Why Osteoporosis Isn't Just a Woman's Disease

Men often fail to recognize osteoporosis risk

Man rowing in canoe
Hero Images/Getty Images

Osteoporosis, a disease that causes the skeleton to weaken and bones to break, is a significant threat to more than two million men in the U.S. Experts estimate that:

  • One-fifth to one-third of all hip fractures occur in men.
  • Symptomatic vertebral (spine) fractures occur about half as often in men as in women.
  • After age 50, 6 percent of men will suffer a hip fracture due to osteoporosis.

Despite these compelling figures, a majority of American men view osteoporosis solely as a disease of women, according to a 1996 Gallup Poll.

More importantly, of men whose lifestyle habits put them at increased risk for osteoporosis, few recognize the disease as a significant threat to their mobility and independence.

Osteoporosis develops less often in men than in women because men have larger skeletons, bone loss starts later and progresses more slowly, and there is no period of rapid hormonal change and accompanying rapid bone loss. However, 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 double between 1993 and 2050.

More information is needed about the causes and treatment of osteoporosis in men. Researchers are beginning to turn their attention to this long-neglected group. For example, in 1999, the NIH launched a major research effort that focused on many unanswered questions. The seven-year, multi-site study followed more than 5,000 men, ages 65 and older, to determine how much the risk of fracture in men is related to:

  • bone mass and structure
  • biochemistry
  • lifestyle
  • tendency to fall
  • other factors

The results of such studies help physicians better understand how to prevent, manage, and treat osteoporosis in men.

What Causes Osteoporosis in Men?

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. The amount of tissue or bone mass in the skeleton reaches its maximum amount when we are in our late 20s. 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.

In their 50s, men do not experience the rapid loss of bone mass that women have 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.

Once bone is lost, it cannot be replaced. Excessive bone loss causes bone to become fragile and more likely to fracture. This condition, known as osteoporosis, is called a "silent disease" because it progresses without symptoms until a fracture occurs.

Fractures resulting from osteoporosis can be permanently disabling and most commonly occur in the:

Hip fractures are likely to be disabling. Perhaps because such fractures tend to occur at older ages in men than in women, men who sustain hip fractures are more likely to die from complications than are women.

More than half of all men who suffer a hip fracture are discharged to a nursing home, and 79 percent of those who survive for one year after a hip fracture still live in nursing homes or intermediate care facilities.

What Are the Risk Factors for Osteoporosis in Men?

Several risk factors have been linked to osteoporosis in men:

  • chronic diseases that affect the kidneys, lungs, stomach, and intestines or alter hormone levels
  • undiagnosed low levels of the sex hormone testosterone
  • unhealthy lifestyle habits (e.g., smoking, excessive alcohol use, low calcium intake, inadequate physical exercise)
  • age — the older you are, the greater your risk
  • heredity (a son is almost four times as likely to have low bone mineral density (BMD) if his father has low BMD, and nearly eight times as likely if both parents have low BMD)
  • race (Caucasian men appear to be at particularly high risk, but all men can develop osteoporosis)

Primary and Secondary Osteoporosis in Men

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

  • Glucocorticoid excess
  • Other immunosuppressive drugs
  • Anticonvulsant drugs
  • Hypogonadism
  • Alcohol excess
  • Smoking
  • COPD
  • Asthma
  • Cystic fibrosis
  • Gastrointestinal disease
  • Hypercalciuria (a disorder that causes too much calcium to be lost in the urine)
  • Hyperthyroidism
  • Hyperparathyroidism
  • Immobilization

Glucocorticoid excess

Glucocorticoids include steroid medications, such as prednisone.

Bone loss is a very common side effect of these drugs. In fact, exposure to glucocorticoids accounts for 16-18% of osteoporosis in men. The damage these drugs 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.

Bone mass often decreases quickly and continuously with ongoing use of glucocorticoids, with most of the bone loss in the ribs and vertebrae. About one-third of patients have evidence of vertebral fractures after 5 to 10 years of treatment with glucocorticoids. The risk of hip fracture is increased nearly three-fold.

Therefore, patients taking these medications should talk to their doctor about having a bone mineral density (BMD) test. Men should also be tested to monitor testosterone levels, as glucocorticoids often reduce testosterone in the blood.

A treatment plan to minimize damage to bone during long-term glucocorticoid therapy may include:

  • using the minimal effective dose
  • discontinuation of the drug when practical
  • topical (skin) administration if possible

Adequate calcium and vitamin D nutrition is important, as these nutrients help reduce the impact of glucocorticoids on bone. Other possible treatments include testosterone replacement and medication. Alendronate and risedronate are two bisphosphonate drugs approved by the FDA for use by men and women with glucocorticoid-induced osteoporosis.


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 the sex hormones may also cause osteoporosis. In fact, it is estimated that up to 30% of men with osteoporotic vertebral fractures have low testosterone levels. While it is natural for testosterone levels to decrease with age, there should not be a sudden drop in this hormone comparable to the drop in estrogen experienced by women at menopause. However, medications like steroids, 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 will usually treat the osteoporosis directly, using medications approved for this purpose.

Research suggests that estrogen deficiency may 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 of estrogen action. Therefore, the role of estrogen in men is under 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 found in 25 to 50% of men who seek medical help for alcohol abuse. One early study found the bone mass of young alcoholic males to be comparable to that of elderly females. In cases where bone loss is linked to alcohol abuse, the first goal of treatment is, of course, to help the patient stop or at least reduce his consumption of alcohol.


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, of course, as smoking is harmful in many ways.

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. Treatment for bone loss in this case may include supplementation of the poorly absorbed nutrient(s).

How Is Osteoporosis Diagnosed in Men?

Osteoporosis can be effectively treated if detected before significant bone loss has occurred. A medical work-up to diagnose osteoporosis will include:

  • a complete medical history
  • x-rays
  • urine and blood tests

The doctor may also order a BMD test (bone mineral density test) or bone mass measurement. The BMD is safe, accurate, quick, painless, and non-invasive and can be used to detect low bone density, predict risk for future fractures, diagnose osteoporosis and monitor the effectiveness of treatments.

It is increasingly common for women to be diagnosed with osteoporosis or low bone mass using a BMD test, often at mid-life when doctors begin to watch for signs of bone loss. In men, however, the diagnosis is often not made until the patient sees his doctor complaining of back pain or until a fracture occurs. This makes it especially important for men to inform their doctor about:

  • risk factors for developing osteoporosis
  • loss of height
  • change in posture
  • fracture
  • sudden back pain

Some doctors may be unsure how to interpret the results of a BMD test in male patients. For example, it is not known whether the guidelines used to diagnose osteoporosis or low bone mass in women (developed by the World Health Organization) are also appropriate for men. Until that question is answered and until separate criteria are established for men, if necessary, most experts suggest using the WHO criteria for men.

What Treatments Are Available?

Once a man has been diagnosed with osteoporosis, his doctor may prescribe one of the medications approved by the Food and Drug Administration (FDA) for this disease.

  • Fosamax (alendronate) has been approved for the treatment of the disease in men and postmenopausal women.
  • Actonel (risedronate) and Fosamax (Alendronate) are approved for the treatment of glucocorticoid-induced osteoporosis in both men and women.
  • Forteo (teriparatide) is approved for the treatment of osteoporosis in men and women who are at increased risk of fracture.

The treatment plan will also likely include other nutrition, exercise, and lifestyle guidelines for preventing bone loss.

If bone loss is due to glucocorticoid use, the doctor may prescribe a bisphosphonate, monitor bone density and testosterone levels and may suggest using the minimal effective dose of glucocorticoid or discontinuing the drug when practical.

Other possible prevention or treatment approaches include:

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

Recommendations for Calcium and Vitamin D Intake in Men

  • Age 19-30: 1,000 mg. calcium and (no recommendation) for vitamin D
  • Age 31-50: 1,000 mg. calcium and 200 IU vitamin D
  • Age 51-70: 1,200 mg. calcium and 400 IU vitamin D
  • Age 70+: 1,200 mg. calcium and 600 IU vitamin D
  • Upper limit: 2,500 mg. calcium and 2000 IU vitamin D

How Can Osteoporosis Be Prevented in Men?

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.
  • Increase levels of physical activity.
  • Ensure a daily calcium intake that is adequate for your age.
  • Discuss with your doctor the use of medications, such as corticosteroids, that are known to cause bone loss.
  • Recognize and treat any underlying medical conditions that affect bone health.
  • Ensure an adequate vitamin D intake. (Normally, the body makes enough vitamin D from exposure to as little as 10 minutes of sunlight a day. If exposure to sunlight is inadequate, dietary vitamin D intake should be at least 400 IU but not more than 800 IU/day; 400 IU is the amount found in one quart of fortified milk and most multivitamins.)
  • Engage in a regular regimen of weight-bearing exercise where bones and muscles work against gravity.

Weight-bearing exercise includes:

  • walking
  • jogging
  • racquet sports
  • stair climbing
  • team sports
  • lifting weights
  • using resistance machines

A doctor should evaluate the exercise program of anyone already diagnosed with osteoporosis or arthritis to determine if twisting motions and impact activities, such as those used in golf, tennis, or basketball, need to be curtailed.


Osteoporosis in Men. NIH Osteoporosis and Related Bone Diseases. National Resource Center. June 2015.

Continue Reading