Osteoporosis in men

O R I G I N A L

A R T I C L E

Osteoporosis in men Anne M. Sutcliffe This article highlights the relative lack of knowledge and current research on osteoporosis in men.The annual cost of osteoporotic fracture in the UK is in excess of £940 million, of which 23% is due to fractures in men.Twenty per cent of symptomatic vertebral fractures and 30% of hip fractures occur in men. Bone density in men is influenced by genetic, hormonal, mechanical and nutritional factors.There is no wellestablished treatment for idiopathic osteoporosis in men, but options include bisphosphonates and testosterone supplementation. Further work is required to clarify the causes of osteoporosis in men and to develop criteria for the diagnosis of male osteoporosis. © 2001 Harcourt Publishers Ltd

Editor’s comment Men’s health has had a relatively low profile until recently. More importantly, health promotion in areas of men’s health seems to be lagging behind that of women; compare health education, screening and treatment of breast cancer in women with that of prostate cancer in men. While osteoporosis leading to fracture occurs less in men than in women it is still significant and draws heavily on health service resources. PD

KEY WORDS: male osteoporosis, osteoporotic fracture

INTRODUCTION Osteoporosis is characterized by a reduction in bone density associated with skeletal fragility and an increased risk of fracture after minimal trauma. Although osteoporosis is considered to be a condition predominantly affecting women, up to 20% of symptomatic vertebral fractures and 30% of hip fractures occur in men (Eastell et al. 1998).

EPIDEMIOLOGY OF FRACTURES IN MEN

Sister A. M. Sutcliffe BSc (Hons), RGN, HV, DN, Osteoporosis Specialist Nurse, Musculoskeletal Unit, Newcastle upon Tyne NHS Trust, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.Tel.: + 44 (0) 191 284 3111, ext 26979; Fax: + 44 (0) 191 223 1161; E-mail: anne.sutcliffe@nuth. northy. nhs. uk

The incidence of fractures with advancing age has a bimodal distribution, with peaks in youth and old age. The major osteoporotic fractures are those of the forearm, vertebral body and hip, but fractures of the humerus, tibia, pelvis and ribs also occur. The lifetime risk of symptomatic fracture for a 50year-old white man in UK has been estimated to be 2% for the forearm, 2% for the vertebra and 3% for the hip, whilst the corresponding figures for a 50year-old woman are 13%, 11% and 14% respectively (Cooper 1996). The number of men with osteoporotic fractures is rising due to increased life

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expectancy and a doubling of the age specific incidence of fracture over the past 30 years. Osteoporotic fractures are associated with marked morbidity in both men and women. Hip fracture in men can cause considerable disability; 1 year after fracture 21% will live independently, whereas 26% will receive a degree of home support and 53% will live in nursing homes (Poor et al. 1995). Men with symptomatic vertebral fractures commonly complain of back pain, height loss and kyphosis and may have less energy, poorer sleep, more emotional problems and impaired mobility compared with age-matched control subjects (Scane et al. 1999). Following hip fracture there is increased mortality of 20%, with much of this excess mortality occurring in the first year (Cooper 1993). A number of studies indicate a higher mortality after hip fracture in men than women, but the reason for this remains unclear (Poor et al. 1994). Vertebral fractures are also associated with excess mortality of about 18% at 5 years, due largely to co-existing conditions associated with osteoporosis, rather than the fracture itself (Cooper 1993). The annual cost of osteoporotic fractures in UK has been estimated at £942 million, of which 23% is due to fractures in men (Dolan & Torgerson 1998).

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CAUSES OF OSTEOPOROSIS IN MEN Osteoporosis and the risk of fracture is determined by a number of features, including bone mass, bone turnover, skeletal structure, and the frequency and severity of trauma to the skeleton. Bone mass is determined by peak bone mass, the age at which bone loss starts and the rate at which it proceeds. Absolute peak bone mass is higher in men than women with approximately 95% being attained by the age of 18 years. Genetic predisposition accounts for up to 80% of variance in peak bone mass in both sexes. Men with a family history of osteoporosis have a bone mineral density (BMD) that is lower than expected with an increased risk of vertebral fractures. Although progress is being made in elucidating the major underlying genetic factors, they remain uncertain. Other determinants of peak bone mass in men include dietary calcium intake, exercise during childhood and age at puberty (Scane & Francis 1993). In both genders, bone loss starts at approximately 35 years and ultimately men lose 15–45% of trabecular bone and 5–15% of cortical bone with advancing age. In men age-related bone loss is probably influenced by a reduction in circulating free testosterone, adrenal androgens, growth hormone and insulin-like growth factor (Seeman 1999). Other factors that have been implicated in bone loss in men include physical inactivity, tobacco and alcohol consumption, poor dietary calcium intake and vitamin D insufficiency (Scane & Francis 1993).

Secondary causes of osteoporosis The development of osteoporosis may be accelerated by underlying secondary causes of bone loss, which are found in more than 50% of men presenting with symptomatic vertebral fractures (Baillie et al. 1992). Studies from the USA and UK have shown that the major secondary causes of vertebral fractures are oral steroid therapy, hypogonadism and alcohol abuse (Scane et al. 1999). Thyroidectomy, gastric surgery and hypogonadism have been related to an increase in hip fractures in men (Poor et al. 1995). Conditions related to an increased risk of falling, particularly Parkinson’s disease, hemiparesis, vertigo and blindness, also lead to a greater risk of hip fracture (Poor et al. 1995).

DIAGNOSIS OF OSTEOPOROSIS IN MEN As osteoporosis may be asymptomatic until fractures occur, the diagnosis is often made retrospectively. Men with vertebral fractures complain of

episodes of acute back pain, which may be accompanied by height loss and kyphosis. As it is not always easy to distinguish causes of back pain it may be appropriate to perform spine X-rays if height loss and kyphosis are accompanying features. Radiological evidence of vertebral collapse is strongly associated with osteoporosis, but apparent osteopaenia on plain radiography is probably a poor indicator of reduced bone density. The introduction of dual-energy X-ray absorptiometry (DEXA) has stimulated interest in the diagnosis of osteoporosis before fractures occur. This technique can measure BMD at the spine and femoral neck with a precision of 1–1.5%. BMD measurements are, therefore, useful to confirm the diagnosis of osteoporosis and may be used to monitor response to treatment. Examination and appropriate investigation should identify secondary causes of osteoporosis. Investigations should include full blood count, erythrocyte sedimentation rate, biochemical profile, thyroid function tests, serum testosterone and sexhormone-binding globulin and gonadotrophins together with serum and urine electrophoresis in men with vertebral fractures. In elderly men, it is worth excluding vitamin-D insufficiency and associated secondary hyperparathyroidism.

MANAGEMENT OF MEN WITH OSTEOPOROSIS Men may be surprised and confused by the initial diagnosis of osteoporosis. It is important that they are given accurate information about the condition, its treatment and the long-term outlook. Literature can be obtained from the National Osteoporosis Society (NOS) who also offer advice through a nurse-led telephone help-line. Contact with a local NOS support group may also prove beneficial for some men and their families. All men with osteoporosis should be given advice on lifestyle measures to decrease bone loss. These include eating a balanced diet rich in calcium, stopping or moderating tobacco and alcohol consumption and maintaining regular physical activity throughout life. If there is a history of falls, it is important to identify intrinsic and extrinsic causes in the hope that these may be modified, and the risk of further falls and fractures decreased. There is also growing interest in the use of hip protectors, which may help to decrease the risk of femoral neck fracture in frail elderly people who fall regularly. Some men will benefit from referral to physiotherapy for general advice on posture and back exercises. In certain cases, it may be appropriate for physiotherapists to offer more specific, individualized exercise programmes. Pain is usually associated with osteoporotic fracture. Initially, this may require management with regular opiates followed by continuing analgesia

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after the acute phase has settled. The use of trans electrical nerve stimulation, acupuncture and hydrotherapy are additional options, which may be considered for some men. There are no well-established treatments for men with idiopathic osteoporosis as no published trials have specifically examined the effects of treatment on bone density and fracture incidence. Possible options include bisphosphonates, testosterone, anabolic steroids, fluoride salts, and calcium and vitamin D. Observational studies in men suggest that intermittent cyclical etidronate (Didronel PMO) increases BMD at the spine by 5–10% with smaller increases at the hip (Francis 1998). In men and women receiving oral corticosteroids, cyclical etidronate prevents bone loss from the lumbar spine and femoral neck in both sexes. A recent randomized controlled trial (RCT) showed that Alendronate (Fosamax) increased BMD at the lumbar spine by 5.3% and femoral neck by 2.6%; there was also a trend for lower vertebral fracture incidence and significant decrease in height loss in those taking Alendronate (Orwoll et al. 1999). Alendronate has also proved effective in increasing bone density in men and women taking corticosteroids with a trend for lower vertebral fracture incidence (Saag et al. 1998). Testosterone, given as intramuscular Sustanon improves bone density in men with hypogonadism and appears to increase spine bone density in eugonadal men with vertebral fractures (Scane et al. 1992). The role of calcium and vitamin-D supplementation in the management of osteoporosis in men remains unclear. In one RCT in men with normal bone density, daily supplementation with calcium and vitamin D had no effect on bone density (Orwoll et al. 1990). In contrast, an American RCT in men and women demonstrated that calcium and vitamin D had a modest beneficial effect on bone density and decreased the incidence of non-vertebral fracture (Dawson-Hughes et al. 1997). Several small studies using calcitonin, nandrolone, fluoride salts and parathyroid hormone have suggested that these agents may have a beneficial effect on bone density in men. However, these drugs are not widely available and their use is currently experimental.

CONCLUSION It is now clear that osteoporotic fractures pose an important public health problem in men and women. Although knowledge about osteoporosis in men is expanding, it is vital to guard against complacency. Further work is required to clarify the causes of osteoporosis in men and to develop

criteria for the diagnosis of male osteoporosis. RCTs are also needed to establish the most effective treatment for osteoporosis in men. Within all healthcare disciplines, there is a need for a more substantive understanding of male osteoporosis and it may be necessary to refer men with this condition to a specialist metabolic bone centre for assessment, advice and monitoring.

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