What are the guidelines for osteoporosis screening in men?

Osteoporosis Screening Guidelines for Men

Primary Screening Recommendation

All men aged 70 years and older should undergo DXA screening for osteoporosis, and men aged 50-69 years should be screened if they have specific risk factors including low body weight, prior fragility fracture, corticosteroid use, androgen deprivation therapy, or physical inactivity. 1, 2, 3

Age-Based Screening Thresholds

Men ≥70 Years

• Universal screening with DXA is recommended regardless of other risk factors 2, 3, 4
• By age 65, at least 6% of men already have DXA-determined osteoporosis, and this percentage increases substantially after age 70 1, 5
• A 60-year-old white man has a 25% lifetime risk for osteoporotic fracture, with 1-year mortality after hip fracture being twice that of women 5

Men Aged 50-69 Years

• Screening should be performed if one or more major risk factors are present 1, 2, 3
• Risk assessment should be individualized and updated periodically for those who initially decline screening 1

Specific Risk Factors Requiring Screening in Men <70 Years

High-Priority Risk Factors (Screen if Present)

• Prior fragility fracture - among the strongest predictors of future osteoporotic fractures 1, 6, 2
• Chronic corticosteroid therapy - one of the most common causes of secondary osteoporosis in men 1, 6, 2
• Androgen deprivation therapy or hypogonadism - strong predictor with dose-dependent effects (≥9 doses of GnRH agonist: RR 1.45; orchiectomy: RR 1.54) 6, 2, 3
• Low body weight (BMI <20-25 kg/m²) - major constitutional risk factor 1, 6, 2
• Weight loss >10% compared to usual adult weight 1, 6, 2
• Physical inactivity - well-established modifiable risk factor 1, 6, 2
• Spinal cord injury - moderate predictor of both low BMD and fracture 6, 2

Medical Conditions Requiring Screening

• Chronic renal failure 2
• Rheumatoid arthritis 2
• Malabsorption disorders (including celiac disease) 6, 2
• Primary hyperparathyroidism 6, 2
• Hyperthyroidism 2
• Chronic liver disease 2

Medications Requiring Screening

• Anticonvulsants 2
• Chronic heparin therapy 2

DXA Testing Protocol

Anatomic Sites to Measure

Both lumbar spine and bilateral hips should be scanned during the same examination 5

• Measuring both sites ensures accurate diagnosis even when one site is unreadable or artificially elevated by degenerative disease 5
• In elderly men, degenerative changes can falsely elevate lumbar spine BMD readings and mask true osteoporosis 5

Diagnostic Thresholds

• Men ≥50 years: Use T-scores with same thresholds as women (osteoporosis: T-score ≤-2.5; osteopenia: T-score -1.0 to -2.5) 3
• Men <50 years: Use Z-scores instead; Z-score ≤-2.0 defined as "below expected range for age" 2
• Osteoporosis cannot be diagnosed in men <50 years based on BMD alone 2

Alternative Screening Tests Are NOT Recommended

Calcaneal ultrasonography and the Osteoporosis Self-Assessment Tool (OST) are insufficient substitutes for DXA 1, 5

• Calcaneal ultrasonography at T-score threshold of -1.0 has only 75% sensitivity and 66% specificity for identifying DXA-determined osteoporosis 1, 5
• OST at risk score threshold of -1 has 81% sensitivity and 68% specificity 1
• Neither test is sufficiently sensitive or specific to serve as a substitute for DXA 1
• Plain radiography cannot quantify bone density accurately enough to guide treatment decisions 5

Follow-Up DXA Scanning Intervals

• Men at high risk of accelerated bone loss (e.g., on androgen deprivation therapy): repeat DXA at 1-2 year intervals 2
• Men with diagnosed osteoporosis or on treatment: repeat DXA in 1-2 years to monitor treatment effectiveness 5, 2
• Men with osteopenia: repeat DXA in 2-3 years 5
• Men with stable risk factors: repeat DXA every 2 years 2

Critical Pitfalls to Avoid

• Do not rely solely on lumbar spine DXA in elderly men - degenerative changes can falsely elevate readings 5
• Do not delay screening in high-risk men - men account for 24% of hip fractures but only 10% of BMD tests, indicating significant underdiagnosis 2
• Do not skip screening after a fracture - only 19% of people over 65 undergo BMD testing after fracture, with rates in men only half those in women 2
• Do not use alternative screening methods as substitutes for DXA when making treatment decisions 1, 5

Special Populations

Men on Androgen Deprivation Therapy

• Baseline DXA before or within 6 months of starting therapy 2
• Follow-up scans at 1-2 year intervals 2

Men with Spinal Cord Injuries

• DXA of total hip, proximal tibia, and distal femur as soon as medically stable 2
• Follow-up scans at 1-2 year intervals 2

Transgender Individuals

• Screening based on hormone therapy compliance, gonadal removal, and additional risk factors 2
• Z-scores calculated using reference data conforming to gender identity 2