Osteoporosis in men: causes, testing and treatment

Osteoporosis weakens bones so that they are more likely to break. The NHS describes it as developing slowly over several years and often being found only after a fall or a sudden impact causes a fracture. Women are more at risk, particularly after the menopause, but the NHS is clear that osteoporosis can also affect men, younger women and children.

For men the condition is easier to miss. Because it is less common, it is less often suspected, and a first fracture of the wrist, hip or spine may be the point at which it is recognised. The Royal Osteoporosis Society suggests that men, and especially younger men, benefit from seeing a specialist who understands the condition, since there are more factors to think through in diagnosis and treatment.

The NHS says that in most cases the cause in men is unknown, but that there is a link to testosterone, which helps keep bones healthy. The risk rises in men with low testosterone, and the NHS notes that in around half of these men the exact cause of the low level is unknown. Known causes include steroid tablets, alcohol misuse and hypogonadism, a condition that leads to abnormally low testosterone.

The Royal Osteoporosis Society takes a slightly different emphasis: it says at least half of men with osteoporosis have an underlying reason, even if it is not always found. Many causes are shared with women, including coeliac disease, steroids, eating disorders and age. Others act through very low testosterone:

• Klinefelter's syndrome and Kallmann syndrome

• injury to the testicles

• some conditions affecting the pituitary gland

• some prostate cancer drug treatments, as well as radiotherapy and chemotherapy

Hormone treatments for prostate cancer work by stopping the body making testosterone or changing how it acts, because prostate cancer cells usually need testosterone to grow. The same effect can reduce bone strength over time. The Royal Osteoporosis Society advises men on these treatments to discuss a fracture risk assessment with their doctor, who may also refer them to an osteoporosis specialist.

The national osteoporosis guideline group (NOGG) includes a dedicated section on men receiving androgen-deprivation therapy in its 2024 guideline. For anyone starting such treatment, it is reasonable to ask about bone health early.

Diagnosis follows the same principles as in women. The NHS says doctors can estimate your future risk of a broken bone using an online programme such as FRAX or QFracture, and may refer you for a bone density (DEXA) scan, which takes 10 to 20 minutes and is painless. A T-score below -2.5 is defined as osteoporosis.

NICE Clinical Knowledge Summaries add that investigations for non-osteoporotic causes of fracture and for undiagnosed secondary causes, such as an overactive thyroid, should be arranged where appropriate before relying on the risk score. For men this step carries extra weight, which is why tests for testosterone levels, coeliac disease, medicines and alcohol use are often part of the work-up. A specialist can interpret the DEXA scan in this context.

Treatment is recommended when the chance of breaking a bone is high enough that the bones would benefit. According to the Royal Osteoporosis Society, the drugs licensed for men of all ages include alendronate, risedronate, zoledronate, denosumab and teriparatide. Other osteoporosis drugs lack enough research to be sure they reduce fractures in men. Hormone replacement therapy and raloxifene are not suitable for men because they contain or act like oestrogen in bone.

The NHS describes how bisphosphonates are taken: on an empty stomach with a full glass of water, staying upright for 30 minutes, and waiting between 30 minutes and 2 hours before eating or drinking anything else. They usually take 6 to 12 months to work and may be taken for 5 years or longer. Calcium and vitamin D supplements may be added, at a different time of day.

Testosterone replacement is available as an injection or gel and is prescribed by a hospital specialist. The Royal Osteoporosis Society says it may help strengthen bones in men with very low testosterone caused by a condition, but that if your testosterone level is normal it is unlikely to help your bones, and other osteoporosis drugs exist.

It is not suitable for everyone: the society lists prostate, breast or liver cancer, heart problems, diabetes and blood clotting disorders among the reasons. Regular blood tests and blood pressure checks are needed. It is usually only offered to men under 60, because it has been linked with an increased chance of prostate cancer and heart disease as you get older, and the balance varies with age, weight, medical history and family history. The decision should be reviewed regularly.

Men often worry about physical jobs. The Royal Osteoporosis Society says you should be able to keep working, and suggests adjustments such as reducing the size of loads, cutting repetitive bending and twisting, and using safe lifting techniques that keep the back straight. It notes that an employer has a duty to make reasonable adjustments. Osteoporosis alone does not qualify for disability-related financial support, but broken bones that make everyday tasks or work hard may.

Looking after bone health follows the usual pattern: a varied calcium-rich diet, safe sun exposure, impact and strength exercise, not smoking, staying within alcohol limits and lowering the chance of falls. The NHS notes that weight-bearing exercise such as brisk walking and resistance exercise such as weights are particularly useful, whereas swimming and cycling are not weight-bearing.