Do we perform Dual-Energy X-ray Absorptiometry (DEXA) scans in males?

DEXA Scanning in Males: Evidence-Based Guidelines

DEXA scans should be performed in men who are at increased risk for osteoporosis, particularly those aged 70 years and older, as they are candidates for drug therapy to reduce fracture risk. 1

Risk Assessment and Screening Criteria for Men

DEXA scanning in males should follow a risk-based approach rather than universal screening. The American College of Physicians strongly recommends that clinicians perform individualized risk factor assessment for osteoporosis in older men 1.

Key Risk Factors for Men Requiring DEXA:

• Age: Men aged ≥70 years 1, 2
• Low body weight: BMI <20-25 kg/m² 1
• Weight loss: >10% compared to usual adult weight 1
• Physical inactivity: No regular physical activities 1
• Medication use:
  • Corticosteroid therapy (≥5 mg prednisone daily for ≥3 months) 1
  • Androgen deprivation therapy for prostate cancer 1, 2
• Previous fragility fracture 1
• Spinal cord injury 1
• Secondary causes: Hypogonadism, hyperparathyroidism 2

Specific Indications for DEXA in Men

According to the International Society for Clinical Densitometry (ISCD) and other guidelines, DEXA is specifically indicated for:

• Men aged ≥70 years with T-score ≤-1.0 at the femoral neck 1
• Men aged 70-79 years with T-score ≤-1.5 at lumbar spine, total hip, or femoral neck 1
• Men aged ≥80 years with T-score ≤-1.0 at lumbar spine, total hip, or femoral neck 1
• Men with height loss >4 cm (>1.5 inches) 1
• Men on long-term glucocorticoid therapy 1, 2
• Men with conditions associated with bone loss (hyperparathyroidism, hypogonadism) 1, 2

Clinical Significance and Implementation

Despite osteoporosis being common in men (affecting approximately 20% of all men), screening rates remain significantly lower than in women. Studies show that while 60% of eligible women receive appropriate DEXA screening, only 18.4% of eligible men do 3. This disparity exists despite the fact that men with hip fractures have twice the one-year mortality rate compared to women 1.

A retrospective study of US veterans aged 70 years and older without known risk factors found that:

• 22% had osteoporosis
• 54% had osteopenia
• Among those with osteopenia, 35% had FRAX scores indicating need for treatment 4

This demonstrates that screening in this population is highly valuable, as up to 50% of men aged ≥70 may qualify for diagnostic workup or pharmacological therapy 4.

Monitoring and Follow-up

For men who undergo DEXA scanning:

• Standard monitoring interval is 2 years 2
• Shorter intervals (1 year) recommended for:
  • Patients initiating osteoporosis therapy
  • Those at high risk for rapid bone loss
  • After cessation of pharmacologic therapy 2

Common Pitfalls to Avoid

1. Underscreening: Men are frequently not screened despite meeting criteria, leading to underdiagnosis and undertreatment 3
2. Relying solely on T-scores: FRAX scores should be calculated for men with osteopenia to identify those who would benefit from treatment despite not meeting osteoporosis criteria 4
3. Using different machines for follow-up: Patients should be scanned on the same DEXA machine for accurate comparison 2
4. Comparing T-scores instead of BMD values: BMD absolute values should be compared between previous and current scans 2

DEXA remains the gold standard for diagnosing osteoporosis in men, with no acceptable alternatives currently available. While calcaneal ultrasonography can predict fracture risk, it is not sufficiently sensitive or specific to replace DEXA for diagnosis or treatment decisions 1.