London Osteoporosis Clinic · Course 9

Osteoporosis in Men

Osteoporosis is a common condition in which bones become weaker and more likely to break (fracture).

Healthy bone is living tissue. Throughout life, old bone is continually removed and replaced with new bone in a process known as bone remodelling. Osteoporosis develops when bone is lost more quickly than it can be replaced, leading to reduced bone strength.

The condition is characterised by both:

• a reduction in bone mineral density (bone mass), and
• deterioration of the microscopic structure (microarchitecture) of bone.

Together these changes make bones more fragile.

Because bone loss occurs silently over many years, osteoporosis usually causes no symptoms until a fracture occurs. For this reason it is often called the "silent disease."

Fragility fractures occur after a minor fall or even a simple everyday activity that would not normally break a healthy bone.

The most common fracture sites

• the spine (vertebrae)
• the hip
• the wrist
• the upper arm (proximal humerus)
• the pelvis

Although osteoporosis itself is painless, the fractures it causes can lead to:

• severe pain
• loss of independence
• reduced mobility
• reduced quality of life
• increased risk of future fractures
• premature death

Hip fractures are particularly serious. Around one in five people die within the first year following a hip fracture, with mortality being even higher in men.

Osteoporosis in men

Osteoporosis is often thought of as a women's disease, but it affects men too.

Approximately one in five men over the age of 50 will sustain an osteoporosis-related fracture during their lifetime — making the lifetime risk greater than that of developing prostate cancer.

After one fragility fracture, the risk of another fracture increases substantially, making early diagnosis and treatment particularly important.

A growing public health challenge

As populations age and people live longer, osteoporosis and fragility fractures are becoming an increasing global health challenge.

Fortunately, osteoporosis is one of the few chronic diseases that can often be:

• identified before a fracture occurs,
• investigated for underlying causes,
• prevented through lifestyle measures,
• monitored over time, and
• effectively treated when appropriate.

Early recognition, good nutrition, regular weight-bearing and resistance exercise, falls prevention, and targeted medical treatment can dramatically reduce fracture risk and help people maintain independence throughout later life.

Osteoporosis is one of the most common long-term health conditions affecting older men, yet it remains widely under-recognised.

Although often regarded as a disease affecting women, osteoporosis is also a major cause of fractures, disability and loss of independence in men. Most men who develop osteoporosis have no symptoms until they experience a fragility fracture, making early identification particularly important.

In the UK, an estimated 820,000 men are living with osteoporosis, alongside almost 3 million women. Together, around 3.8 million people are affected. Every year, more than 500,000 fragility fractures occur in the UK — approximately one fracture every minute. These fractures place a substantial burden on individuals, families and the NHS.

Osteoporosis is under-recognised in men

Despite its prevalence, osteoporosis in men remains substantially underdiagnosed and undertreated.

Many men — and sometimes healthcare professionals — continue to think of osteoporosis as a condition that primarily affects women. As a result, many men are only diagnosed after experiencing their first fragility fracture, representing a missed opportunity for prevention.

Compared with women, men are less likely to undergo bone density (DXA) scanning, are often diagnosed later, and are less likely to receive appropriate treatment despite having similar — or in some cases worse — outcomes following fractures.

Approximately one in five men over the age of 50 will experience an osteoporosis-related fracture during their remaining lifetime. This lifetime risk is greater than the risk of developing prostate cancer.

Hip fractures in men

Hip fractures are among the most serious consequences of osteoporosis.

Although women sustain more hip fractures overall, around one-third of all hip fractures occur in men. Men are also more likely to experience complications following a hip fracture and have a higher risk of death than women of a similar age.

Fragility fractures frequently result in prolonged hospital admission, loss of independence, reduced mobility, persistent pain and reduced confidence. Many people never regain their previous level of function after a major fracture.

A growing public health challenge

As populations continue to age, osteoporosis is expected to become an even greater healthcare challenge over the coming decades. Earlier identification of people at risk, better public awareness and timely intervention are therefore becoming increasingly important.

The encouraging news is that osteoporosis is not an inevitable consequence of ageing. Many fractures can be prevented by identifying underlying causes, optimising nutrition, maintaining adequate calcium, vitamin D and protein intake, undertaking regular weight-bearing and resistance exercise, reducing falls risk, and using appropriate medical treatment when indicated.

At the London Osteoporosis Clinic, we believe that prevention is always better than treatment. By understanding risk early and taking action before fractures occur, many people can maintain stronger bones, preserve their independence and continue living active, healthy lives.

Factors determining bone development

The strength of your bones in later life depends not only on what happens during adulthood, but also on how well your skeleton develops during childhood and adolescence.

Bone is living tissue that continually grows, remodels and strengthens. During childhood and the teenage years, the body builds bone faster than it removes it. This allows the skeleton to increase in both size and strength.

Most people reach their peak bone mass — the greatest amount of bone they will ever have — by their late twenties or early thirties. The higher this peak, the greater the "bone reserve" available later in life, reducing the risk of osteoporosis and fractures as we age.

Exercise

Regular physical activity is one of the most important influences on bone development.

Weight-bearing activities, running, jumping, climbing and resistance exercise stimulate bones to become stronger. Children and adolescents who are more physically active generally achieve a higher peak bone mass than their less active peers.

Encouraging regular exercise during childhood and adolescence is therefore one of the most effective strategies for reducing the future risk of osteoporosis.

Calcium

Calcium is an essential building block of bone.

A substantial proportion of adult bone mass is acquired during puberty, making adolescence a particularly important period for ensuring adequate calcium intake.

Most children and young people can obtain sufficient calcium through a healthy, balanced diet that includes dairy products or suitable calcium-rich alternatives, green vegetables, nuts and fortified foods where appropriate.

Vitamin D

Vitamin D is essential because it helps the body absorb calcium efficiently.

Severe vitamin D deficiency causes rickets in children, but even milder deficiency may impair bone development and prevent children from achieving their full bone-strength potential.

Because vitamin D is produced in the skin following sunlight exposure, deficiency is common in many countries, particularly during winter months and in individuals with limited sun exposure or darker skin pigmentation.

Where appropriate, vitamin D supplementation should be considered in accordance with national guidance.

Protein

Protein is another essential nutrient for healthy bone development.

Bones are not made of calcium alone. Approximately half of bone volume consists of a collagen-rich protein framework upon which minerals such as calcium and phosphorus are deposited.

Adequate protein intake supports both bone formation and muscle development. Strong muscles improve balance, physical function and place healthy loads on bone, encouraging it to become stronger.

Protein also stimulates the production of insulin-like growth factor-1 (IGF-1), an important hormone involved in normal growth and skeletal development.

Building stronger bones for life

Genes influence bone strength, but lifestyle choices also play a major role. The combination of:

• regular weight-bearing and resistance exercise
• adequate calcium intake
• sufficient vitamin D
• a healthy protein intake
• avoiding smoking and excessive alcohol in later life

helps maximise peak bone mass and provides the strongest possible foundation for lifelong bone health.

Your bones are living tissue that continually grow, strengthen and remodel throughout life.

During childhood and adolescence, the body builds bone much faster than it removes it. This allows the skeleton to increase in both size and strength, laying the foundation for lifelong bone health.

Most people reach their peak bone mass between 20 and 30 years of age. This represents the maximum amount of bone they will ever have.

The higher your peak bone mass, the greater your "bone reserve" for later life. This reserve helps delay the development of osteoporosis and reduces the risk of fragility fractures as we age.

The graph below illustrates how bone mass changes throughout life in males and females

Understanding the graph

During childhood, boys and girls develop bone at a similar rate.

At puberty, bone growth accelerates rapidly in both sexes under the influence of hormones, nutrition and physical activity.

Boys generally continue growing for longer and develop larger bones with a greater peak bone mass than girls. This is largely due to the effects of testosterone, growth hormone and insulin-like growth factor-1 (IGF-1), together with increased muscle mass and greater mechanical loading of bone.

Although genetics play an important role in determining peak bone mass, lifestyle factors also have a major influence.

Building the strongest possible skeleton

The most important factors that help maximise peak bone mass are:

• Regular weight-bearing and resistance exercise
• Adequate calcium intake
• Sufficient vitamin D
• A healthy protein intake
• Normal hormone levels
• Good general health during childhood and adolescence

Children and young adults who exercise regularly and consume a balanced diet generally develop stronger bones than those who are inactive or have poor nutrition.

Why does this matter?

Bone loss begins gradually from around the fourth decade of life.

Everyone loses bone as they age, but people who begin adulthood with a stronger skeleton have a much larger "bone reserve." It therefore takes much longer before bone strength falls to the level where osteoporosis develops.

Think of your skeleton as a bone savings account. The more bone you build during the first 30 years of life, the more you have available to draw upon during the decades that follow.

For this reason, encouraging healthy lifestyles in childhood and adolescence is one of the most effective long-term strategies for preventing osteoporosis.

Between the ages of 30 and 60, most people have reached their peak bone mass. During this stage of life, the primary objective is to maintain bone strength and minimise bone loss.

Although bone is continually renewed throughout adulthood, the balance between bone formation and bone breakdown gradually changes with age. From around the fourth decade of life, bone breakdown slowly begins to exceed bone formation, resulting in a gradual decline in bone mass.

Fortunately, this process can be influenced by healthy lifestyle choices.

Maintain muscle as well as bone

Healthy muscles are essential for healthy bones.

Muscles generate the forces that stimulate bones to remain strong. Maintaining muscle mass and strength also improves balance, mobility and coordination, helping to reduce the risk of falls and fractures.

Age-related loss of muscle, known as sarcopenia, often begins during midlife. Regular resistance exercise and adequate protein intake are among the most effective ways to slow this process.

Protect your bones

The years between 30 and 60 provide an important opportunity to preserve bone health. Simple measures can make a significant difference:

• Take regular weight-bearing and resistance exercise.
• Maintain adequate calcium, vitamin D and protein intake.
• Maintain a healthy body weight.
• Avoid smoking.
• Keep alcohol within recommended limits.
• Identify and treat medical conditions that may weaken bone.
• Review medications that can affect bone health, particularly long-term corticosteroids.

For men, this is also the time to consider other factors that influence bone health, including testosterone levels, chronic inflammatory diseases, gastrointestinal disorders and certain medications.

Why this stage matters

The stronger your bones remain during midlife, the lower your risk of osteoporosis and fragility fractures in later life.

Maintaining bone health is far easier than trying to restore it after substantial bone loss has occurred.

After the age of 60, bone loss generally accelerates, making the preservation of bone strength increasingly important.

Although some bone loss is a normal part of ageing, osteoporosis is not an inevitable consequence of growing older. Many people maintain strong, healthy bones well into later life through appropriate lifestyle measures, early diagnosis and, when required, effective treatment.

Bone and muscle work together

Healthy ageing depends on maintaining both bone and muscle.

As we grow older, muscle mass and strength naturally decline, a condition known as sarcopenia. This increases the risk of falls, while weaker bones increase the risk that a fall will result in a fracture.

For this reason, maintaining muscle strength, balance and mobility becomes just as important as preserving bone density.

Preventing fractures

Fragility fractures can have a major impact on health and independence.

Hip and spinal fractures are associated with:

• loss of independence
• reduced mobility
• persistent pain
• admission to hospital
• increased need for social care
• reduced quality of life
• an increased risk of premature death

Fortunately, many fractures can be prevented.

Looking for underlying causes

Osteoporosis in older men is frequently associated with underlying medical conditions or medications.

Common causes include:

• Low testosterone (hypogonadism)
• Long-term corticosteroid treatment
• Excessive alcohol consumption
• Smoking
• Vitamin D deficiency
• Chronic kidney disease
• Gastrointestinal disorders causing poor nutrient absorption
• Inflammatory diseases
• Certain cancer treatments

Identifying and treating these underlying causes is an important part of osteoporosis management.

Staying active

The most effective strategies for maintaining bone health after the age of 60 include:

• Regular weight-bearing and resistance exercise
• Balance and flexibility training to reduce falls
• Adequate calcium, vitamin D and protein intake
• Avoiding smoking
• Keeping alcohol within recommended limits
• Maintaining a healthy body weight
• Reviewing medications that may affect bone health
• Bone density assessment (DXA) when appropriate
• Taking osteoporosis medication when indicated

Remaining physically active is one of the best ways to preserve bone strength, muscle function and independence.

Unlike osteoporosis in women, osteoporosis in men is more likely to have an identifiable underlying cause.

This is one of the reasons why every man diagnosed with osteoporosis should undergo a thorough clinical assessment. Identifying and treating the underlying cause may slow bone loss, improve bone strength and reduce the risk of future fractures.

At the London Osteoporosis Clinic, investigating why osteoporosis has developed is a fundamental part of our holistic approach to care.

Common causes

The most common causes of osteoporosis in men include:

• Low testosterone (hypogonadism)
• Long-term corticosteroid therapy (for example, prednisolone)
• Vitamin D deficiency
• Inadequate calcium intake
• Smoking
• Excessive alcohol consumption
• Family history (genetic predisposition)
• Physical inactivity

Medical conditions associated with osteoporosis

A number of medical conditions can weaken bone, including:

• Hyperthyroidism (thyrotoxicosis)
• Primary hyperparathyroidism
• Type 1 and Type 2 diabetes
• Chronic kidney disease
• Chronic liver disease
• Coeliac disease and other conditions causing poor nutrient absorption
• Inflammatory bowel disease
• Rheumatoid arthritis
• Ankylosing spondylitis
• Cushing's syndrome

Medications that affect bone health

Certain medications increase the risk of osteoporosis, particularly when used for prolonged periods. These include:

• Corticosteroids
• Antiepileptic medications
• Androgen deprivation therapy for prostate cancer
• Some immunosuppressive medications
• Long-term anticoagulation with warfarin in selected patients

If you are prescribed one of these medications, your healthcare professional may recommend lifestyle measures, bone density assessment or treatment to help protect your bones.

Less common and rare causes

Less common causes include:

• Low body weight (BMI below 20 kg/m²)
• Hypercalciuria
• Multiple myeloma
• Human immunodeficiency virus (HIV) infection and some HIV treatments
• Mastocytosis
• Osteogenesis imperfecta and other rare inherited bone disorders

Although individually uncommon, these conditions should be considered when osteoporosis develops at a young age, is unusually severe or does not respond as expected to treatment.

Why identifying the cause matters

Osteoporosis is not simply a consequence of ageing.

In many men, there are one or more reversible factors contributing to bone loss. Identifying and treating these underlying causes, alongside optimising nutrition, exercise and lifestyle, provides the best opportunity to improve bone health and reduce fracture risk.

Testosterone plays an important role in maintaining healthy bones throughout adult life.

Low testosterone levels, a condition known as hypogonadism, are one of the most common secondary causes of osteoporosis in men. For this reason, testosterone deficiency should always be considered when assessing a man with osteoporosis or an unexplained fragility fracture.

How does testosterone affect bone?

Testosterone helps to:

• Maintain bone formation
• Preserve muscle mass and strength
• Improve balance and physical function
• Reduce the risk of falls and fractures

Some testosterone is also converted into oestrogen, which is essential for maintaining bone density in men. Both hormones play important roles in lifelong skeletal health.

Symptoms of testosterone deficiency

Men with low testosterone may experience:

• Reduced libido
• Erectile dysfunction
• Fatigue
• Loss of muscle mass and strength
• Reduced body hair
• Low mood
• Reduced energy
• Osteoporosis or fragility fractures

Some men have few symptoms, making blood tests an important part of the assessment when osteoporosis is diagnosed.

Causes of hypogonadism

Hypogonadism is broadly divided into primary and secondary forms.

Primary hypogonadism (testicular causes)

In primary hypogonadism, the testes are unable to produce sufficient testosterone despite normal stimulation from the brain.

Causes include:

• Klinefelter syndrome (47,XXY)
• Undescended testes (cryptorchidism)
• Loss or injury of the testes
• Mumps orchitis
• Chemotherapy or radiotherapy
• Testicular trauma or torsion
• Excessive alcohol consumption
• Chronic liver or kidney disease
• Haemochromatosis

Secondary hypogonadism (pituitary or hypothalamic causes)

In secondary hypogonadism, the testes are normal but receive insufficient hormonal stimulation from the pituitary gland or hypothalamus.

Causes include:

• Pituitary tumours
• Prolactinoma
• Head injury
• Cranial surgery or radiotherapy
• Chronic illness
• Excessive exercise combined with low body weight
• Certain medications, including long-term opioids
• Androgen deprivation therapy for prostate cancer

Assessment

Men with osteoporosis should undergo appropriate blood tests to assess testosterone levels and, where indicated, other hormones such as luteinising hormone (LH), follicle-stimulating hormone (FSH), prolactin and thyroid function.

The results help distinguish between primary and secondary hypogonadism and guide further investigation.

Treatment

Treatment depends on the underlying cause.

Where appropriate, correcting testosterone deficiency may help improve bone density, muscle strength and quality of life. However, testosterone replacement therapy is not suitable for every man and should only be considered following specialist assessment.

Lifestyle measures — including resistance exercise, adequate protein intake, vitamin D optimisation and appropriate osteoporosis treatment — remain essential components of care.

One of the greatest barriers to improving bone health in men is the misconception that osteoporosis only affects women.

Although women are affected more frequently, millions of men worldwide also have osteoporosis, and many remain undiagnosed until after they have sustained a fragility fracture.

Osteoporosis is a condition that affects both men and women. The difference is that men are often diagnosed later and are therefore more likely to experience serious complications before treatment begins.

The facts

• Osteoporosis affects men as well as women.
• Approximately 1 in 5 men over the age of 50 will experience an osteoporosis-related fracture during their lifetime.
• Around one-third of all hip fractures occur in men.
• Men have a higher risk of disability and death following a hip fracture than women of a similar age.
• Osteoporosis in men is frequently under-recognised and underdiagnosed.
• Many men are first diagnosed only after experiencing a fragility fracture.
• Healthy lifestyle choices throughout life can substantially reduce the risk of osteoporosis.
• Early diagnosis and appropriate treatment can prevent many fractures.

Why awareness matters

Changing the perception of osteoporosis is essential.

If men, their families and healthcare professionals recognise that osteoporosis is also a male disease, more people at risk can be identified before fractures occur.

Earlier diagnosis allows time to:

• identify underlying causes
• optimise nutrition
• encourage regular weight-bearing and resistance exercise
• reduce falls risk
• start appropriate treatment where necessary

This can help preserve bone strength, maintain independence and reduce the risk of future fractures.

The message to remember

Osteoporosis is not an inevitable part of ageing, and it is not exclusively a woman's disease.

Strong bones are important for everyone.

Understanding your risk, adopting healthy lifestyle habits and seeking assessment when appropriate can make a significant difference to lifelong bone health.

Despite growing awareness, osteoporosis in men continues to be under-recognised, underdiagnosed and undertreated throughout the world.

Many men are not investigated until after they have sustained a fragility fracture. This represents a missed opportunity to identify osteoporosis earlier and prevent future fractures.

Although clinical guidance has improved considerably over recent years, significant gaps remain between what is recommended and what happens in everyday clinical practice.

The diagnosis gap

Many men with osteoporosis remain undiagnosed. Common reasons include:

• Osteoporosis is still widely perceived as a condition affecting only women.
• Bone health is often not discussed during routine health assessments in men.
• Men are less likely to undergo bone density (DXA) scanning.
• Fragility fractures may not always trigger further investigation for osteoporosis.

As a result, osteoporosis is frequently diagnosed only after a major fracture has occurred.

The treatment gap

Even after a fragility fracture, many men do not receive appropriate osteoporosis assessment or treatment.

This is known as the osteoporosis treatment gap.

Every fragility fracture should prompt an assessment of future fracture risk and consideration of measures to prevent further fractures, including lifestyle advice, investigation for underlying causes and, where appropriate, osteoporosis medication.

The implementation gap

The scientific evidence supporting the diagnosis and treatment of osteoporosis in men has grown substantially over the past two decades.

National and international guidelines increasingly recognise that men should be assessed and treated according to their fracture risk rather than their sex.

However, translating evidence into routine clinical practice remains a challenge in many healthcare systems.

Closing the gap

Improving care for men with osteoporosis requires:

• Greater public awareness that osteoporosis affects men as well as women.
• Earlier identification of people at increased fracture risk.
• Investigation of underlying causes, including testosterone deficiency.
• Timely bone density (DXA) assessment where appropriate.
• Better access to evidence-based treatment.
• Coordinated fracture prevention services, including Fracture Liaison Services (FLS).

Earlier diagnosis and treatment can substantially reduce the risk of future fractures and help maintain independence and quality of life.

At the London Osteoporosis Clinic, our approach is to identify osteoporosis before fractures occur whenever possible, investigate why bone loss has developed, and provide personalised care that combines lifestyle measures with appropriate medical treatment.

Why this matters

A diagnosis of osteoporosis does not automatically mean lifelong medication.

The most effective treatment plan begins by understanding why osteoporosis has developed and addressing the factors that can still be improved. Medication is important for some people, particularly those at high risk of fracture, but it should usually form part of a broader strategy rather than being the entire treatment.

Our holistic approach

At the London Osteoporosis Clinic, we aim to identify and address the underlying causes of osteoporosis wherever possible.

Treatment may include:

• Optimising nutrition
• Ensuring adequate protein intake
• Correcting vitamin D deficiency
• Using calcium only when appropriate
• Building muscle strength through progressive exercise
• Improving balance and reducing falls risk
• Treating underlying medical conditions
• Reviewing medications that may affect bone health
• Supporting long-term healthy lifestyle habits

Our goal is to improve bone strength, reduce fracture risk and help people maintain independence for as long as possible.

When is medication needed?

Not everyone requires medication.

However, drug treatment can significantly reduce fracture risk in people who have:

• Previous fragility fractures
• Very low bone density
• A high calculated fracture risk
• Rapid bone loss
• Certain medical conditions affecting bone

The choice of treatment depends on your overall risk profile, medical history and personal circumstances.

Medicines used in osteoporosis

Treatment is personalised

There is no single treatment that is right for everyone.

The best results come from combining:

• An accurate diagnosis
• Treatment of underlying causes
• Healthy nutrition
• Regular weight-bearing and resistance exercise
• Falls prevention
• Appropriate medication when indicated
• Ongoing monitoring

Treatment should be reviewed regularly and adjusted as your health and fracture risk change.

Osteoporosis is a common condition that affects both men and women, yet it remains under-recognised in men.

The good news is that osteoporosis is not an inevitable consequence of ageing. Many fractures can be prevented through earlier identification of people at risk, investigation of underlying causes, healthy lifestyle choices and, when appropriate, effective medical treatment.

Throughout this course, you have learned that:

• Bone health begins in childhood and continues throughout life.
• Strong bones depend on regular exercise, good nutrition, adequate vitamin D and protein, and healthy lifestyle habits.
• Many men with osteoporosis have an identifiable and sometimes reversible underlying cause.
• Osteoporosis is often silent until a fracture occurs, making early assessment particularly important.
• Modern treatments can substantially reduce fracture risk and improve quality of life.

At the London Osteoporosis Clinic, our approach is to understand why osteoporosis has developed, optimise every aspect of bone health and provide personalised care that combines lifestyle measures with evidence-based medical treatment when appropriate.

Our aim is simple:

To help people achieve stronger bones, fewer fractures and healthier, more independent lives.

What should you do next?

If you think you may be at risk of osteoporosis, don't wait until a fracture occurs.

If your risk assessment suggests an increased risk, or if you have already experienced a fragility fracture, speak to your GP or seek assessment from a healthcare professional with expertise in bone health.

Early action can make a lifelong difference.

Remember

• Osteoporosis affects men as well as women.
• It is often silent until a fracture occurs.
• Most fractures are not inevitable.
• Many fractures can be prevented through earlier diagnosis and appropriate treatment.
• Looking after your bones today is an investment in your health, mobility and independence for the future.

Strong bones support active lives. It is never too early — or too late — to invest in your bone health.

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Written by Dr Taher Mahmud of the London Osteoporosis Clinic.
Provided for education and not a substitute for personalised medical advice.