Osteoporosis in Men
NOT JUST FOR GIRLS
by Felicia Cosman, M.D.
Osteoporosis is more common in women than in men, but it is still
an extremely common condition in men. For example, the lifetime
risk of a hip fracture in men is about 6 percent (six in one hundred
men will have one), whereas the lifetime risk for a woman is about
15 to 17 percent. At the age of fifty, the likelihood of having
osteoporosis by BMD measurement of hip, spine, or wrist is about
35 percent in women and about 19 percent in men. Approximately
one in four Caucasian men will suffer an osteoporosis-related
fracture at some point in his lifetime. This is a greater lifetime
risk than that of developing prostate cancer. Also, men tend to
have greater problems than women after suffering certain fractures,
particularly those of the hip, and are at greater risk for dying
in the year following the hip fracture than are women. The likelihood
that a man will return to the fully independent lifestyle he had
prior to the hip fracture is even lower than it is for a woman.
When men require stays in rehabilitation hospitals after a hip
fracture, they usually stay longer than women.
Many of the risk factors for women are the same for men, such
as family history of osteoporosis, personal history of fracture,
having a small frame or low body weight, taking medications such
as steroids, or having certain underlying endocrine or rheumatologic
diseases. Some of these diseases include AIDS, chronic lung disease
such as emphysema or chronic bronchitis, Type I diabetes (insulin
requiring), hyperparathyroidism, inflammatory bowel disease, chronic
kidney or liver disease, rheumatoid arthritis, malabsorption problems
including gastric or duodenal surgery, and neurologic diseases
such as Parkinson’s disease or multiple sclerosis. Men also
have increased risk if they make too little testosterone—similar
to the phenomenon of menopause in women, when estrogen production
dramatically declines. Heavy alcohol ingestion or alcoholism and
smoking are also important risk factors for osteoporosis in men.
In men with prostate cancer, use of gonadotropin-releasing hormone
analogues such as lupron can increase the risk of bone loss and
osteoporosis. Excessive use of thyroid hormone or lack of monitoring
of thyroid hormone therapy as well as chronic need for blood-thinning
medications, chemotherapy or immunosuppressive drugs for certain
rheumatologic diseases, or organ transplants also increase the
risk of bone loss.
Besides the presence of osteoporosis, the other major determinant
of fracture risk in men is falling (just as it is in women). Falls
can be related to frailty or specific medical problems, including
low body weight or weight loss, poor nutrition including deficient
protein intake, chronic diseases, low physical activity, muscle
weakness or neurologic diseases (Parkinson’s disease is
a common one), problems with cognitive functioning, and the use
of sleeping or anxiety medications or other medicines that can
The prevention of osteoporosis in men is similar to that in women.
Any possible risk factors should be eliminated or reduced. Major
attempts at smoking cessation should be made. Alcohol ingestion
should not be excessive, and alcohol abuse should be specifically
treated. Calcium intake should be maintained at about 1,000 to
1,200 mg per day in younger men and at least 1,200 mg per day
in men fifty and older. Similarly to women, vitamin D intake should
be between 400 and 800 IU per day, depending on age. All men should
engage in regular physical activity, preferably weight bearing
(standing on your feet) and muscle strengthening of the large
muscle groups—back, shoulder, hip, and pelvic muscles.
Those men at high risk should strongly consider a bone density
test. Currently, there are no well-accepted guidelines as to which
men should undergo this test. These are being developed and will
likely come out of a large epidemiologic study called “Mr.
Os” over the next few years. This study will look at both
the frequency of fracture occurrence and its relationship to bone
density as well as the importance of other risk factors, such
as family history. It will provide us with the age at which osteoporosis
risk is high enough that routine testing should be recommended.
This will probably be between age seventy and seventy-five. Obtaining
reimbursement for bone density testing from insurance companies
will probably follow from the guidelines expected in the next
The actual values on bone density tests in men come out higher
than those in women since men on average have a higher BMD than
women. This may in part be due to genetically predetermined gender
difference and in part be related to the differences in body size,
weight, and bone size. The gender difference is probably not there
at birth but develops during puberty, when boys gain substantially
more bone than girls, in part related to gaining more height and
bone length at this stage of life. When you look at smaller men
and compare them to larger women, you see less of a gender difference
in bone density. In fact, bone size alone is a mechanically protective
factor against osteoporosis for men. Larger bones are more resistant
to mechanical stresses than smaller bones, so larger men have
generally lower risk than smaller women.
Nevertheless, on average men have bone densities about 5 to 10
percent higher than those of age-matched women. Currently, the
most accepted way of defining osteoporosis in men is by calculating
T-Scores in much the same way we do for women. Thus, an individual
man’s bone density values are compared to those of young
healthy men, and the difference between the average young man’s
and the patient’s score is calculated as standard deviation
scores just as for women. A T-Score of –2.5 or below in
a man is in the osteoporosis category, just as it would be in
Bone density testing is presently indicated and definitely reimbursable
for the following conditions: men found to have a vertebral compression
fracture or thinned bone on X ray; men who have been treated with
steroid medications such as prednisone for three to six months
or more; men with a diagnosis of hyperparathyroidism; and men
being treated for osteoporosis. I would also advocate bone density
testing in men who have had substantial height loss (one and a
half to two or more inches), more than one adulthood fracture
in the absence of significant trauma, and men with any of the
conditions mentioned above. Check with your insurance company
to find out if it will cover the cost of the test.
Men who do have vertebral fractures on X ray do not always have
osteoporosis, however. It is believed that because men have in
general more active lifestyles than women, some of the deformities
that show up on X ray are actually traumatic and not related to
osteoporosis. While this may be true of some women also, it is
more common in men.
If you have been diagnosed with osteoporosis, you should make
sure you are getting at least 1,200 mg of calcium each day (through
the diet and a supplement if necessary). You should get between
400 and 800 IU of vitamin D per day. Make sure you are engaging
in physical activity, preferably weight bearing and muscle strengthening
through a resistance program. Measures to limit the risk of falling
should be instituted. There are also medical treatment options.
Alendronate and PTH (Forteo) are both approved by the FDA for
the treatment of osteoporosis in men, but risedronate is also
an option. Studies of alendronate and PTH in men are much smaller
than those in women and only efficacy against vertebral fractures
has been shown (as well as increases in BMD).
In short, we have less information at this time about osteoporosis
in men because most of the initial research was performed in women.
Since the disease is far more common in women than men, this approach
made sense, but current research efforts are aimed at making up
for this inequity. If you are or know a man who has osteoporosis
or is worried about it, consult a doctor about whether testing
or treatment is recommended.
The Bare Bones
• Men have higher bone mass than women because of bigger
body and bone size as well as other genetic factors.
• Men do not have accelerated bone loss in midlife, as do
women at menopause, but men do experience ongoing age-related
bone loss just like women.
• Men have a lower osteoporosis-related fracture risk than
women—but it is still substantial. Approximately one in
every four white men will have one of these fractures.
• Men have a worse prognosis after hip fracture than women.
• Risk factors for men are similar to those for women and
include personal fracture history, family history of osteoporosis
or fractures, smoking, alcohol abuse, and many chronic diseases
• Men should follow the preventive measures outlined in
this book, including getting enough calcium and vitamin D, exercising
regularly, and avoiding smoking and excessive alcohol consumption.
• There are two medications approved for the treatment of
osteoporosis in men: alendronate (Fosamax) and PTH
• (Teriparatide or Forteo).
Excerpted from What Your Doctor May Not Tell You
About Osteoporosis by Felicia Cosman, M.D. Copyright © 2003
by Felicia Cosman, M.D. Excerpted by arrangement with Warner Books,
Inc., New York, NY. All rights reserved. $14.95. Available in
local bookstores or click