From the Guidelines
Yes, hypogonadism (low testosterone) is a common risk factor for osteoporosis in men. According to the most recent evidence-based guideline for the management of osteoporosis in men [ 1 ], serum total testosterone should be assessed as part of the pre-treatment assessment of men with osteoporosis. This is because testosterone plays a crucial role in maintaining bone density by promoting bone formation and inhibiting bone resorption [ 1 ]. When testosterone levels fall below normal, men experience accelerated bone loss, increasing fracture risk.
Key Points
- Testosterone replacement therapy (TRT) may be indicated in the case of symptomatic deficiency, with the decision to recommend TRT made on the basis of a holistic assessment of the patient [ 1 ].
- Hypogonadal men with osteoporosis should usually be treated with an established anti-osteoporosis medication, regardless of whether testosterone therapy is instituted, in order to most effectively reduce fracture risk [ 1 ].
- Additional management may include calcium, vitamin D, weight-bearing exercise, and sometimes bisphosphonates if bone density is significantly decreased [ 1 ].
Management
- Serum total testosterone levels should be measured as a facet of the investigatory ‘work-up’ for osteoporosis in men [ 1 ].
- Testosterone therapy might be indicated in the case of symptomatic deficiency, with the decision to recommend testosterone therapy made on the basis of a holistic assessment of the patient across bone, cardiometabolic and sexual function [ 1 ].
- Men with unexplained fractures or significant height loss should be evaluated for both osteoporosis and testosterone deficiency [ 1 ].
From the Research
Hypogonadism and Osteoporosis in Men
- Hypogonadism, or low testosterone, is a common secondary cause of osteoporosis in men 2, 3, 4
- Studies have shown that low bioavailable testosterone levels are associated with lower bone mineral density (BMD) in men 5, 3
- Testosterone deficiency syndrome (TDS) is a risk factor for low BMD and osteoporosis, and men with TDS should be screened for osteoporosis using dual X-ray absorptiometry (DXA) scanning 3
- Treatment options for osteoporosis in men with hypogonadism include bisphosphonates, teriparatide, and selective estrogen receptor modulating drugs 4, 6
- Testosterone replacement therapy (TRT) may be beneficial for men with osteoporosis and hypogonadism, but its use should be carefully considered and monitored 3, 6
Risk Factors and Treatment
- Risk factors for osteoporosis in men include low testosterone levels, advanced age, low body mass index (BMI), and physical inactivity 2, 5, 4
- Treatment of osteoporosis in men should be individualized and based on the presence of secondary causes, such as hypogonadism, and the severity of bone loss 4, 6
- First-line treatment of osteoporosis in hypogonadal or eugonadal men is with bisphosphonates, and teriparatide may be used as an anabolic treatment in the near future 4, 6
Future Directions
- Further research is needed to fully understand the relationship between testosterone and bone health in men, and to develop effective treatments for osteoporosis in this population 5, 4, 6
- New compounds, such as odanacatib and romosozumab, are being developed and may offer new treatment options for osteoporosis in men in the future 6