Doctors often fail to talk to men about their bone health or to test them for bone loss. Most men with osteoporosis learn they have the disease only after they break a hip. Some doctors think early detection and treatment of osteopenia—a thinning of the bones that can be thought of as preosteoporosis—may help prevent osteoporosis and its debilitating fractures. Others view osteopenia as a normal part of aging that requires no treatment until osteoporosis actually develops. It’s a gray area.
Recognizing that bone loss often goes underdiagnosed and undertreated in men, the American College of Physicians published guidelines in 2008 urging doctors to periodically perform individualized assessments of risk factors for osteoporosis in older men—and to have men at increased risk undergo testing to evaluate bone mineral density (BMD) to detect thinning bones. Special X-ray tests or ultrasound (another type of imaging test) can be used to measure BMD at different bone sites (hip, spine, wrist, heel or some combination). A test called dual X-ray absorptiometry (DXA) is the gold standard for making a diagnosis of osteoporosis.
What the numbers mean: BMD test results are given as T-scores, which gauge how far from normal density your bones are. You have osteopenia if your T-score is between –1 and –2.5, according to the World Health Organization; you have osteoporosis if your T-score is –2.5 or lower (each one-point decline represents about a 10 to 12 percent decrease in bone density).
Yet the distinction between osteopenia and osteoporosis is somewhat arbitrary, because there’s no consensus as to what normal bone density is. T-scores, for example, are based on the average bone density of healthy young white women, which may not be a meaningful way to evaluate other women’s bones, much less men’s bones. And how you are classified also may vary depending on the machine used (they do not produce uniform results) and which bones are measured.
Your chances of fracture involve more than just your bone mineral density. Bone quality (the structure of the bone) also is important—yet this is not taken into account in BMD testing. Your balance and muscle strength are other contributing factors. The greatest chance of fracture is when people fall; those who don’t fall are less likely to experience an osteoporotic fracture.
Help for osteoporosis and osteopenia
You should tell your doctor if you have noticed a loss of height or have sudden back pain, since that can indicate a collapsed vertebra. Also consider having BMD testing if you have had a previous fracture (especially a “low-trauma” one, such as breaking a bone from a light fall that you wouldn’t expect to cause a fracture), if you have been on long-term corticosteroids, if osteoporosis runs in your family, or if you have multiple risk factors. Your doctor may also recommend blood and urine tests that can reveal underlying causes of bone loss.
If you have osteoporosis, your doctor will probably prescribe medication. Some osteoporosis drugs approved for women are also approved for men, although they have been less studied in men. These include bisphosphonates—such as alendronate (Fosamax), risedronate (Actonel and Atelvia) and zoledronic acid (Reclast)—which slow bone loss, and teriparatide (Forteo), a parathyroid hormone given by injection that speeds bone formation.
Fosamax and Actonel are taken orally once a week, while Reclast is given once a year. Side effects include diarrhea, leg and arm pain, irritation of the esophagus, flu-like symptoms and fever. The most serious and rare side effects are deterioration of the jawbone and unusual fractures in the thigh bone. Bisphosphonates are known to work best during the first three years, so talk to your doctor if you’ve been on them longer than that. Possible side effects of Forteo include leg cramps and dizziness, and animal studies suggest an increased risk of bone cancer with long-term use. The drug is approved for two-year use only.
Testosterone therapy may be an option for some men with osteoporosis who have markedly low hormone levels. However, this approach has not been proven to reduce fractures, and little is known about its long-term side effects. A well-planned exercise program, along with dietary changes, also may help slow progression of the disease.
If you have osteopenia, there are too many unanswered questions about the benefits of treatment with medication to recommend it in most cases. Few studies show that drugs actually prevent fractures in individuals who don’t already have osteoporosis or a previous vertebral fracture. Discuss this with your doctor, who should take a complete personal and family medical history to evaluate your risk factors and may also do blood and urine tests to better assess your risk. Also, ask your doctor about using the FRAX risk assessment tool, which can help clarify whether treatment with drugs is likely to provide a benefit.