Osteoporosis in Men: What to Know

Osteoporosis in men is significantly under-recognised and under-treated compared to the same condition in women. Approximately one in four men over the age of 50 will sustain a fragility fracture in their remaining lifetime, yet men are far less likely than women to receive a DEXA bone density scan, be assessed with the FRAX tool, or be started on pharmacological bone protection after a fracture. Part of the reason is historical — early research focused on postmenopausal women, and the clinical narrative of osteoporosis as a “women’s disease” persisted long after the epidemiological evidence showed otherwise. Men who sustain hip fractures have a significantly higher 12-month mortality than women with the same fracture — approximately 37% versus 20% — partly because of later diagnosis, older age at fracture, and higher burden of comorbidities.

Understanding the specific biology of male bone loss, the secondary causes that are more common in men, and the treatment approaches available is important for men, their families, and the clinicians managing their health in middle age and beyond.

The under-recognition of osteoporosis in men operates at multiple levels. Many men are unaware that osteoporosis is a risk for their sex. Many GPs do not routinely discuss bone health with male patients at the kind of midlife health reviews that routinely address it in women. And when men do sustain a fragility fracture, they are less likely than women to receive a DEXA scan, a FRAX risk assessment, or a prescription for bone protection — a gap in care that the fracture liaison service (FLS) model has been specifically designed to address, with measurable success where FLS access is equitable. Addressing this gap requires both patient awareness and clinical practice change, starting with recognition that osteoporosis in men is common, consequential, and treatable.

How Bone Loss Develops in Men

Men do not experience the equivalent of the female menopause — there is no abrupt, age-defined withdrawal of sex hormones. Instead, testosterone levels in men decline gradually from approximately the age of 30 onwards, at a rate of roughly 1–2% per year. This gradual decline means that male bone loss is less dramatic than the acute postmenopausal trajectory in women, but it is cumulative and accelerates in the 70s when testosterone falls more steeply.

Testosterone supports bone health through two mechanisms: direct androgen receptor activity in osteoblasts and osteoclasts, and conversion (aromatisation) to oestradiol — which, counterintuitively, is the primary mediator of bone turnover in men as well as women. Low oestradiol (below approximately 40 pmol/L) in men is associated with more rapid bone loss and higher fracture risk than low testosterone alone. This means that conditions causing low oestradiol in men — not just conditions causing low testosterone — are relevant to fracture risk.

Peak bone mass in men is approximately 20–25% higher than in women, largely because testosterone-driven periosteal expansion during puberty results in wider, thicker bones. This higher structural reserve means that men generally need more bone loss to reach the osteoporosis diagnostic threshold, and fractures typically occur approximately ten years later in men than in women for an equivalent skeletal condition. Hip fractures in women peak in frequency in the late 70s; in men, the equivalent peak is in the mid-80s.

Secondary Causes: More Common in Men

Secondary causes of osteoporosis — medical conditions and medications that independently reduce bone density — are identifiable in up to 60% of men who present with osteoporosis or a fragility fracture. This is a substantially higher proportion than in postmenopausal women, where the dominant cause is usually oestrogen deficiency with secondary causes present in approximately 30%. The implication is that when a man presents with osteoporosis or an unexpectedly low T-score, a thorough investigation for secondary causes is always warranted.

The most clinically important secondary causes in men are:

• Hypogonadism — low testosterone (and consequent low oestradiol) from any cause: Klinefelter syndrome, pituitary disease, chronic opioid use, haemochromatosis, or age-related decline below the reference range. Testosterone replacement can stabilise bone density in men with confirmed hypogonadism and osteoporosis.
• Androgen deprivation therapy (ADT) — used in the treatment of hormone-receptor-positive prostate cancer; suppresses testosterone to castrate levels, resulting in bone loss of 2–5% per year at the spine; fracture risk is markedly increased with prolonged ADT. Bone protection (bisphosphonate or denosumab) should be co-prescribed from the start of ADT for men with existing osteoporosis or significant fracture risk.
• Glucocorticoids — long-term prednisolone use for inflammatory conditions (COPD, inflammatory bowel disease, polymyalgia rheumatica) directly suppresses osteoblast function and increases osteoclast activity; the bone-loss effect is dose-dependent and begins within the first months of treatment
• Alcohol excess — chronic heavy alcohol use is independently associated with low bone density and increased fracture risk through direct toxic effects on osteoblasts, nutritional deficiency (calcium, vitamin D, protein), and increased falls risk
• Coeliac disease — malabsorption of calcium and vitamin D; often under-diagnosed in men; serological screening (anti-tissue transglutaminase IgA) is appropriate in men with unexplained low bone density
• Chronic kidney disease (CKD) — impairs conversion of vitamin D to its active form (calcitriol), disrupts calcium-phosphate-PTH balance, and causes renal osteodystrophy in advanced stages

Diagnosis and the FRAX Tool

The diagnostic threshold for osteoporosis in men — a DEXA T-score at the hip or spine of −2.5 or below — is the same as for women. T-scores for men are calculated against a male reference population, meaning a T-score of −2.5 in a man represents the same degree of deviation from the male peak bone mass standard deviation as it does from the female standard in women.

The FRAX tool has a specific calculation for men that accounts for the higher peak bone mass, later fracture age, and different risk factor weighting in men compared with women. FRAX inputs for men include age, body weight and height, prior fragility fracture, parental hip fracture, current smoking, alcohol use above 3 units per day, glucocorticoid use, rheumatoid arthritis, and secondary osteoporosis — with optional BMD input if a DEXA has been performed. The FRAX output gives a 10-year major fracture probability and a 10-year hip fracture probability, from which treatment decisions are made. More detail on FRAX and DEXA is in our guides to osteoporosis risk factors and bone density test: a simple guide.

Z-scores (age-matched comparisons) are particularly relevant in men under 50, where a Z-score below −2.0 indicates bone density significantly lower than expected for age and sex and should prompt thorough investigation for secondary causes.

Androgen Deprivation Therapy and Bone

ADT for prostate cancer deserves specific attention because it represents the single most common cause of severe, rapidly progressive osteoporosis in men. ADT suppresses testosterone to near-zero by either surgical castration (orchidectomy) or chemical castration (LHRH agonists such as leuprorelin or LHRH antagonists such as degarelix). The consequence is the equivalent of a sudden male menopause — oestradiol levels (which depend on peripheral aromatisation of testosterone) fall alongside testosterone, and osteoclast activity increases rapidly.

Men on ADT for two or more years who do not receive bone protection lose approximately 5–8% of spinal BMD and experience a 30–40% increase in fracture risk relative to similarly aged men not on ADT. Both zoledronate (annual intravenous infusion) and denosumab (six-monthly subcutaneous injection) have established evidence for preventing bone loss in ADT-treated men and are recommended by NICE for men with existing osteoporosis or high fracture risk on ADT. For men with a normal DEXA T-score starting ADT, baseline DEXA and monitoring are appropriate; pharmacological bone protection is initiated when the T-score falls into the osteoporosis range or fracture risk becomes sufficiently elevated on FRAX assessment.

Falls Risk and Fracture Prevention in Older Men

Falls are the proximate cause of the majority of fragility fractures in both men and women, and falls risk in older men carries its own specific profile. Men aged 75 and over who fall are more likely to sustain a hip fracture per fall than younger men, and the consequences — higher mortality, longer hospital stay, greater loss of independent living — make falls prevention as important as bone density management in this age group.

Risk factors for falls that are particularly relevant in older men include:

• Sarcopenia — age-related muscle mass loss and reduced grip strength; more prevalent and more rapidly progressive in men with hypogonadism; contributes to reduced postural stability and slower corrective responses to balance perturbation
• Orthostatic hypotension — a postural blood pressure drop of ≥20 mmHg systolic; commonly caused by antihypertensive medications, alpha-blockers used for prostate symptoms (tamsulosin, doxazosin), and dehydration; responsible for a significant proportion of falls in men with prostate-related comorbidities
• Visual impairment — uncorrected refractive error, cataracts, and glaucoma are modifiable contributions to falls risk; cataract removal has been shown to reduce hip fracture rates in older adults
• Polypharmacy — men over 75 on five or more medications have substantially higher falls risk; sedatives, antidepressants, antipsychotics, and diuretics are particularly associated with balance impairment and falls
• Balance and gait impairment — Parkinson’s disease, peripheral neuropathy (including diabetic neuropathy), and prior stroke are more prevalent in older men and significantly increase falls risk

The interaction between falls risk and bone fragility is multiplicative — a man with a T-score of −2.5 who falls twice per year has a much higher absolute fracture risk than the same T-score in a man who falls rarely. The FRAX tool accounts for falls as a secondary osteoporosis indicator via the “previous fragility fracture” variable, but does not directly incorporate falls frequency as an input — meaning clinical assessment of falls risk is an essential complement to FRAX and DEXA in older men.

Post-fracture care for men is an area of systematic underprovision. Men who sustain a hip, vertebral, or wrist fragility fracture are less likely to be referred to a fracture liaison service (FLS), less likely to receive a DEXA scan, and less likely to be started on pharmacological bone protection after the fracture than women with the same injury. Studies of FLS programmes show that proactive identification and treatment of men after fracture reduces re-fracture rates by 20–30%, equivalent to the benefit seen in women — making equitable access to post-fracture bone health services a clinical priority. Men who sustain a fragility fracture and are not automatically referred to an FLS or bone health service should ask their GP or hospital team about this specifically.

Treatment

Treatment for osteoporosis in men follows the same general principles as in women, with bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) as the first-line pharmacological intervention. Alendronate has marketing authorisation for male osteoporosis in the UK and is NICE-recommended. The evidence for fracture reduction in men is less extensive than in women, but bisphosphonate-treated men with osteoporosis show comparable improvements in BMD to women, and the mechanism of action — osteoclast inhibition — is the same in both sexes.

Denosumab (60 mg subcutaneous injection every six months) is licensed for male osteoporosis and is an effective alternative for men who cannot tolerate oral bisphosphonates or have renal impairment that precludes bisphosphonate use. Teriparatide (recombinant PTH, used for two years in severe osteoporosis with multiple vertebral fractures) is also licensed for use in men. Full detail on pharmacological treatments is in our guide to osteoporosis: symptoms, causes, and prevention.

Calcium (700–1,200 mg/day) and vitamin D (400–800 IU/day supplementation) are co-prescribed with all pharmacological treatments. Weight-bearing and resistance exercise maintains bone density and reduces falls risk in men as well as women. Smoking cessation and reduction of alcohol to within recommended limits are important modifiable interventions for men with bone health concerns. Our guides on calcium and bone health and vitamin D and bone health cover the nutritional aspects in detail.

Frequently Asked Questions

Summary

Osteoporosis in men is common, under-recognised, and associated with worse outcomes after hip fracture than in women. Unlike postmenopausal osteoporosis in women, which is primarily oestrogen-driven, male osteoporosis has an identifiable secondary cause in up to 60% of cases — making thorough investigation essential when it presents. Androgen deprivation therapy for prostate cancer is the single most common cause of rapidly progressive osteoporosis in men and requires proactive bone protection from treatment initiation. Bisphosphonates, denosumab, and teriparatide are effective treatments for male osteoporosis. Falls risk management is as important as pharmacological treatment in older men, and post-fracture care through fracture liaison services should be equally accessible to men and women. The same foundations of bone health apply to men as women: weight-bearing exercise, calcium and vitamin D adequacy, and avoiding smoking and excess alcohol. Any man aged 50 or over with one or more risk factors should ask their GP about fracture risk assessment. Our full series of bone health guides covers osteoporosis: symptoms, causes, and prevention, osteoporosis in women after menopause, and DEXA scan: what adults should know.

Medical disclaimer: This article is for general educational purposes and does not constitute medical advice. Consult a qualified healthcare professional for personalised bone health assessment and management.

References:
NHS. Osteoporosis. nhs.uk. 2023.
NICE CG146. Osteoporosis: assessing the risk of fragility fracture. NICE. 2023.
Royal Osteoporosis Society. Clinical guidance for the prevention and treatment of osteoporosis. theros.org.uk. 2023.
Watts NB, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802–1822.
Golds G, Houdek D, Arnason T. Male hypogonadism and osteoporosis: the effects, clinical consequences, and treatment of testosterone deficiency in bone health. Int J Endocrinol. 2017:4602129.