Osteoporosis is commonly thought of, as an old woman’s disease, it is not seen as a disease that affects men. As a result, men are not encouraged to go for screening, even if they have symptoms and/or risk factors for bone loss. One in five men will develop an osteoporotic fracture during their lifetime. Men are more likely than women to die within a year after fracturing a hip and also to require care in a long-term facility. More men die from Osteoporosis than prostate cancer, this is why you need to screen your male patients.
Up to 20 per cent of symptomatic vertebral fractures and 30 per cent of hip fractures occur in men. All low trauma fractures should be considered osteoporosis, unless DXA of spine and hips are negative. Androgen deficiency during growth and ageing is pivotal to bone fragility. There is an increased morbidity and mortality after all major osteoporotic fractures, which is higher in men than women.
Hypogonadism occurs in 20-30 per cent of older men, and contributes to bone loss, resulting in reduced periosteal and endosteal apposition, reduced bone, with reduced cortical and trabecular thickness, predisposing to fractures.
Men, like women with symptomatic vertebral fractures, commonly complain of back pain, loss of height and kyphosis, but men have significantly less energy, poorer sleep, more emotional problems and impaired mobility than age-matched control subjects. Osteoporosis is a complication of many medical and surgical specialties, either the disease itself or medications used to treat these conditions, as well as lifestyle factors. Many fractures are preventable when patients are screened for risk factors.
Risk factors for bone loss for Men
The commonest cause of osteoporosis in men is lack of the male hormone testosterone, causing hypogonadism. This may be the result of a variety of causes, which include low testosterone levels due to abnormality of testes e.g. undescended testes, inflammation of testes due to mumps or tuberculosis. Surgical removal for trauma or testicular tumours, treatment by chemotherapy, radiation or androgen deprivation therapy for prostate cancer.
Abnormal Chromosomal Syndromes, Klinefelter’s Syndrome: XXY
Is the most common form of male hypogonadism and 50 per cent of cases are not diagnosed. It is thought to be due partly because of the great variation in the clinical symptoms. Small testes, <10cc, lack of sperm production, little or no body hair, enlarged breasts and infertility. Blood levels of testosterone are low, but the levels of Serum LH, FSH and Serum Oestrogen are high. This leads to an inadequate bone development, low BMD in men, which varies from person to person. Excessive stress either physical or psychological, is associated with low levels of testosterone, high levels of cortisol and low bone density.
Lifestyle: low caloric intake, inadequate calcium and vitamin D, Alcohol abuse i.e. more than 21 units of alcohol a week, excessive caffeine intake and smoking. Males with a family history of osteoporosis or a relative with a history of a low trauma hip or vertebral fractures should be referred for a DXA scan.
Previous fragility fracture, high parathyroid and high cortisol levels due to excessive stress, either psychological (loss of job, separation or divorce) or physical due to excessive exercise and inadequate calories. Physical inactivity, high fibre, endocrine disorders, diabetics, gastrointestinal disorders: Coeliac and undiagnosed gluten and wheat sensitivity. Collagen disorders and drug induced osteoporosis: Heparin, Warfarin, Corticosteroids, Proton pump inhibitors, Diuretics, Prolactin raising psychiatric meds, Anticonvulsants, some Antidepressants.
Prevention of further fractures
If there is a history of falls (which you need to ask, as most will not volunteer this information due to embarrassment), attempts should be made to identify and modify underlying intrinsic and extrinsic causes, in the hope that these may be modified and the risk of further falls and fractures decreased. Most common causes of falls: Low vitamin D levels, polypharmacy, neurological disorders, tranquilisers, TIA’s, vertigo, alcoholism, blindness and sarcopenia.
All treatments should be prescribed on an individual basis. Any underlying secondary causes of osteoporosis should be treated. If there is a marked reduction in the level of male hormone in a young patient, then treatment with replacement male hormone i.e. Testosterone may be appropriate. Bisphosphonates, Prolia and Forsteo are all options for men. However, those with gastrointestinal disorders usually have difficulty taking Bisphosphonates.
NOTE: All patients need normal Vitamin D, PTH and Kidney function to get the maximum benefit from all treatments. All men with osteoporosis should be given lifestyle advice on how to decrease bone loss, including an adequate caloric intake and dietary calcium and vitamin D, 30 minutes of appropriate daily weight bearing exercise, cessation of smoking and reduction of alcohol intake.