Osteoporosis in men: prevention, diagnosis and when to see a doctor

Men rarely check their bone density, and osteoporosis in them is often diagnosed only after a fracture. At the same time, most risk factors can be identified in advance, and modern treatment effectively reduces the likelihood of fractures. The editorial team explains how to prevent the disease, which examinations to undergo and when a doctor is needed.

Why osteoporosis in men is underestimated

Osteoporosis is asymptomatic for a long time, and its first manifestation is often a fracture: of a vertebra, the femur, the radius at the wrist. Compression fractures of the vertebrae may manifest only as back pain, a decrease in height or a stoop.

Men, less often than women, receive a referral for densitometry, even after fractures from a minor injury. This creates a situation where the disease is detected at late stages, and the consequences of hip fractures in men are more severe.

In younger men, in particular athletes, osteoporosis almost always has a secondary cause: hormonal disturbances, energy deficiency, drug use, intestinal diseases. Identifying this cause is the key to treatment.

This is why the editorial team advises regarding stress fractures, fractures from a fall from one's own height and a decrease in height as signals for examination, not as coincidence.

Who should have densitometry and when

The 2012 Endocrine Society guidelines recommend measuring bone mineral density in all men from 70 years, and at 50-69 years in the presence of risk factors. Such factors include low body weight, previous fractures, smoking, alcohol abuse, hypogonadism and the use of glucocorticoids.

The main method is dual-energy X-ray absorptiometry (DXA) of the lumbar spine and hip. For men from 50 years the diagnosis of osteoporosis is established at a T-score of −2.5 and below. For younger men the Z-score is used, comparing with peers.

The FRAX tool assesses the 10-year probability of osteoporotic fractures taking into account age, body weight, risk factors and, if available, femoral neck density. It helps the doctor decide whether treatment is needed.

For athletes with suspected REDs, stress fractures or prolonged hormonal imbalance, densitometry may be prescribed by a sports doctor regardless of age, guided by the clinical situation.

Tests to look for secondary causes

After low bone density is found, the doctor prescribes an examination to look for the cause. Basically this is a complete blood count, calcium, phosphorus, creatinine and GFR, liver function tests, alkaline phosphatase, 25(OH)D, as well as total testosterone.

As indicated, parathyroid hormone, TSH, tests for celiac disease, protein electrophoresis (to rule out myeloma), daily urinary calcium excretion and an assessment of cortisol are added. The choice depends on age, history and clinical picture.

• complete blood count, calcium, phosphorus, alkaline phosphatase;
• creatinine and GFR, liver function tests;
• 25(OH)D;
• testosterone (as indicated - LH, estradiol);
• TSH, parathyroid hormone, tests for celiac disease - at the doctor's decision.

For athletes the details of the history are important: use of anabolic steroids, aromatase inhibitors, thyroid hormones, glucocorticoids, long periods of calorie deficit. Frankness with the doctor here directly affects the correctness of the diagnosis.

Markers of bone metabolism (for example CTX and P1NP) are sometimes used to assess metabolic activity and monitor treatment, but they are not the main ones for making a diagnosis.

Prevention: load and nutrition

Impact and strength loads are the best non-drug stimulus for bone. Combining strength training with jumping exercises helps maintain bone density, and balance exercises reduce the risk of falls in older age.

Calcium should mainly be obtained from food: dairy products, fortified plant-based drinks, hard cheeses, fish with bones, green leafy vegetables. Supplements are prescribed if the diet is insufficient. Vitamin D is maintained at a level sufficient for bone health, if necessary with supplements.

Sufficient protein and overall energy are critical: protein is the structural basis of the bone matrix, and an energy deficit disrupts the hormones that regulate bone. For athletes with prolonged periods of 'cutting' this is perhaps the most important point.

Giving up smoking, limiting alcohol and avoiding the non-medical use of hormonal drugs are other important measures. Any hormonal treatment must be justified by medical indications.

Treatment and when to see a doctor

Drug treatment of osteoporosis in men includes bisphosphonates, denosumab and anabolic drugs such as teriparatide, which are prescribed by a doctor based on examination and an assessment of fracture risk. In parallel, secondary causes are eliminated.

Testosterone therapy is indicated only for men with confirmed hypogonadism. In a study by Snyder and co-authors (2017), testosterone treatment in older men with low testosterone increased volumetric density and estimated bone strength, but this is not a substitute for specific treatment of osteoporosis.

1. a fracture from a fall from one's own height;
2. stress fractures or repeated bone injuries;
3. a decrease in height, sudden back pain;
4. long-term use of glucocorticoids or hormonal drugs;
5. symptoms of low testosterone.

You should see a doctor after any fracture from a minor injury, in case of stress fractures, a decrease in height, sudden back pain, and also in the presence of risk factors - long-term use of glucocorticoids, hypogonadism, intestinal diseases.

For athletes who have used or are using hormonal drugs, it is important to inform the doctor about this: hypogonadism after steroid withdrawal and suppression of estradiol can be a direct cause of bone mass loss, and they must be taken into account in treatment.

Editorial conclusions

Osteoporosis in men is underestimated: the disease is often detected only after a fracture, although risk factors can be identified in advance. Densitometry is indicated for all men from 70 years and for younger ones in the presence of risks.

For younger men, especially athletes, it is important to look for secondary causes - from energy deficiency to the consequences of using hormonal drugs.

Prevention is based on impact and strength training, sufficient energy, protein, calcium and vitamin D. Treatment is prescribed by a doctor, and it effectively reduces the risk of fractures.

We also advise getting acquainted with our articles on the causes of osteoporosis in male athletes, on vitamin D deficiency and on tests to monitor hormonal balance.

References

1. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802–1822.
2. Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. 2019;393(10169):364–376.
3. Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19(4):385–397.
4. Snyder PJ, Kopperdahl DL, Stephens-Shields AJ, et al. Effect of testosterone treatment on volumetric bone density and strength in older men with low testosterone: a controlled clinical trial. JAMA Intern Med. 2017;177(4):471–479.
5. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073–1097.
6. Tenforde AS, Barrack MT, Nattiv A, Fredericson M. Parallels with the female athlete triad in male athletes. Sports Med. 2016;46(2):171–182.