Osteoporosis in Men

Osteoporosis is a condition that affects 1 in 12 men over the age of 50. Perhaps surprisingly the men who are given this diagnosis often feel uninformed and isolated, not because the condition is rare in men but rather because it is often regarded as a women's disease. The National Osteoporosis Society aims to meet the needs of men by providing them with information and support specifically designed for them. A major feature of this initiative is a biannual conference in which male members of the society are invited to hear about advances in the field from leading medical experts.

The 2002 Osteoporosis in Men conference took place in London in April and was attended by 80 male members of the NOS. The varied programme aimed to provide delegates with an insight into some of the recent research and technological advances in the field. Dr Terry O'Neill, senior lecturer at the University of Manchester's Arthritis Research Centre set the scene with some interesting epidemiological data. The severity of the problem was highlighted when he estimated that approximately £200 million is spent every year on treating male hip fractures in the UK. This was made even more significant when he stated that because of our ageing population the number of men with osteoporosis is set to increase, with male hip fractures set to double in the UK over the next 50 years.

The major impact that genetics has on bone density was described by Dr Aamir Qureshi, senior lecturer in Medicine at the University of Aberdeen. He stated that osteoporosis is generally considered to result from a complex interaction of several genes, each with relatively small effects on bone mass. The exciting possibility of identifying genetic markers as a risk assessment tool for osteoporosis was recognised as a potential growth area in the future.

Fracture of the forearm in women has been recognised as an indication that bone density may be low and further investigation is warranted. Dr Steve Tuck, Specialist Registrar in rheumatology at Newcastle's Freeman Hospital described a recent case-controlled study, which demonstrated that men with distal forearm fractures have lower bone mineral density than their peers. This suggests that colles fracture in men may, like in women, be a useful sign that osteoporosis is present.

The incidence of spinal fractures in men is difficult to assess because only one third come to medical attention. Dr Roger Francis, Consultant Physician at the Bone Clinic at Newcastle's Freeman Hospital and one of the UK's leading experts on osteoporosis in men, explained how men with symptomatic spinal fractures commonly complain of back pain, loss of height and kyphosis. They also have significantly less energy, poorer sleep, more emotional problems and impaired mobility compared with age-matched control subjects. Dr Francis' work has shown that 50 percent of men with symptomatic spinal fractures have secondary osteoporosis due to underlying causes such as oral corticosteroid therapy, hypogonadism and alcohol abuse.

Dr Ira Pande, Consultant Rheumatologist at Nottingham's City Hospital, discussed the personally devastating and extremely expensive issue of hip fracture in men. The lifetime risk for a 50-year-old man in the UK suffering a hip fracture is three percent In England, the direct hospital cost of treating a fractured hip is £4,800. One in five who break a hip go on to need long-term nursing home care at an average annual cost of £19,000. The hip fracture mortality rate is about 18% in the UK but men have a three-fold higher chance of death than women and they tend to stay longer in hospital. A number of factors have been shown to increase male mortality post hip fracture including advanced age, pre-existing medical conditions, deteriorating mental function, previous poor functional status and residence in institutional care. There is also substantial morbidity after male hip fracture. Studies show that only 21 percent of men surviving a hip fracture are living independently a year later, 26 percent are receiving home care and 53 percent are living in institutions.

Having discussed the personal and economic costs of osteoporotic fracture in men the theme of the conference turned to issues of diagnosis and treatment. Dr Juliet Compston from the Department of Medicine at the University of Cambridge's School of Clinical Medicine looked at methods of assessing risk prior to fractures occurring. She discussed factors which can affect the optimal peak bone density in men and also factors which can accelerate bone loss. Contributory factors have been found to include sex hormone and vitamin D deficiency, reduced physical activity, corticosteroid use, alcohol abuse, low body weight and a number of medical conditions including gastrointestinal and liver disease. Diagnosis of osteoporosis in men is made using measurements of bone density and x-ray examination, the latter being used to confirm the presence of fracture. Because of the 50 percent incidence of secondary osteoporosis in men investigations should also be informed to exclude underlying medical conditions.

Once a diagnosis of osteoporosis has been made either through assessment of risk factors, low bone density or presence of fractures, treatment may be considered. Dr Peter Selby, Consultant Physician at the Manchester Royal Infirmary discussed the interesting finding that oestrogen, like testosterone, has an important role to play in the male skeleton. Dr Frazer Anderson, Senior lecturer in Geriatric Medicine at the University of Southampton described the shortage of evidence which hampers our ability to treat osteoporosis in men. Of the hundreds of published studies into treatments for osteoporosis, less than 30 include men and only about a third of these concentrate on idiopathic male osteoporosis. The situation has improved recently with the publication of two trials showing increased bone density and reduced fractures with either alendronate or fluoride. Alendronate now has a UK product licence for male osteoporosis. Fluoride remains a more specialist treatment due to troublesome side effects. Of the other treatments tested, the male hormone testosterone showed promise in a small pilot study and is now the subject of a large, multi-centre UK trial fund by the National Osteoporosis Society. Calcium with vitamin D may be an appropriate treatment for older men, particularly if housebound, but this is not proven and neither component reduces fractures on its own.

Professor Graham Russell, NOS Council Chairman and Director of Oxford University Institute for Musculoskeletal Sciences, closed the programme with a look ahead to the future of the prevention, diagnosis and treatment of osteoporosis in men. He foresaw advances in genetic studies described early and among physiological hot topics listed the relative contributions of androgens and oestrogen to bone biology in men and also the contribution of bone shape and micro architecture to bone strength. Professor Russell predicted that in the future there will be increased emphasis on drug development that stimulates bone formation with anabolic agents. The impressive clinical results recently obtained with parathyroid hormone are a forerunner of other opportunities in this area.

Throughout the day, delegates were encouraged to put questions to the experts providing a unique opportunity to access leaders in the field. Positive feedback from both speakers and delegates has clearly shown that the conference was extremely well received and the National Osteoporosis Society plans to organise similar initiatives in the future. For information on joining the society and to receive a free information pack on osteoporosis please phone 01761 471771 or access our website on www.nos.org.uk