Male Osteoporosis: Bone Mass Matters

20% of people with osteoporosis are men. What causes it, and what can you do about it?

Medically Reviewed by Brunilda Nazario, MD on April 30, 2009
6 min read

Real men get osteoporosis, too.

As many as 2 million American men already have osteoporosis, the bone thinning that makes bones brittle and porous and at likely to fracture. Twelve million men are at risk, and may have early signs of bone loss and low bone density, called osteopenia. But given that four times as many women have osteoporosis, men are less likely to end up with thin bones than women.

Why this lower risk?

"Women live longer, so they're more likely to get osteoporosis," says Paul Mystkowski, MD, an endocrinologist at Virginia Mason Medical Center in Seattle and clinical faculty member of the University of Washington in Seattle. And because men are generally more physically active over the course of their lives, he says, men are less likely to lose bone mass, since exercise has been shown to protect bone density.

But there's an even bigger difference with male osteoporosis.

"In general, osteoporosis in men is considered a symptom of something else," says Mystkowski, "whereas in older women, it's almost always postmenopausal."

And for many men, that "something" is hormonal.

The most common cause of male osteoporosis is testosterone deficiency, says Mystkowski. "There's a clear consensus that when you're evaluating men with osteoporosis, you always evaluate for testosterone deficiency," he says.

For low-testosterone men, doctors may advise testosterone replacement to build bone mass. The dilemma is that science hasn't yet shown how much of the bone-building benefit is a direct testosterone effect -- or the result of turning testosterone into estrogen. "Probably the bulk of the benefit is the testosterone," Mystkowski says, "but it's important not to minimize the role of testosterone to estrogen conversion."

Men also need a small amount of estrogen, says Mystkowski. Estrogen preserves bone density -- in both men and women. In fact, all men normally convert testosterone to estrogen to build bone mass.

"If you look at men who lack an enzyme to make even small amounts of estrogen because they were genetically born that way," says Mystkowski, "they get osteoporosis. If you give them estrogen, their osteoporosis improves. So even though estrogen doesn't circulate in very high concentrations in men, it's a critical factor for bone health."

Bones continually grow over your lifetime, in a natural process called remodeling, with old bone cells sloughing off and new bone cells growing in to replace them. But to make new bone, your body needs plenty of calcium and vitamin D.

"It's a giant construction project," says Mystkowski. But without enough calcium and vitamin D, you can't build the scaffolding for new bone and replace bone density solidly with calcium and other minerals.

Your bones continually monitor the mechanical stress you put on them. Bone mass is a use-it-or-lose-it kind of thing, just like muscle. When muscle pulls on bone, the bone responds by growing.

But if you're not exercising, both bone and muscle weaken. A sad truth: The Surgeon General's report found that only about 35% of men aged 25 to 64 met the minimum exercise prescription -- a modest 30 minutes of moderate activity, like brisk walking, on most days of the week.

Studies have shown that exercise boosts bone mass -- but only at the sites of skeletal stress. Walking or jogging can increase bone density in the hips, but weight-lifting won't.

A host of medications can lead to bone loss in men, just as they can for women. These "red flag" drugs include:

  • Corticosteroids. These aren't muscle-building "steroids." They're anti-inflammatory steroids that dampen the body's immune response, also known as cortisone, hydrocortisone, glucocorticoids, and prednisone. These drugs, useful for treating everything from asthma to ulcers, can wreak havoc with bone. In one study, doses of prednisone higher than 7.5 mg a day shut down new bone growth completely -- and sped up the normal loss of old bone.
  • Drugs for prostate cancer. Taking drugs called GnRH agonists, often used for men with prostate cancer, can lead to low bone mineral density (BMD) and a higher rate of fractures.
  • Antiseizure drugs. These drugs have been associated with bone loss, especially for men who take long-term high doses and don't get enough calcium or vitamin D.

Talk with your doctor about your risk of osteoporosis and bone fractures if you're taking any of these "red flag" drugs. Together, you can weigh these potential risks against the benefits of these drugs for you.

A long list of diseases can lead to low bone mass, from genetic conditions like cystic fibrosis to diabetes, rheumatoid arthritis, and digestive and blood disorders. If you have any chronic condition -- especially if you've been taking medications for years -- it's even more crucial to maximize your diet and exercise to maintain your bone health.

Smoking is not a good idea, especially for strong bones. Smokers have a higher risk of fracture -- a 55% higher risk of hip fracture than nonsmokers, as well as lower bone mineral density, says a 2004 analysis of 10 international studies. Nicotine has a direct toxic effect on bone cells.

So what can you do to help your bones -- even if you've already been diagnosed with osteoporosis? Here are two lifestyle tips.

1. Exercise for Strong Bones

Many men have spent a lifetime playing sports, so it may be easier to commit to exercise in their later years. And since the peak years to "bank" your calcium and bone density is during adolescence, men may have built up stronger bones over their years of high school and college sports. That comes in handy in later years, when bone-building has slowed.

Exercise can preserve bone mass -- especially if it's the right kind. Weight-bearing exercise and impact sports are best for maintaining bone mass, says the Surgeon General's report. Not "impact" as in helmet-crashing, contact sports like football -- but sports where, when your foot hits the ground, there's some force and impact there. Jogging, running around a basketball court, and jumping rope are high-impact. Walking, cross-country skiing, and inline skating are low-impact.

Ideally, the experts say, do at least:

  • 30 minutes of moderate activity, like brisk walking, on most days of the week
  • Strength training, like weight-lifting or resistance training with weight machines, twice a week

2. Bone Up on Calcium

The same advice for calcium holds true for men as for women. If you already have signs of low bone mass, here's the Surgeon General's recommendation:

  • 1,000 mg of calcium a day from ages 19 to 50
  • 1,200 mg of calcium a day if you're over 50

Be sure you're getting enough vitamin D, which you need to absorb calcium -- otherwise, all that calcium goes to waste. While the standard RDA (recommended daily allowance) for adults is 400 IU of vitamin D, some doctors suggest taking more.

"I'd say most people with osteoporosis should be on 800 IU a day," says Mystkowski. He advises even higher doses -- up to 1,200 IU of vitamin D a day -- if you have osteoporosis or osteopenia and live in a climate without much sun. That's because sunlight is the body's primary source of vitamin D.

Finally, check in with your doctor if you have any question about a possible hormone deficiency or medical condition that could be weakening your bones. Bone mass does matter. It can mean the difference between a hip fracture later in life -- or keeping an active, high-energy lifestyle.