Osteoporosis is a disease that causes the skeleton to weaken and the bones to break. It poses a significant threat to millions of men in the United States.

Despite these compelling figures, surveys suggest that a majority of American men view osteoporosis solely as a “woman’s disease.” Moreover, among men whose lifestyle habits put them at increased risk, few recognize the disease as a significant threat to their mobility and independence.

Osteoporosis is called a “silent disease” because it progresses without symptoms until a fracture occurs. It develops less often in men than in women because men have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss. However, in the past few years the problem of osteoporosis in men has been recognized as an important public health issue, particularly in light of estimates that the number of men above the age of 70 will continue to increase as life expectancy continues to rise.

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones).

Osteoporosis is a “silent” disease because you typically do not have symptoms, and you may not even know you have the disease until you break a bone. Osteoporosis is the major cause of fractures in postmenopausal women and in older men. Fractures can occur in any bone but happen most often in bones of the hip, vertebrae in the spine, and wrist.

However, you can take steps to help prevent the disease and fractures by:

• Staying physically active by participating in weight-bearing exercises such as walking.
• Drinking alcohol in moderation.
• Quitting smoking, or not starting if you don’t smoke.
• Taking your medications, if prescribed, which can help prevent fractures in people who have osteoporosis.
• Eating a nutritious diet rich in calcium and vitamin D to help maintain good bone health.

Bone is constantly changing – that is, old bone is removed and replaced by new bone. During childhood, more bone is produced than removed, so the skeleton grows in both size and strength. For most people, bone mass peaks during the third decade of life. By this age, men typically have accumulated more bone mass than women. After this point, the amount of bone in the skeleton typically begins to decline slowly as removal of old bone exceeds formation of new bone.

Men in their fifties do not experience the rapid loss of bone mass that women do in the years following menopause. By age 65 or 70, however, men and women lose bone mass at the same rate, and the absorption of calcium, an essential nutrient for bone health throughout life, decreases in both sexes. Excessive bone loss causes bone to become fragile and more likely to fracture.

Fractures resulting from osteoporosis most commonly occur in the hip, spine, and wrist, and can be permanently disabling. Hip fractures are especially dangerous. Perhaps because such fractures tend to occur at older ages in men than in women, men who sustain hip fractures are more likely than women to die from complications.

There are two main types of osteoporosis: primary and secondary. In cases of primary osteoporosis, either the condition is caused by age-related bone loss (sometimes called senile osteoporosis) or the cause is unknown (idiopathic osteoporosis). The term idiopathic osteoporosis is typically used only for men younger than 70 years old; in older men, age-related bone loss is assumed to be the cause.

The majority of men with osteoporosis have at least one (sometimes more than one) secondary cause. In cases of secondary osteoporosis, the loss of bone mass is caused by certain lifestyle behaviors, diseases, or medications. Some of the most common causes of secondary osteoporosis in men include exposure to glucocorticoid medications, hypogonadism (low levels of testosterone), alcohol abuse, smoking, gastrointestinal disease, hypercalciuria, and immobilization.

Glucocorticoid medications: Glucocorticoids are steroid medications used to treat diseases such as asthma and rheumatoid arthritis. Bone loss is a very common side effect of these medications. The bone loss these medications cause may be due to their direct effect on bone, muscle weakness or immobility, reduced intestinal absorption of calcium, a decrease in testosterone levels, or, most likely, a combination of these factors.

When glucocorticoid medications are used on an ongoing basis, bone mass often decreases quickly and continuously, with most of the bone loss in the ribs and vertebrae. Therefore, people taking these medications should talk to their doctor about having a bone mineral density test. Men should also be tested to monitor testosterone levels, as glucocorticoids often reduce testosterone in the blood.

A treatment plan to minimize loss of bone during long-term glucocorticoid therapy may include using the minimal effective dose and discontinuing the drug or administering it through the skin, if possible. Adequate calcium and vitamin D intake is important, as these nutrients help reduce the impact of glucocorticoids on the bones. Other possible treatments include testosterone replacement and osteoporosis medication.

Hypogonadism: Hypogonadism refers to abnormally low levels of sex hormones. It is well known that loss of estrogen causes osteoporosis in women. In men, reduced levels of sex hormones may also cause osteoporosis.

Although it is natural for testosterone levels to decrease with age, there should not be a sudden drop in this hormone that is comparable to the drop in estrogen experienced by women at menopause. However, medications such as glucocorticoids (discussed above), cancer treatments (especially for prostate cancer), and many other factors can affect testosterone levels. Testosterone replacement therapy may be helpful in preventing or slowing bone loss. Its success depends on factors such as age and how long testosterone levels have been reduced. Also, it is not yet clear how long any beneficial effect of testosterone replacement will last. Therefore, doctors usually treat the osteoporosis directly, using medications approved for this purpose.

Research suggests that estrogen deficiency may also be a cause of osteoporosis in men. For example, estrogen levels are low in men with hypogonadism and may play a part in bone loss. Osteoporosis has been found in some men who have rare disorders involving estrogen. Therefore, the role of estrogen in men is under active investigation.

Alcohol abuse: There is a wealth of evidence that alcohol abuse may decrease bone density and lead to an increase in fractures. Low bone mass is common in men who seek medical help for alcohol abuse.

In cases where bone loss is linked to alcohol abuse, the first goal of treatment is to help the patient stop, or at least reduce, his consumption of alcohol. More research is needed to determine whether bone lost to alcohol abuse will rebuild once drinking stops, or even whether further damage will be prevented. It is clear, though, that alcohol abuse causes many other health and social problems, so quitting is ideal. A treatment plan may also include a balanced diet with lots of calcium- and vitamin D-rich foods, a program of physical exercise, and smoking cessation.

Smoking: Bone loss is more rapid, and rates of hip and vertebral fracture are higher, among men who smoke, although more research is needed to determine exactly how smoking damages bone. Tobacco, nicotine, and other chemicals found in cigarettes may be directly toxic to bone, or they may inhibit absorption of calcium and other nutrients needed for bone health. Quitting is the ideal approach, as smoking is harmful in so many ways. As with alcohol, it is not known whether quitting smoking leads to reduced rates of bone loss or to a gain in bone mass.

Gastrointestinal disorders: Several nutrients, including amino acids, calcium, magnesium, phosphorous, and vitamins D and K, are important for bone health. Diseases of the stomach and intestines can lead to bone disease when they impair absorption of these nutrients. In such cases, treatment for bone loss may include taking supplements to replenish these nutrients.

Hypercalciuria: Hypercalciuria is a disorder that causes too much calcium to be lost through the urine, which makes the calcium unavailable for building bone. Patients with hypercalciuria should talk to their doctor about having a bone mineral density (BMD) test and, if bone density is low, discuss treatment options.

Immobilization: Weight-bearing activity is essential for maintaining healthy bones. Without it, bone density may decline rapidly. Prolonged bed rest (following fractures, surgery, spinal cord injuries, or illness) or immobilization of some part of the body often results in significant bone loss. It is crucial to resume weight-bearing activities (such as walking, jogging, and dancing) as soon as possible after a period of prolonged bed rest. If this is not possible, you should work with your doctor to minimize other risk factors for osteoporosis.

Several risk factors have been linked to osteoporosis in men:

• Chronic diseases that affect the kidneys, lungs, stomach, and intestines or alter hormone levels
• Regular use of certain medications, such as glucocorticoids
• Undiagnosed low levels of the sex hormone testosterone
• Unhealthy lifestyle habits: smoking, excessive alcohol use, low calcium intake, and inadequate physical exercise
• Age. The older you are, the greater your risk.
• Race. White men appear to be at particularly high risk, but all men can develop this disease.

The impact of prostate cancer

Next to skin cancer, prostate cancer is the most common type of cancer among American men. The cancer usually grows very slowly, however, and most men who are diagnosed with prostate cancer live for many years. Still, prostate cancer can be serious and, in some cases, life threatening.

Facts about osteoporosis

Osteoporosis is a condition in which bones become weaker, less dense, and more likely to break. Many people – even some doctors – think of osteoporosis as a women’s disease, but millions of men develop it, too. Men who break bones are less likely than women to be treated for bone disease, even though treatment can help prevent broken bones in the future.

Risk factors for developing osteoporosis include:

• Being thin or having a small frame.
• Having a family history of the disease.
• Using certain medications, such as glucocorticoids.
• Not getting enough calcium.
• Not getting enough physical activity.
• Smoking.
• Drinking too much alcohol.

Osteoporosis is a silent disease because it can weaken bones over the years without causing symptoms. For men coping with prostate cancer, weak bones may not seem very important. But weak bones can cause problems because they break easily, and broken bones often initiate a downward health spiral. But it is never too late to improve your bone health: osteoporosis can be treated and prevented.

The link between prostate cancer and osteoporosis

Most men diagnosed with prostate cancer are age 65 or older. And, as men get older, their risk for osteoporosis also increases.

Studies show that men who receive hormone deprivation therapy for prostate cancer have an increased risk of developing osteoporosis and broken bones. Hormone deprivation therapy is also called androgen deprivation therapy because it deprives cancer cells of the male hormones (called androgens) that the cancer needs to grow.

Hormones such as testosterone protect against bone loss. So, once these hormones are blocked, bone becomes less dense and can break more easily.

Osteoporosis management strategies

Several strategies can reduce a man’s risk for osteoporosis or lessen its effects if he already has it.

Nutrition. A well-balanced diet rich in calcium and vitamin D is important for bone health. Good sources of calcium include low-fat dairy products; dark green, leafy vegetables; and calcium-fortified foods and beverages. Taking dietary supplements or multivitamins also can help ensure that you meet your body's daily calcium requirement.

However, some evidence suggests that high calcium intake might be associated with the development of prostate cancer. But the studies that produced these findings are not definitive. In fact, other studies have shown a weak relationship, no relationship at all, or the opposite relationship between calcium and prostate cancer. At this point, researchers can only say that the relationship between calcium and prostate cancer risk remains unclear. Currently, it is recommended that men age 19 to 70 consume 1,000 mg (milligrams) of calcium per day, and those over age 70 consume 1,200 mg per day.

Vitamin D plays an important role in calcium absorption and bone health. Some individuals may require vitamin D supplements to achieve the recommended intake of 600 to 800 IU (International Units) each day.

Exercise. Like muscle, bone is living tissue that responds to exercise by becoming stronger. The best exercises for bones are weight-bearing and resistance exercises. Weight-bearing exercises force you to work against gravity. These include walking, climbing stairs, and dancing. Resistance exercises – such as lifting weights – can also strengthen bones.

Regular exercise, such as walking, may help prevent bone loss and provide many other health benefits, such as reducing pain, relieving stress, and making cancer treatment easier to handle.

Healthy lifestyle. Smoking is toxic to bones as well as the heart and lungs. In addition, people who smoke may absorb less calcium from their diets. Studies also have found that heavy drinking hurts your overall health, weakens your bones, and increases your risk of broken bones. Moderate drinking – for most men, this means not more than two alcoholic drinks per day – has not been shown to hurt your bones.

Bone mineral density test. A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a central dual-energy x-ray absorptiometry (DXA) test. The test is painless – a bit like having an x-ray, but with much less exposure to radiation – and can measure bone density at your hip and spine.

Men being treated for prostate cancer with hormone deprivation therapy should discuss with their doctor whether BMD testing is a good idea.

Medication. There is no cure for osteoporosis, but medications are approved by the U.S. Food and Drug Administration for men with the disease. Although no medications have been approved specifically to treat men with bone problems caused by hormone deprivation therapy for prostate cancer, studies of several medications are underway for this purpose.

Some causes of osteoporosis in men

• Glucocorticoid medications.
• Other immunosuppressive drugs.
• Hypogonadism (low testosterone levels).
• Excessive alcohol consumption.
• Smoking.
• Chronic obstructive pulmonary disease and asthma.
• Cystic fibrosis.
• Gastrointestinal disease.
• Hypercalciuria.
• Anticonvulsant medications.
• Thyrotoxicosis.
• Hyperparathyroidism.
• Immobilization.
• Osteogenesis imperfecta.
• Homocystinuria.
• Neoplastic disease.
• Ankylosing spondylitis and rheumatoid arthritis.
• Systemic mastocytosis.

Osteoporosis can be effectively treated if it is detected before significant bone loss has occurred. A medical workup to diagnose osteoporosis can include a complete medical history, x-rays, and urine and blood tests. The doctor may also order a bone mineral density test. This test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a central dual-energy x-ray absorptiometry, or central DXA test. It is painless – a bit like having an x-ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.It is increasingly common for women to be diagnosed with osteoporosis or low bone mass using a BMD test, often at midlife when doctors begin to watch for signs of bone loss. In men, however, the diagnosis is often not made until a fracture occurs or a man complains of back pain and sees his doctor. This makes it especially important for men to inform their doctors about risk factors for developing osteoporosis, loss of height or change in posture, a fracture, or sudden back pain.

Once a man has been diagnosed with osteoporosis, his doctor may prescribe one of the medications approved by the U.S. Food and Drug Administration for this disease. The treatment plan will also likely include nutrition, exercise, and lifestyle guidelines for preventing bone loss.

If bone loss is due to glucocorticoid use, the doctor may prescribe a medication approved to prevent or treat glucocorticoid-induced osteoporosis, monitor bone density and testosterone levels, and suggest using the minimum effective dose of glucocorticoid.

Other possible prevention or treatment approaches include calcium and/or vitamin D supplements and regular physical activity.

If osteoporosis is the result of another condition (such as testosterone deficiency) or exposure to certain other medications, the doctor may design a treatment plan to address the underlying cause.

For many people, finding a doctor who is knowledgeable about osteoporosis can be difficult. There is no physician specialty dedicated solely to osteoporosis, nor is there a board certification program for physicians who treat the disease. A variety of medical specialists treat people with osteoporosis, including internists, gynecologists, family doctors, endocrinologists, rheumatologists, physiatrists, orthopaedists, and geriatricians.

There are a number of ways to find a doctor who treats osteoporosis patients. If you have a primary care or family doctor, discuss your concerns with him or her. Your doctor may treat the disease or be able to refer you to an osteoporosis specialist.

If you are enrolled in a health maintenance organization (HMO) or a managed care health plan, consult your assigned doctor about osteoporosis. This doctor should be able to give you an appropriate referral.

If you do not have a personal doctor or if your doctor cannot help, contact your nearest university hospital or academic health center and ask for the department that cares for patients with osteoporosis. The department will vary from institution to institution. For example, in some facilities, the department of endocrinology or metabolic bone disease treats osteoporosis patients. In other medical centers, the appropriate department may be rheumatology, orthopaedics, or gynecology. Some hospitals have a separate osteoporosis program or women’s clinic that treats patients with osteoporosis.

Once you have identified a doctor, you may wish to ask whether the doctor has specialized training in osteoporosis, how much of the practice is dedicated to osteoporosis, and whether he or she has access to bone density testing.

Your own primary care doctor –whether an internist, orthopaedist, or gynecologist – is often the best person to treat you because she or he knows your medical history, your lifestyle, and your special needs.

Medical specialists who treat osteoporosis

After an initial assessment, it may be necessary to see an endocrinologist, a rheumatologist, or another specialist to rule out the possibility of an underlying disease that may contribute to osteoporosis:

Endocrinologists treat the endocrine system, which comprises the glands and hormones that help control the body’s metabolic activity. In addition to osteoporosis, endocrinologists treat diabetes and diseases of the thyroid and pituitary glands.

Rheumatologists diagnose and treat diseases of the bones, joints, muscles and tendons, including arthritis and collagen diseases.

Family doctors have a broad range of training that includes internal medicine, gynecology, and pediatrics. They place special emphasis on caring for an individual or family on a long-term, continuing basis.

Geriatricians are family doctors or internists who have received additional training on the aging process and the conditions and diseases that often occur among the elderly, including incontinence, falls, and dementia. Geriatricians often care for patients in nursing homes, in patients’ homes, or in office or hospital settings.

Gynecologists diagnose and treat conditions of the female reproductive system and associated disorders. They often serve as primary care doctors for women and follow their patients’ reproductive health over time.

Internists are trained in general internal medicine. They diagnose and treat many diseases. Internists provide long-term comprehensive care in the hospital and office, have expertise in many areas, and often act as consultants to other specialists.

Orthopaedic surgeons are doctors trained in the care of patients with musculoskeletal conditions, such as congenital skeletal malformations, bone fractures and infections, and metabolic problems.

Physiatrists are doctors who specialize in physical medicine and rehabilitation. They evaluate and treat patients with impairments, disabilities, or pain arising from various medical problems, including bone fractures. Physiatrists focus on restoring the physical, psychological, social, and vocational functioning of the individual.

In addition to the treatments your doctor recommends, the following tips can help you manage and live with osteoporosis, prevent fractures, and prevent falls.

Preventing fractures is important when you have osteoporosis because fractures can cause other medical problems and take away your independence. Exercise can help prevent fractures that occur as a result of falling and improve bone strength, when your health care provider tailors a program to your individual need. If you have osteoporosis or bone loss, it is important to talk to your doctor or physical therapist before beginning any exercise program.

In addition, preventing falls helps prevent fractures. Falls increase your likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. Taking steps to prevent falls both inside and outside of the house can help prevent fractures.

Some factors that may contribute to falls include:

• Loss of muscle mass.
• Illnesses that impair your mental or physical functioning, such as low blood pressure or dementia.
• Use of four or more prescription medications.
• Poor vision.
• Poor balance.
• Certain diseases that affect how you walk.
• Alcohol use.
• Side effects of some medications, such as:
  • Sedatives or tranquilizers.
  • Sleeping pills.
  • Antidepressants.
  • Anticonvulsants.
  • Muscle relaxants.
  • Heart medicines.
  • Blood pressure pills.
  • Diuretics.

If you have osteoporosis, it is important to be aware of any physical changes you may experience that affect your balance or gait and to discuss these changes with your doctor or other health care provider. It is also important to have regular checkups and tell your doctor if you have had problems with falling.

Falls can also be caused by factors around you that create unsafe conditions. Here are some tips to help prevent falls outdoors and when you are away from home:

• Use a cane or walker for added stability.
• Wear shoes that provide support and have thin nonslip soles. Avoid wearing slippers and athletic shoes with deep treads.
• Walk on grass when sidewalks are slippery; in winter, put salt or kitty litter on icy sidewalks.
• Stop at curbs and check their height before stepping up or down.

Some ways to help prevent falls indoors are:

• Keep rooms free of clutter, especially on floors. Avoid running electrical cords across walking areas.
• Use plastic or carpet runners on slippery floors.
• Wear shoes, even when indoors, that provide support and have thin nonslip soles. Avoid wearing slippers and athletic shoes with deep treads.
• If you have a pet, be mindful of where they are to avoid tripping over them.
• Do not walk in socks, stockings, or slippers.
• Be careful on highly polished floors that are slick and dangerous, especially when wet, and walk on plastic or carpet runners when possible.
• Be sure carpets and area rugs have skid-proof backing or are tacked to the floor. Use double-stick tape to keep rugs from slipping.
• Be sure stairs are well lit and have rails on both sides.
• Install grab bars on bathroom walls near the tub, shower, and toilet.
• Use a rubber bathmat or slip-proof seat in the shower or tub.
• Improve lighting in your home. Use nightlights or keep a flashlight next to your bed in case you need to get up at night. Install ceiling fixtures or lamps that can be turned on by a switch near the room’s entrance.
• Use a sturdy stepstool with a handrail and wide steps.
• Add more lights in rooms.
• Keep a cordless phone or cell phone with you so that you don’t have to rush to the phone when it rings. In addition, if you fall, you can call for help.
• Consider having a personal emergency-response system; you can use it to call for help if you fall.

Other tips that can help you manage your osteoporosis include:

• Talking with other people who have osteoporosis.
• Reaching out to family and friends for support.
• Learning about the disorder and treatments to help you make decisions about your care.

There have been fewer research studies on osteoporosis in men than in women. However, experts agree that all people should take the following steps to preserve their bone health:

• Avoid smoking, reduce alcohol intake, and increase your level of physical activity.
• Ensure a daily calcium intake that is adequate for your age.
• Ensure an adequate intake of vitamin D. Dietary vitamin D intake should be 600 IU (International Units) per day up to age 70. Men over age 70 should increase their uptake to 800 IU daily (see table below). The amount of vitamin D found in 1 quart of fortified milk and most multivitamins is 400 IU.
• Engage in a regular regimen of weight-bearing exercises in which bones and muscles work against gravity. This might include walking, jogging, racquet sports, climbing stairs, and team sports. Resistance exercises, such as lifting weights and using resistance machines, are also important. A doctor should evaluate the exercise program of anyone already diagnosed with osteoporosis to determine if twisting motions and impact activities, such as those used in golf, tennis, or basketball, need to be curtailed.
• Discuss with your doctor the use of medications that are known to cause bone loss, such as glucocorticoids.
• Recognize and seek treatment for any underlying medical conditions that affect bone health.

Recommended calcium and vitamin D intakes