Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures. Osteoporotic fractures are most commonly seen in the hip, spine and wrist, although any bone can be affected. In simpler terms, osteoporosis is a condition in which the bones become weak and can break from a minor fall or, in serious cases, from a simple action such as a sneeze.
Osteoporosis results from a disturbance in bone metabolism. Throughout our lives, there is a continual dance between the cells that lay down new bone (osteoblasts) and the cells that take away old bone (osteoclasts). During childhood, more bone is produced than removed, so the skeleton grows in both size and strength. For most people, bone mass peaks during the late teens or early twenties. By this age, men typically have accumulated more bone mass than women. After this point, the amount of bone in the skeleton typically begins to decline slowly as removal of old bone exceeds formation of new bone. Osteoporosis develops when bone is no longer replaced as quickly as it is removed.
Adequate hormone balance is intricately involved in bone metabolism and bone health. Androgens (testosterone, DHEA and growth hormone) are vital to new bone formation. Estrogen is necessary to maintain normal bone mass. The lack of estrogen enhances the ability of osteoclasts to absorb bone. In women, progesterone improves osteoblast mediated new bone formation. In men, the lack of testosterone and estrogen increases the rate of osteoporosis.[i] As men and women age, their hormones decline and the risk of developing osteoporosis climbs dramatically.
Osteoporosis is generally thought of as a woman’s disease, with more than half of all women over age 50 in the US suffering a fracture as a result of this condition.[ii] What is not as well known is that nearly a third of all men over age 50 will also experience a fracture due to osteoporosis in their lifetime. It is projected that number will increase by nearly 50% during the next 15 years, with rates of hip fracture in men expected to double by 2040.[iii] In fact, men are more likely to die following hip fractures than women, in part related to the fact that men tend to get osteoporosis about 10 years later then women. It is well established that older adults are five to eight times as likely to die for any reason in the first 3 months following hip fracture. The one year mortality rate following hip fracture for men is double that of women, and that excess mortality persists for up to 10 years.[iv]
Today, 2 million American men have osteoporosis, and another 12 million are at risk for this disease. Yet, despite the large number of men affected, osteoporosis in men remains underdiagnosed and underreported.[v] Men begin losing testosterone in their mid to late 30’s at a rate of 2-3% yearly. Although not below the normal range, by age 50 most men are relatively deficient in testosterone. In my practice, 63% of men screened over age 45 had osteopenia, the early stage of bone loss, and 12% had osteoporosis. All of them were surprised that they were affected.
Unlike women, there has not traditionally been any standard screening procedure for men before age 70; the age that the National Osteoporosis Foundation recommends screening men. In 2008, the American College of Physicians issued new clinical guidelines for screening men for osteoporosis. It recommends performing individualized risk assessments to determine who should be screened. Although better than not having any specific recommendation, this guideline falls far short of the ideal. Osteoporosis is a potentially preventable disease. This guideline, much like the screening recommendations for women, is primarily designed to detect the disease in individuals considered “good candidates for [pharmaceutical] drug therapy”. And, that typically means bisphosphonate therapy.
Bisphosphonates, such as Actonel, Boniva, Fosamax and Reclast, have been the standard recommended therapy to treat osteoporosis. They work by poisoning osteoclasts, thereby inhibiting bone resorption, but do nothing to enhance bone formation. It has been suspected for some time that this unnatural process could result in formation of relatively brittle bone. Two studies reported at the conference of the American Academy of Orthopedic Surgeons in March of this year showed that the bones of some postmenopausal women taking bisphosphonates for more than four years stopped rejuvenating and became brittle, resulting in unusual hip (femur) fractures.[vi] One of the researchers, Dr. Joseph Lane, chief of metabolic bone diseases at the Hospital for Special Surgery in New York commented “normally, bone is a distribution of young bone, middle-aged bone and old bone…when we look at these bones, it’s all old bone”. Another researcher, Dr Melvin Rosenwasser of Columbia University Medical Center, found buckling potential in the femur area in similar patients. This type of association was first reported in 2005.
A separate study, funded by the pharmaceutical companies Novartis and Merck, both makers of bisphosphonates, refute the association.[vii] Bisphosphonates are among the nations top selling drugs, with annual sales exceeding $3.5 billion.[viii] The FDA has weighed in only to say that there is “no conclusive proof” of the association between these fractures and bisphosphonate therapy. Hmmm, haven’t we heard that before?
Preventing osteoporosis is preferable to treating it. Eating a healthy diet including fruits, vegetables and adequate protein, along with sufficient intake of vitamin D, calcium, magnesium and vitamin K is essential. Regular resistance and weight bearing exercises increase androgen levels, muscle strength and bone mass. Avoid excess alcohol consumption and smoking. Maintain optimal hormone balance and consider early screening to look for evidence of bone loss or altered bone metabolism to reduce your risk of suffering the debilitating consequences of this preventable disease.
[i] Fink H, Ewing S, et al. Association of Testosterone and Estradiol Deficiency with Osteoporosis and Rapid Bone Loss in Older Men. J. Clin. Endocrinol. Metab., July 18, 2006; Vol. 91, No. 10 3908-3915
[ii] National Osteoporosis Foundation. http://www.nof.org/women/
[iii] Quaseem A, Snow V, et al. Screening for Osteoporosis in Men: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2008; 148:680-684, 685-701
[iv] Haentjens P, Magaziner J, et al. Meta-analysis: Excess Mortality After Hip Fracture Among Older Women and Men. Annals Intern Med 2010; 152:380-390
[v] National Osteoporosis Foundation. http://www.nof.org/men/
[vi] Long-Term Bisphosphonate Use Linked to Abnormal Bone Formation. Amer Assoc Ortho Sur 2010 Annual Meeting
[vii] Black D, Kelly M, Genant H. Bisphosphonates and Fractures of the Subtrochanteric or Diaphyseal Femur. Published at www.nejm.org March 24, 2010 (10.1056/NEJMoa1001086)
[viii] IMS Health Incorporated