant bone tumor, although it is considered a bone marrow tumor.
- Primary bone tumors: Although less common than bone metastasis, these tumors should be considered as potential causes of fractures. Osteosarcoma is the most common type of malignant primary bone tumor, but it usually affects younger patients.
- Avascular necrosis of the femur: If a patient has subtle pain and a limited range of motion in the hip and these symptoms are not related to an injury, this condition should be considered as a potential cause, especially if the patient has risk factors like glucocorticoid use or sickle cell disease.
What to expect with Osteoporosis in Males
Osteoporosis, a condition that weakens bones and makes them more prone to fractures, is more common in women than in men. However, studies reveal that men tend to face more severe health consequences following fractures caused by osteoporosis.
For example, a large survey in Canada showed that about 10% of elderly men passed away during their hospital stay after a hip fracture. Moreover, over a third (37.5%) of those who were discharged from the hospital died within a year. Furthermore, after a hip fracture, men tend to become more reliant on others for help compared to women.
Possible Complications When Diagnosed with Osteoporosis in Males
Men experiencing fractures can face complications related to long-term immobility, such as venous thromboembolism. Venous thromboembolism is a blood clot that starts in a vein, usually in the lower leg, thigh, or pelvis. Also, if the fracture is severe, there’s a seldom risk of air embolism. This condition occurs when air bubbles enter a vein or artery and block it.
Patients who suffer from vertebral compression fractures, a spinal condition that happens when one or more bones in the spine collapse, are at a heightened risk of cord compression if the damaged vertebra is not supported or stabilized.
Common Complications:
- Complications related to long-term immobility
- Venous thromboembolism
- Rare risk of air embolism in severe fractures
- Risk of cord compression in vertebral compression fractures
Preventing Osteoporosis in Males
It’s crucial to inform and check on patients about how they can prevent fractures. Ways to decrease the chances of falls include wearing suitable footwear, removing things that could cause trips or slips in the home, brightening the area where they live, and if needed, using aids for movement such as walking sticks.
Additionally, patients should be told about the importance of getting calcium from their regular meals. If they can’t get the needed amount from food alone, only then should they consider supplementing with calcium tablets. A balanced diet is crucial for maintaining healthy bones and preventing fractures.