Osteoporosis & Men


Osteoporosis is the commonest bone disease worldwide and it is known as the "silent disease". The patient usually has NO signs or symptoms until they break a bone (fracture) e.g. a person tripping and falling and fracturing their forearm, is usually considered unfortunate, but it should be seen as a red flag to be screened for osteoporosis. e.g. A person who fractures bones in their spine (called vertebral fractures) will result in initial back pain, however 75% of fractures in the spine are "clinically silent”. This means that there is pain initially but then the pain decreases or can stop.  A person who has fractured bones in their spine, usually starts to loose height. Loss of height can occur because as the bones in the spine collapse (fracture) loss of height and/or a hump can develop. Osteoporosis if left undiagnosed and treated, can cause severe pain, loss of independence and can lead to premature death.  

Osteoporosis is preventable and treatable in the majority of people but men are usually not diagnosed till they have had multiple fractures. Because osteoporosis is widely considered to be a condition that only affects older women, men are at a disadvantage, as it is not considered as a diagnosis in men. As a result they are not usually scanned to determine whether they have osteoporosis.

One in five men over 50 will develop an osteoporotic fracture during their lifetime. Up to 20% of symptomatic vertebral fractures and 30% of hip fractures occur in men, where they are associated with excess mortality, substantial morbidity, possibly due to co-existing conditions associated with osteoporosis rather than the fracture itself. All low trauma fractures in both sexes should be considered Osteoporosis, unless proven otherwise. A risk factor Osteoporosis questionnaire should be filled out when any male has a “low trauma fracture”. This is a fracture from a standing position or less. Examples: Broken bone/s from: a trip and fall, cough, sneeze, turning over in bed.
There is an increased morbidity and mortality after all major osteoporotic fractures, which is higher in men than women. 20% of people aged 60+ who fracture a hip will die within 6-12 months due to the secondary complications of osteoporosis, which are blood clots, pneumonia or infection from being bed bound. 50% of people aged 60+ who fracture a hip, will no longer be able to dress, wash or walk unassisted. Only 30% of people aged 60+ who fracture a hip will regain their independence.

Men, similar to women with symptomatic vertebral fractures, commonly complain of back pain, loss of height and kyphosis (hump on back), but men have significantly less energy, poorer sleep, more emotional problems and impaired mobility than age-matched control subjects.
The commonest cause of osteoporosis is hypogonadism. (Lack of the male hormone  testosterone), this may be the result of a variety of conditions which include abnormal chromosomes, excessive stress, either physical or psychological.

Overtraining in athletes particularly those that have to maintain a low body weight, is usually associated with low levels of testosterone and high levels of cortisol (which affects bone) and low bone density.

Dietary problems, low caloric intake, inadequate calcium and vitamin D levels in the diet, also play a role. Alcohol abuse i.e. More than 21 units of alcohol a week for a man, excessive caffeine intake, smoking and lack of exercise are also risk factors. Males with a Family history of Osteoporosis or a close relative with a history of a low trauma hip fracture or vertebral fracture should be referred for a DXA Scan. Genetics is one of the strongest links for osteoporosis, as 80% of bone is genetic. A low trauma fracture, which is a broken bone from a trip and fall should not be considered normal at any age, if your bones were healthy they would not break easily.

Osteoporosis can occur as the result of a wide variety of medical or surgical conditions or their treatment, these include use of any of the following treatments:
Corticosteroids, some anticonvulsant therapy,(anti epileptic drugs,)  chronic Warfarin or Heparin, long-term Lithium, Antipsychotic Prolactin raising medication, proton pump inhibitors, chemotherapy, radiation for cancer, Aromatase inhibitors used in treatment of prostatic cancer, or immunosuppressive drugs, post organ transplant and some diuretics (water pills).

There is also a greater risk of hip fracture with conditions related to an increased risk of falling, such as stroke, Parkinson’s disease, dementia, vertigo, alcoholism and blindness. A prospective study from Australia demonstrated a higher risk of hip fracture in men with low hip bone density, quadriceps weakness (front thigh muscles), increased body sway and history of falls in the past year. It is recommended that anyone with one or more risk factors, regardless of age or sex should consider having a DXA scan as the disease is silent and therefore you will not know if you already have it. If you have a DXA scan and you have a normal result, with lifestyle risk factors, you can than help to prevent yourself from developing Osteoporosis by making lifestyle changes. If you have a DXA scan and the result shows that you have a low bone density, you can take the appropriate steps to improve it.

Diagnosis

The assessment of a male patient for osteoporosis should be made after a comprehensive risk factor questionnaire, as it is essential that the cause/s be found and addressed as well as the osteoporosis. A DXA scan of the spine and hips is the gold standard for measuring bone mineral density. The Irish osteoporosis society does not recommend any type of heel scan for the diagnosis of osteoporosis. The risk of fracture is determined by the risk factors and the results of the bone mineral density of the spine and hips (BMD),
Again, all patients with spinal fractures or low trauma fractures should be investigated for osteoporosis.

Treatment

All men with osteoporosis should be given lifestyle advice on how to decrease bone loss, including an adequate caloric intake, calcium and vitamin D, 30 minutes of appropriate daily weight bearing exercise, cessation of smoking and reduction of alcohol intake. If there is a history of falls, attempts should be made to identify and modify underlying and causes, in the hope that these may be modified and the risk of further falls and fractures decreased. Example: A pair of walking shoes should be worn inside the house, to give maximum support. Open back slippers or sandals are not recommended.

All treatments should be prescribed on an individual basis. Any underlying secondary cause of osteoporosis should be treated. Various blood and urine tests may be required before starting an Osteoporosis treatment.  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.   There are many treatment options for men with osteoporosis.
Patients on steroids or on certain immuno-suppressant therapy for cancer or aromatase inhibitors should have a DXA scan; they should be proactively protected with Calcium, Vitamin D3 and an appropriate Osteoporosis medication, appropriate weight-bearing exercise and be monitored.

Summary

In summary osteoporosis in men should be intensively investigated to look for the underlying secondary causes.  Decrease in bone mass should be addressed by avoiding risk factors.   Patients on steroids or on immuno-suppressant therapy should all be treated pro-actively (preventively).  Calcium, Vitamin D3, weight bearing exercise and an Osteoporosis medication are the principal therapies of osteoporosis in men. Patients need to be monitored by having repeat DXA scans every two years to ensure the treatment is working and to help increase patient compliance. Most patients will not feel any different after taking their osteoporosis medication, however when a person is rescanned the DXA scan will show the improvement, as long as all the cause/s have been found and addressed and the patients has taken the medication.