When to Screen Men for Osteoporosis
Screen all men aged 70 years and older with DXA scanning, and screen younger men (aged 50-69) who have significant risk factors including prior fragility fracture, corticosteroid use ≥3 months, low body weight (BMI <20-25 kg/m²), androgen deprivation therapy, or other major risk factors. 1, 2
Age-Based Screening Thresholds
- Men ≥70 years: Universal screening is recommended regardless of other risk factors 1, 2, 3
- Men aged 50-69 years: Screen only if risk factors are present 1, 2
- Men <50 years: Screen only if history of fragility fracture or other significant risk factors exist 2
Major Risk Factors Requiring Screening in Men Aged 50-69
Strongest Risk Factors (Screen Immediately)
- Prior fragility fracture (fracture from standing height or less) 1, 4
- Chronic corticosteroid use ≥5 mg prednisone daily for ≥3 months 1, 4
- Androgen deprivation therapy for prostate cancer (pharmacologic or surgical) 1, 4
- Low body weight: BMI <20-25 kg/m² 1, 4
- Weight loss >10% compared to usual adult weight 1, 4
Additional Important Risk Factors
- Hypogonadism (low testosterone levels) 1, 4
- Physical inactivity (no regular weight-bearing activity) 1, 4
- Current cigarette smoking 1, 4
- Excessive alcohol consumption (≥3 drinks/day) 1, 5, 4
- Spinal cord injury 1, 4
- Family history of hip fracture 1
Secondary Causes to Consider
- Malabsorption syndromes (celiac disease, inflammatory bowel disease) 4, 6
- Chronic obstructive pulmonary disease 1, 6
- Organ transplantation 6
- Chronic liver disease with cirrhosis 1
- Haemochromatosis 1
Screening Method
- DXA scanning of the lumbar spine and hip is the gold standard for diagnosis 1, 2
- Osteoporosis is diagnosed when T-score ≤-2.5 at spine, hip, or femoral neck 1, 3
- Calcaneal ultrasonography can predict fractures but is not sufficiently sensitive/specific to diagnose DXA-determined osteoporosis (sensitivity 75%, specificity 66% at T-score -1.0) 1
Risk Assessment Tools
- FRAX calculator can estimate 10-year fracture risk using clinical factors with or without BMD 1
- The Osteoporosis Self-Assessment Tool (OST) using only age and weight performs similarly to calcaneal ultrasonography for identifying men needing DXA 1
- Men with weight <70 kg are at particularly high risk 1
Special Populations Requiring Screening
Men on Glucocorticoid Therapy
- Screen all men starting prednisone ≥2.5 mg/day for ≥3 months, regardless of age 1
- Perform DXA within 6 months of starting therapy 1
- Men <40 years require screening only if prior fracture or other significant risk factors present 1
Men with Prostate Cancer
- Screen all men receiving androgen deprivation therapy at baseline and at 1-2 year intervals 1
- Use "secondary osteoporosis" option in FRAX when calculating risk 1
Men with Chronic Alcoholism
- Screen men drinking >10 units/day with cumulative exposure >24 years 1, 5
- Alcohol increases fracture risk approximately 2-fold at 3-4 drinks/day, with escalating risk at higher intake 5
- 30% of heavy drinkers have vertebral compression fractures even without cirrhosis 1
Common Pitfalls to Avoid
- Don't wait until age 70 to screen men with major risk factors like prior fracture or chronic corticosteroid use 1, 2
- Don't rely on calcaneal ultrasonography alone for diagnosis—it predicts fractures but cannot definitively diagnose osteoporosis 1
- Don't forget to check for secondary causes: 30-60% of men with vertebral fractures have contributing medical conditions 7
- Don't overlook hypogonadism: measure testosterone levels when clinically suspected 1, 6
- Don't assume normal BMI excludes risk: low body weight is a major risk factor, but normal or high BMI does not eliminate risk in presence of other factors 5
Laboratory Evaluation When Screening
When osteoporosis is identified, obtain: