Osteoporosis in the aging male
Until recently, osteoporosis was considered a disease affecting mostly women. However, 30% of all hip fractures occur in men, suggesting that male osteoporosis is a major health issue as well. Low trauma fractures may also arise at other sites such as the vertebrae, distal forearm and proximal humerus. Although these osteoporotic fractures in elderly men occur less frequent than in women, mortality and disability following these fractures is greater in men than women. Beside advancing age, personal and familial history of fractures and low bone density as measured by dual-energy absorptiometry (DEXA) is also associated with an increased risk for fractures in elderly men. The cost-effectiveness of DEXA screening remains however a matter of debate. In addition, other risk factors such as use of corticosteroids, the presence of significant concomitant medical conditions and smoking are now well established not only in women but also in men. The association between osteoporosis and many of these risk factors is only partly explained by bone loss. Frailty of elderly men and subsequent risk of falls appears an independent risk factor for osteoporosis as well. Therefore, every model that aims to assess the absolute risk of osteoporosis in an individual should include many different cumulative risk factors. For instance, vitamin D insufficiency is common in elderly men as well as women, but low vitamin D is associated with low bone density, bone loss, risk of falls as well as risk for hip fractures in men. Recently, low estrogen as well as increased sex hormone binding globulin concentrations were also related to both bone loss as well as fracture risk in men. In contrast, the impact of age-related decline of serum testosterone concentrations in ageing men on the risk of osteoporosis as well as frailty is less well established, at least in the absence of overt hypogonadism. Therapy of osteoporosis is also less well defined in elderly men than in postmenopausal women. Nevertheless, current recommendations justify not only adequate calcium and vitamin D supplementation but also anti-osteoporotic medications such as bisphosphonates in elderly men at risk for osteoporosis. Bisphosphonates appear to have similar effects in men than women. Although the available studies in osteoporotic men are relatively small, parathyroid hormone (Teriparatide) also appears to have similar effects on bone remodeling and vertebral fracture risk in men and women. In conclusion, our current understanding of the risk factors, the diagnosis as well as therapy of osteoporosis in men is increasing rapidly.