Should a DEXA (Dual-Energy X-ray Absorptiometry) scan be checked in males, particularly those over 70 or with risk factors for osteoporosis?

DEXA Scan Screening in Males

Yes, DEXA scans should be checked in men aged 70 years and older routinely, and in younger men with specific risk factors who are candidates for drug therapy. 1

Age-Based Screening Thresholds

• Men aged 70 years and older should undergo routine DEXA screening regardless of other risk factors, as this represents a strong recommendation with moderate-quality evidence from the American College of Physicians 1, 2
• By age 65 years, at least 6% of men already have DXA-determined osteoporosis, making assessment of risk factors before this age reasonable 1
• 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 3
• The Bone Health & Osteoporosis Foundation recommends screening for men aged 70-79 years with T-score ≤-1.5 at lumbar spine, total hip, or femoral neck 2

Risk Factor-Based Screening (Any Age)

Men younger than 70 years should undergo DEXA screening if they have any of the following high-risk conditions:

Major Risk Factors Requiring Immediate Screening

• Previous fragility fracture (fracture from standing height or lower) 1, 2
• Chronic glucocorticoid therapy (≥5 mg prednisone daily for ≥3 months) 1, 2
• Androgen deprivation therapy for prostate cancer 1, 2
• Spinal cord injury (screen as soon as medically stable) 1, 2

Additional High-Risk Medical Conditions

• Hypogonadism or surgically/chemotherapeutically induced castration 2
• Hyperparathyroidism, hyperthyroidism, or Cushing syndrome 2
• Rheumatoid arthritis or other chronic inflammatory arthritides 2
• Gastrointestinal malabsorption, malnutrition, or vitamin D deficiency 2
• Chronic liver disease or chronic alcoholism 2
• Organ transplantation 2
• Eating disorders 2

Clinical Risk Factors

• Age >70 years 1
• Low body weight (BMI <20-25 kg/m²) 1
• Weight loss >10% (compared with usual young/adult weight) 1
• Physical inactivity (no regular walking, stair climbing, weight carrying, housework, or gardening) 1

Optimal Scanning Protocol

• Both lumbar spine and bilateral hips must be measured during the same examination to ensure accurate diagnosis, as recommended by the American College of Physicians 3, 2
• Measuring both sites ensures accurate diagnosis even when one site is unreadable or artificially elevated by degenerative disease 3
• DXA is the accepted reference standard for diagnosing osteoporosis in men and remains the only test validated for guiding treatment decisions 1, 3

Critical Pitfalls to Avoid

• Do not rely solely on lumbar spine DXA in elderly men, as degenerative changes (including DISH, osteophytes, and facet arthropathy) can falsely elevate BMD readings and mask true osteoporosis 3, 4
• Do not use calcaneal ultrasonography or the Osteoporosis Self-Assessment Tool (OST) as substitutes for DXA—they have only 75% sensitivity and 66% specificity for identifying DXA-determined osteoporosis 1, 3
• Do not delay screening in high-risk men based on age alone—risk factors trump age thresholds 1
• Plain radiography cannot quantify bone density accurately enough to guide treatment decisions, even when demineralization is visible 3

When to Add Vertebral Fracture Assessment (VFA)

VFA should be performed during the same DEXA session for men with T-score <-1.0 and any of the following:

• Age ≥80 years 2
• Historical height loss >4 cm 2
• Self-reported but undocumented prior vertebral fracture 2
• Glucocorticoid therapy ≥5 mg prednisone daily for ≥3 months 2

Follow-Up Screening Intervals

• If osteoporosis is diagnosed or treatment initiated: repeat DEXA in 1-2 years to monitor treatment effectiveness 3, 2
• If results show osteopenia: repeat DEXA in 2-3 years 3, 2
• For spinal cord injuries: follow-up DEXA at 1-2 year intervals 2
• A minimum of 2 years is needed to reliably measure a change in BMD due to testing precision limitations 2

Why This Matters for Morbidity and Mortality

• Osteoporotic fractures in men carry significant morbidity and mortality, with 1-year mortality after hip fracture being twice that of women 3
• Worldwide, 1 in 5 men older than 50 years experience osteoporotic fractures in their lifetime 5
• Early detection through DEXA allows initiation of antiresorptive therapy (bisphosphonates or denosumab), which reduces vertebral fractures by 52 per 1000 person-years and hip fractures by 6 per 1000 person-years 5
• Treatment decisions are based on DXA-determined BMD, as treatment trials have established effectiveness using DXA thresholds 3