In men, minimal trauma fractures due to osteoporosis result in higher mortality rates compared with women. Despite this, treatment uptake in men is low, with 90% of men eligible for osteoporosis medicines remaining untreated. Several factors increase the risk of osteoporosis in men, including hypogonadism, alcohol consumption and long-term corticosteroid use.

Undertreatment of osteoporosis in men

Osteoporosis – a progressive metabolic bone disease characterised by low bone mineral density (BMD) –results in decreased bone strength, increased bone fragility and increased risk of minimal trauma fracture.1 (A minimal trauma fracture is one that occurs after a fall from standing height or less, or from a minor force that would not normally cause a fracture in a healthy younger person.)

A previous minimal trauma fracture doubles a person's subsequent risk of fracture.2,3 However, osteoporosis remains under-recognised and undertreated, even in people who present with minimal trauma fracture.4-6

Men, in particular, are undertreated. A large epidemiological study of elderly Australian men found only 10% of those eligible for PBS-subsidised treatments were taking a bisphosphonate medicine.7

Higher mortality in men following osteoporotic fracture

While osteoporosis is more common in women,8 the risk of death from minimal trauma fractures is greater in men.9-11

The Dubbo Osteoporosis Epidemiology Study examined mortality rates following minimal trauma fracture.9 In the first 5 years post-fracture, the study found that approximately 26% of women and 37% of men died.9

If a repeat fracture occurred within the same timeframe, the mortality risk increased dramatically to 75% for men and 50% for women. The total 5-year mortality rate was 39% in women and 51% in men.9

It has also been reported that after a hip fracture, the fatality rate for those aged > 75 years was 20.7% in men compared with 7.5% in women.11

What puts men at high risk of osteoporosis?

In both genders, a previous minimal trauma fracture is strongly associated with an increased risk of repeat fractures.5,12 Up until 80 years of age, a previous minimal trauma fracture is the strongest risk factor for hip fractures and non-hip fractures.13

In addition to previous minimal trauma fracture, other risk factors for osteoporosis include:5,12

  • age
  • low BMD
  • smoking
  • alcohol consumption
  • low BMI (body mass index)
  • physical inactivity
  • inadequate dietary calcium intake and vitamin D levels.5,12

For a comprehensive list of risk factors see RACGP Clinical guideline for osteoporosis.

Up to 50% of osteoporosis in men can be attributed to an underlying or secondary cause, including predisposing medicines or conditions and lifestyle factors.11,12 The major causes of secondary osteoporosis in men are hypogonadism, long-term corticosteroid use and excessive alcohol consumption.11

Other risk factors that can increase the likelihood of osteoporosis in men include:5,11,12,14

  • decreased testosterone and other sex hormone levels due to ageing
  • androgen deprivation therapy in patients with prostate cancer.

For more information on assessing patients for risk of osteoporosis, visit NPS MedicineWise Risk assessment in osteoporosis.

Effectiveness of pharmacological treatments in men

Evidence on whether osteoporosis medicines reduce fracture risk in men is limited by small patient numbers. However, when compared with placebo, osteoporosis medicines increase BMD to a similar degree in both men and women.12,15-20

For more information on the pharmacological management of osteoporosis, including a decision pathway for PBS-subsidised osteoporosis medicines, see our clinical topic Osteoporosis.

For a summary of the guideline recommendations on lifestyle changes to improve bone health, see Optimising treatment of osteoporosis.

GP-mediated resources such as the Bone Health Action Plan can help facilitate discussion about modifiable risk factors, and medicine effectiveness and safety for patients taking osteoporosis medicines.

References

  1. Bolster MB. Osteoporosis. Merck Manual, 2012. [Online] (accessed 15 September 2015).
  2. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone 2004;35:375– [PubMed].
  3. National Institute of Clinical Studies. Evidence-practice gaps report: volume 2. Melbourne: NICS, 2005. [Online] (accessed 7 July 2015).
  4. Osteoporosis Australia. What you need to know about osteoporosis. Australia: Osteoporosis Australia, 2014. [Online] (accessed 10 June 2015).
  5. Royal Australian College of General Practitioners. Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. Melbourne: RACGP, 2010. [Online] (accessed 30 April 2015).
  6. Therapeutic Guidelines. Osteoporosis. Melbourne: Therapeutic Guidelines Limited, 2015. [TG online] (accessed 14 May 2015).
  7. Bleicher K, Naganathan V, Cumming RG, et al. Prevalence and treatment of osteoporosis in older Australian men: findings from the CHAMP study. Med J Aust 2010;193:387– [PubMed].
  8. Henry MJ, Pasco JA, Nicholson GC, et al. Prevalence of osteoporosis in Australian men and women: Geelong Osteoporosis Study. Med J Aust 2011;195:321– [PubMed].
  9. Bliuc D, Nguyen ND, Nguyen TV, et al. Compound risk of high mortality following osteoporotic fracture and refracture in elderly women and men. J Bone Miner Res 2013;28:2317– [PubMed].
  10. Bass E, French DD, Bradham DD, et al. Risk-adjusted mortality rates of elderly veterans with hip fractures. Ann Epidemiol 2007;17:514– [PubMed].
  11. Gennari L, Bilezikian JP. Osteoporosis in men. Endocrinol Metab Clin North Am 2007;36:399– [PubMed]
  12. Scottish Intercollegiate Guidelines Network. Management of osteoporosis and the prevention of fragility fractures. A national clinical guideline. Edinburgh: SIGN, 2015. [Online] (accessed 14 May 2015).
  13. Kanis JA, Johnell O, Oden A, et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008;19:385– [PubMed].
  14. Banu J. Causes, consequences, and treatment of osteoporosis in men. Drug Des Devel Ther 2013;7:849– [PubMed].
  15. Boonen S, Reginster JY, Kaufman JM, et al. Fracture risk and zoledronic acid therapy in men with osteoporosis. N Engl J Med 2012;367:1714– [PubMed].
  16. Boonen S, Orwoll ES, Wenderoth D, et al. Once-weekly risedronate in men with osteoporosis: results of a 2-year, placebo-controlled, double-blind, multicenter study. J Bone Miner Res 2009;24:719-– [PubMed].
  17. Boonen S, Orwoll E, Magaziner J, et al. Once-yearly zoledronic acid in older men compared with women with recent hip fracture. J Am Geriatr Soc 2011;59:2084– [PubMed].
  18. Kaufman JM, Audran M, Bianchi G, et al. Efficacy and safety of strontium ranelate in the treatment of osteoporosis in men. J Clin Endocrinol Metab 2013;98:592– [PubMed].
  19. Orwoll E, Teglbjaerg CS, Langdahl BL, et al. A randomized, placebo-controlled study of the effects of denosumab for the treatment of men with low bone mineral density. J Clin Endocrinol Metab 2012;97:3161– [PubMed].
  20. Orwoll ES, Scheele WH, Paul S, et al. The effect of teriparatide [human parathyroid hormone (1–34)] therapy on bone density in men with osteoporosis. J Bone Miner Res 2003;18:9– [PubMed].