Do men have a predisposition to fractures due to osteoporosis?

Men's Predisposition to Fractures Due to Osteoporosis

Men do have a predisposition to fractures due to osteoporosis, with approximately 1 in 5 men at risk for an osteoporosis-related fracture during their lifetime, though this risk is lower than in women (1 in 2). 1, 2

Epidemiology and Risk Profile

• Osteoporosis is less common in men than women, but still represents a significant health concern
• By age 65, at least 6% of men have DXA-determined osteoporosis 1
• A 60-year-old white man has a 25% lifetime risk for an osteoporotic fracture 1
• Men experience more severe outcomes after fractures:
  • 1-year mortality rate after hip fracture is twice that of women 1
  • Greater complications including infection and major cardiovascular events 3

Key Risk Factors for Osteoporosis and Fractures in Men

High-quality evidence identifies several strong risk factors for osteoporosis and related fractures in men 1:

• Age: Particularly men over 70 years
• Low body weight: BMI <20-25 kg/m²
• Weight loss: >10% compared to usual adult weight
• Physical inactivity: No regular physical activity
• Prolonged corticosteroid use
• Previous fragility fracture
• Androgen deprivation therapy (pharmacologic or orchiectomy)

Additional moderate-risk factors include:

• Cigarette smoking
• Low dietary calcium intake
• Spinal cord injury
• Alcohol consumption 4

Screening and Diagnosis

The American College of Physicians recommends 1:

1. Periodic individualized risk assessment for osteoporosis in older men
2. DXA testing for men at increased risk who are candidates for drug therapy

The U.S. Preventive Services Task Force notes that men most likely to benefit from screening have a 10-year risk for osteoporotic fracture equal to or greater than that of a 65-year-old white woman without risk factors 1.

Diagnostic Challenges

Despite the prevalence and serious consequences of osteoporosis in men, significant underdiagnosis occurs:

• DXA testing is performed in only 12% of older men compared to 63% of older women 5
• Even in high-risk men (those with previous hip fracture, corticosteroid use, or androgen deprivation therapy), only 27-36% undergo DXA screening 5
• The sensitivity of DXA-determined osteoporosis was only 21% in identifying elderly men who subsequently had a nonvertebral fracture 1

Treatment Considerations

For men with osteoporosis at high risk for fracture, FDA-approved treatments include:

• Denosumab (Prolia): Indicated for treatment to increase bone mass in men with osteoporosis at high risk for fracture 6
• Bisphosphonates: First-line therapy for most men with osteoporosis
• Anabolic medications (teriparatide, abaloparatide, romosozumab): Should be considered for very high-risk individuals 2

All patients should receive calcium 1000 mg daily and at least 400 IU vitamin D daily 6.

Clinical Pitfalls and Considerations

1. Secondary causes: 30-60% of men with vertebral fractures have another illness contributing to bone disease 7
2. Undertreatment: Only 5% of older men receive bisphosphonate prescriptions compared to 44% of women 5
3. Fracture risk assessment: The majority of fractures in men occur at T-scores >-2.5, suggesting factors beyond BMD are important 4
4. Sex hormone considerations: Both testosterone and estrogen levels affect bone health in men, with evidence suggesting estrogens are important in skeletal maintenance 7

Conclusion

While men have a lower overall risk of osteoporosis than women, they experience significant morbidity and mortality when fractures occur. The substantial underdiagnosis and undertreatment of osteoporosis in men represents a critical gap in care that requires greater attention from healthcare providers.