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 cause sedation.

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 several years.

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 a woman.
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 and medications.
• 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 here.

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