What is Osteoporosis?

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. While often thought of as a "woman's disease," osteoporosis in men is more common than many realize and often underdiagnosed.

How Common is it in Men?

• 1 in 4 men over age 50 will have an osteoporotic fracture in their lifetime
• About 2 million American men have osteoporosis
• Men have HIGHER mortality rates after hip fractures than women (30-40% die within 1 year)
• Often diagnosed later than in women because men aren't routinely screened

Causes of Osteoporosis in Men:

Primary Osteoporosis:

• Age-related bone loss
• Idiopathic (no identifiable cause)

Secondary Osteoporosis (60% of cases in men):

• Hypogonadism (Most Common): Low testosterone—from aging, pituitary disorders, medications, or testicular damage
• Glucocorticoid Use: Prednisone, dexamethasone (most common medication cause)
• Alcohol Abuse: Excessive intake impairs bone formation
• Smoking
• Gastrointestinal Diseases: Celiac disease, IBD, malabsorption
• Chronic Kidney Disease
• Hyperthyroidism or Excess Thyroid Hormone
• Hyperparathyroidism
• Multiple Myeloma, Lymphoma
• Rheumatoid Arthritis, Chronic Liver Disease
• Medications: Anticonvulsants, proton pump inhibitors (long-term), chemotherapy
• Androgen Deprivation Therapy (ADT) for Prostate Cancer

Risk Factors:

• Age >70
• Low body weight (BMI <20)< /li>
• Previous fracture after age 50
• Family history of osteoporosis or hip fracture
• Sedentary lifestyle
• Low calcium and Vitamin D intake
• Excessive alcohol or caffeine

Diagnosis:

DEXA Scan (Dual-Energy X-ray Absorptiometry):

• Measures bone mineral density (BMD) at hip and spine
• T-score ≤ -2.5: Osteoporosis
• T-score -1.0 to -2.5: Osteopenia (low bone mass)
• T-score ≥ -1.0: Normal

Who should be screened?

• All men age 70 and older
• Men age 50-69 with risk factors (fracture, low testosterone, steroid use, etc.)
• Any man with a fragility fracture

Labs (to identify secondary causes):

• Testosterone (total and free), LH, FSH
• 25-OH Vitamin D
• Calcium, phosphorus, alkaline phosphatase
• TSH, parathyroid hormone (PTH)
• Complete blood count, liver function, kidney function
• Celiac screen (tissue transglutaminase antibody)
• Bone turnover markers (CTX, P1NP)—optional

Treatment:

1. Lifestyle Modifications:

• Weight-bearing exercise: Walking, jogging, resistance training
• Quit smoking
• Limit alcohol (≤2 drinks/day)
• Fall prevention: Home safety, balance exercises, vision check

2. Calcium and Vitamin D:

• Calcium: 1200 mg/day (diet + supplement)
• Vitamin D: 800-2000 IU/day; maintain 25-OH Vitamin D >30 ng/mL

3. Treat Underlying Causes:

• Testosterone replacement (if hypogonadal)
• Stop or minimize steroids (if possible)
• Treat hyperthyroidism, hyperparathyroidism
• Address alcohol abuse

4. Medications for Osteoporosis:

Bisphosphonates (First-Line):

• Alendronate (Fosamax®): 70 mg weekly (oral)
• Risedronate (Actonel®): 35 mg weekly (oral)
• Zoledronic Acid (Reclast®): 5 mg IV once yearly
• Reduce fracture risk by 40-70%

Denosumab (Prolia®):

• Subcutaneous injection every 6 months
• Very effective; alternative to bisphosphonates

Teriparatide (Forteo®) or Abaloparatide (Tymlos®):

• Daily subcutaneous injection (parathyroid hormone analogs)
• Anabolic agents—BUILD new bone
• Reserved for severe osteoporosis or multiple fractures
• Used for 1-2 years, then transition to anti-resorptive

Romosozumab (Evenity®):

• Monthly subcutaneous injection (sclerostin inhibitor)
• Both builds bone AND reduces breakdown
• Used for 12 months in very high-risk patients

When to Start Treatment:

• T-score ≤ -2.5 (osteoporosis)
• History of hip or vertebral fracture
• T-score -1.0 to -2.5 (osteopenia) + high FRAX score (10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%)
• Long-term glucocorticoid use (prednisone ≥5 mg/day for ≥3 months)

Monitoring:

• DEXA scan every 1-2 years while on treatment
• Reassess Vitamin D, calcium levels annually
• Monitor for side effects