Yes, men get osteoporosis — and far more often than most people realize. Roughly 2 million American men have osteoporosis, and another 16.1 million have low bone density (osteopenia) that puts them on the path toward it. One in five men over 50 will suffer an osteoporosis-related fracture in their remaining lifetime. The real problem? Men are significantly less likely to be screened, less likely to be treated after a fracture, and more likely to die from hip fractures than women.
As a haematologist, I see this gap firsthand. A 68-year-old man breaks his wrist in a fall, gets a cast, and nobody thinks to check his bone density. That same fracture in a 68-year-old woman would almost certainly trigger a DEXA scan referral. This diagnostic blind spot costs lives — mortality after hip fracture is nearly twice as high in men compared to women, with up to 37% of men dying within one year of a hip fracture.
Why Osteoporosis in Men Gets Missed
The core issue is perception. Osteoporosis has been framed as a “women’s disease” for decades, and that framing has seeped into clinical practice. Men start with higher peak bone mass than women (roughly 8–10% greater), and they don’t experience the rapid estrogen-driven bone loss that women face at menopause. But men still lose bone — about 0.5–1% per year after age 50 — and by their 70s and 80s, fracture rates climb steeply.
There’s also a biological nuance many people miss: while testosterone matters for male bone health, estradiol (a form of estrogen) is actually the dominant hormone regulating bone resorption in men. Men who have low estradiol levels lose bone faster than men with low testosterone alone.
Risk Factors Specific to Men
About 50% of osteoporosis cases in men have an identifiable secondary cause — far higher than the rate in women. Here are the major risk factors:
| Risk Factor | How It Affects Bone | Relative Risk Increase |
|---|---|---|
| Glucocorticoid use (e.g., prednisone ≥5 mg/day for ≥3 months) | Suppresses bone formation, increases resorption | 2–5× fracture risk |
| Hypogonadism / low testosterone | Reduces bone formation; lowers estradiol conversion | 1.5–2× |
| Alcohol (≥3 drinks/day) | Directly toxic to osteoblasts; impairs calcium absorption | 1.4–1.7× |
| Smoking (current) | Accelerates bone loss, reduces intestinal calcium absorption | 1.5× |
| Androgen deprivation therapy (prostate cancer) | Dramatic testosterone and estrogen suppression | Up to 5× within 5 years |
| Chronic kidney disease | Impairs vitamin D activation and calcium metabolism | Variable; significant |
| Anticonvulsants, PPIs, excess thyroid hormone | Various mechanisms affecting bone turnover | 1.2–2× |
Other contributing factors include low body weight (BMI under 20), a family history of hip fracture, celiac disease, inflammatory bowel disease, and prolonged immobility.
When Should Men Get a DEXA Scan?
Current guidelines from the Endocrine Society and ISCD recommend bone density screening for:
- All men aged 70 and older, regardless of risk factors
- Men aged 50–69 with one or more risk factors (glucocorticoid use, low testosterone, prior fragility fracture, smoking, excess alcohol, low BMI)
- Men of any age starting or on long-term glucocorticoid therapy
- Men receiving androgen deprivation therapy for prostate cancer
A DEXA scan reports a T-score. In men over 50, a T-score of −1.0 to −2.5 indicates osteopenia, and −2.5 or below means osteoporosis. But a T-score alone doesn’t tell the whole story — the FRAX calculator combines your T-score with clinical risk factors to estimate your 10-year probability of major fracture.
Treatment That Actually Works
Treatment decisions depend on fracture risk, not just bone density numbers. Here’s what the evidence supports:
First-Line Medications
- Bisphosphonates (alendronate, risedronate, zoledronic acid): These are the most commonly prescribed drugs. Alendronate reduces vertebral fracture risk by about 50% in men. Zoledronic acid is given as a once-yearly IV infusion — useful for men who won’t remember a weekly pill.
- Denosumab (Prolia): A twice-yearly injection that inhibits RANKL. Particularly useful in men on androgen deprivation therapy, where it’s been shown to reduce vertebral fractures by 62%.
Anabolic (Bone-Building) Options
- Teriparatide (Forteo): A daily injectable form of parathyroid hormone that stimulates new bone formation. Reserved for men with severe osteoporosis or those who fracture despite bisphosphonate therapy. Limited to 2 years of use.
- Romosozumab (Evenity): An anti-sclerostin antibody approved for men at high fracture risk. Builds bone rapidly but carries a cardiovascular warning — avoid in men with recent heart attack or stroke.
Testosterone Replacement
If hypogonadism is the underlying cause, testosterone replacement can improve bone density. However, testosterone alone is generally not enough for men who already have established osteoporosis with fractures — these patients usually need bisphosphonates or denosumab on top of testosterone.
Lifestyle Measures That Move the Needle
Medications work best alongside real lifestyle changes:
- Calcium: 1,000–1,200 mg daily, ideally from food (dairy, fortified foods, leafy greens). Supplements if dietary intake falls short — but don’t exceed 2,000 mg/day.
- Vitamin D: 800–1,000 IU daily at minimum. Many men with osteoporosis are severely deficient. Target a serum 25-hydroxyvitamin D level of at least 30 ng/mL.
- Weight-bearing exercise: Walking, jogging, stair climbing, and resistance training 3–5 times per week. Resistance training is particularly effective — it directly loads bone and stimulates formation.
- Fall prevention: This matters as much as bone density. Remove tripping hazards at home, check vision annually, review medications that cause dizziness, and consider balance training like tai chi.
When to See a Doctor
Don’t wait for a fracture. See your doctor for a bone health evaluation if you:
- Are over 50 and have lost more than 1.5 inches (4 cm) of height
- Have broken a bone from a minor fall or low-impact injury
- Take prednisone or other glucocorticoids for more than 3 months
- Are on androgen deprivation therapy for prostate cancer
- Have low testosterone symptoms (fatigue, reduced muscle mass, low libido)
- Have a parent who fractured a hip
Ask specifically: “Should I get a DEXA scan?” Many primary care physicians won’t think to order one for a man unless you bring it up.
Frequently Asked Questions
At what age does osteoporosis start in men?
Bone loss in men typically accelerates after age 50, but clinically significant osteoporosis usually shows up in the late 60s to 70s. Men with secondary causes — like long-term steroid use or hypogonadism — can develop it much earlier, even in their 40s or 50s.
Is osteoporosis in men more dangerous than in women?
Fracture for fracture, yes. Men have higher mortality rates after hip and vertebral fractures. About 37% of men die within a year of hip fracture, compared to roughly 20% of women. Men are also diagnosed later, meaning they often have more severe bone loss by the time treatment begins.
Can weight lifting reverse osteoporosis in men?
Resistance training can improve bone density by 1–3% over 12–18 months, which is meaningful but unlikely to fully reverse established osteoporosis on its own. Think of exercise as a critical complement to medication, not a replacement. That said, for men with osteopenia (the stage before osteoporosis), aggressive weight-bearing exercise combined with nutrition may be enough to prevent progression.
Does low testosterone always cause osteoporosis?
No. Many men with low testosterone maintain reasonable bone density, especially if their estradiol levels are preserved. However, profoundly low testosterone (below 200 ng/dL) sustained over years significantly increases risk. The relationship is dose-dependent — the lower and longer, the worse the impact on bone.
Should men take calcium supplements for osteoporosis prevention?
Food sources are preferred. High-dose calcium supplements (over 1,000 mg/day from pills) have been linked in some studies to a modest increase in cardiovascular risk in men, though the data is debated. Aim to get most of your calcium from dairy, fortified plant milks, sardines, and leafy greens, and supplement only the gap between dietary intake and the 1,200 mg target.
