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We usually think of osteoporosis as a woman's disease. But it's common in men too, and often more serious. The solution is to screen men at risk and treat them.
We usually think of osteoporosis as a woman's condition. In fact, it affects men commonly too. And just as in women, the consequences are serious falls, fractures, pain, restricted mobility, and an increased likelihood of death in the months following a fracture.
Right now, the chance of a woman getting an osteoporosis-related fracture sometime in her life is one in three, compared to one in five for men. But both men and women are living longer: and the longer they do, the more likely it is that rates of fracture in men will catch up with those in women.
The Australian and New Zealand Bone and Mineral Society says the number of hip fractures in elderly Australian men is expected to double by the year 2026, and quadruple by 2051.
In men, the consequences of an osteoporotic fracture tend to be more severe than in women. The reason for this is that, in old age, a man is more likely to have other serious conditions like heart disease making complications from the fracture more likely. One year on from an osteoporotic fracture, a man is twice as likely as a woman to have died from its consequences.
So we can expect to hear a lot more about osteoporotic fractures in men in the years ahead.
For now, though, we still tend to think of osteoporosis as a woman's condition, and because of this, men tend to slip through the net. They're not diagnosed as often as women, or they're diagnosed later by which time the damage is done.
The thinning of the bone can't be reversed. But osteoporosis can be prevented, which is why it's important that men who are at risk are identified and steps taken to slow the rate of bone loss.
That's the view of the American College of Physicians, which has come out recommending that men at high risk be screened, and treated to slow bone loss if they have osteoporosis.
How do they define men at risk? They've adopted the findings of a review of the medical literature published in the Annals of Internal Medicine. It looked at 177 studies of more than 28,000 men, and defined 'at risk' as being men who are older than 70 years, men who have low body weight or have lost weight, and men who are physically inactive.
Other less significant risk factors are high alcohol consumption, smoking, and taking certain medications, in particular corticosteroids (commonly used for arthritis and chronic asthma). These men should be offered screening and treatment, the College says.
Osteoporosis can show up in ordinary X-rays and in ultrasound tests, but the most accurate test by far is a bone density scan, say the writers of the Annals of Internal Medicine review.
This test, technically known as a dual energy X-ray absorptiometry (DXA) test, measures bone density: that is, how much bone mineral is packed into a given area of bone. Doctors use data from the test to give two bone density scores: one compares the patient's bone density with the average for a person of the same age and sex (this is the Z-score), and the other compares their bones with those of an average young adult of the same sex (the T-score).
A Z-score or T-score of of zero means a person's bones are of average density; if below zero, their bones are less dense than average; and if greater than zero, more dense than average.
If the test shows significant osteoporosis, drug treatment is an option. The most effective drugs are the bisphosphonates, which can't reverse the thinning of bone but can slow its progress they halve the risk of osteoporotic fractures.
The American College of Physicians says that if a man is at risk of osteoporosis, and is willing to be treated, he should be offered a DXA bone scan and if it does show osteoporosis, offered treatment with bisphosphonates.
There's no official recommendation as to who should be tested for osteoporosis in Australia it's up to the GP to decide who needs to be referred for a bone scan and possible treatment.
Since April last year, though, the DXA test has been covered by Medicare for men and women aged 70 or over, or who are on corticosteroids, have had osteoporosis diagnosed in the past, or have a range of chronic illnesses associated with osteoporosis (such as thyroid and kidney disease).
If a man has a T-score of -2.5 or less, then most doctors will recommend he take bisphosphonates. Bisphosphonates on the market here include risedronate (trade name Actonel), alendronate (Fosamax) and etidronate (Didronel).
The bisphosphonates are now subsidised by the Pharmaceutical Benefits Scheme (PBS) for people who are 70 years and older and have a bone mineral density T-score of -3.0 or lower; and also for people who have had a previous fracture associated with osteoporosis.
However, some men are resistant to the idea of taking drugs for bone thinning. The widespread publicity given to a side effect of the drugs hasn't helped that is, osteonecrosis of the jawbone, in which bone in the jaw is destroyed. In fact, this side effect is a feature of very high doses of bisphosphonates used in treating cancer, not at the lower doses used to prevent osteoporosis. Side effects are in fact uncommon (nausea, heartburn, and in rare cases oesophageal irritation and ulceration).
But if a man is resistant to taking medications, or if the bone loss is milder (between 0 and -2.5), then doctors will usually advise lifestyle measures to help prevent further loss, and monitor future bone loss with further DXA scans.
Those lifestyle measures are:
These measures, by the way, are recommended for all men aged 50 years and over to prevent bone loss from occurring in the first place, whether they have risk factors or not.
Osteoporosis Australia has published new online guidelines on the DXA test, and on how to exercise and prevent fractures (follow the link under 'More info' below).