Not just for women: Osteoporosis jumps gender gap

When geriatrician Cathleen Colon-Emeric, MD, MHSc, worked at the VA Medical Center in Durham, N.C., she noticed that many of her patients with osteoporosis-related hip fractures did not embody the usual image of a patient who confronts such a break.

They were male.

"I had always been taught that osteoporosis was a women's disease," said Dr. Colon-Emeric, now an assistant professor of medicine and senior fellow at Duke University's Center for the Study of Aging and Human Development in Durham. "It actually afflicts a great many men."

She has since published several papers on the subject and is among the growing ranks of physicians recognizing that the reality of osteoporosis doesn't match its perception as a women's disease.

As more evidence of this trend, the American Assn. of Clinical Endocrinologists will issue screening and treatment guidelines for male patients next summer. Meanwhile, a handful of drugs used to increase bone mass in osteoporotic women have been approved in recent years for men, including risedronate sodium (Actonel), which was given the nod by the Food and Drug Administration in August. Also, the International Osteoporosis Foundation's World Congress in Toronto last June featured several studies exploring how this disease occurs in men.

"In the last decade, there's been great attention to public as well as professional education about osteoporosis as a problem in postmenopausal women," said Marc C. Hochberg, MD, MPH, head of the division of rheumatology and clinical immunology at the University of Maryland School of Medicine, Baltimore. "It's time that we ramp up education that men are at risk as well."

Women with osteoporosis still far outnumber men, and many aspects of this disease, such as treatment and prevention, are the same regardless of the patient's gender. Quite a few elements of how the condition presents in men, though, are different enough to make dealing with it a dilemma. By far, the biggest challenge is detecting it before a fracture occurs.

"It's not as common [in men], but even when it's there, we miss it most of the time," said Thomas Mulligan, MD, a geriatrician at the Malcom Randall VA Medical Center and professor of aging and geriatrics at the University of Florida, Gainesville.

In part, this disparity continues because evidence and guidelines supporting screening in women are abundant. The same cannot be said of men. For them, the only guidelines were issued in 2004 by the International Society for Clinical Densitometry. The organization recommends screening all men older than 70 and those older than 65 who have osteoporosis risk factors. This approach is not, however, widely recognized outside of this specialty.

"We don't look for it as much in men," said Jane Corson, MD, assistant professor of family and community medicine at Penn State College of Medicine-Hershey Medical Center and a member of the Mid-Atlantic Osteoporosis Board. "We don't have guidelines yet. We haven't been told to look for it."

Detailing the gender gap

Several studies have shown that even post-fracture, far fewer men are evaluated and treated for osteoporosis than women.

"Oftentimes, fracture, which should be the alarm bell, doesn't trigger the right response," said Nelson Watts, MD, director of the University of Cincinnati's Bone Health and Osteoporosis Center. Dr. Watts will help develop the related AACE guidelines.

Many physicians say the need for guidance is becoming more urgent because, while there are more women than men with osteoporosis, the number of men who are affected is large and expected to grow.

"As men live longer and aren't dying early of heart disease the way that they used to, we are seeing more and more men live into their 70s, 80s and 90s," said Carolyn Becker, MD, associate director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center in New York. "That's when osteoporosis rears its head, and we start seeing fractures."

Primary osteoporosis is generally the result of aging and a decline in hormones, and the resulting health burden is substantial. A study presented at the International Osteoporosis Foundation meeting estimated that in 2005 about 595,000 osteoporotic fractures occurred in men. By 2005, this number is predicted to reach 925,000. The associated expense is also expected to grow, from $4.1 billion per year in 2005 to $6.7 billion in two decades.

"We're talking about a significant economic toll, and we're talking about a significant impact on morbidity and mortality," Dr. Watts said.

Men: The weaker sex?

But the sheer numbers are not the only reason that some physicians are sounding alarms. Men are also more likely than women to be disabled or die after a bone break.

"Men just don't do as well after fracture as women," Dr. Watts said.

The lack of answers surrounding how best to identify and treat male osteoporosis is a central reason why, some doctors say.

"I do get lots of questions from my fellow physicians about what kind of workup to do for these patients," said Joan Neuner, MD, MPH, a general internist and assistant professor of medicine at the Medical College of Wisconsin, Milwaukee, who has researched this issue. "I refer them to a couple of articles with expert opinion, because that's all we have."

For example, it's not entirely clear why men have worse outcomes after a fracture, although many suspect it could be because men's bones are more likely to thin about 10 years after women's. This timeline can mean that men are more likely to have numerous other health problems.

"Men seem to be generally sicker when they fracture," Dr. Hochberg said. "That may contribute to the increase in the infections in the hospital and then after discharge, and to the increase in mortality as well as the poorer recovery."

These facts also might explain why osteoporosis is often overlooked in this population. "In general internal and family medicine offices, we are dealing with patients who often have six or seven chronic illnesses," Dr. Neuner said. "We have to decide how we're going to use our time with a patient and the patient's energy and the patient's money."

Also unknown is the degree to which secondary causes -- for instance, comorbid conditions such as hemochromatosis and some cancers; tobacco or alcohol use; steroid use or other medications -- trigger men's bone loss. Some studies indicate that men are more likely than women to have bone loss as a result of these variables, which could indicate the need for different treatments. Others are not conclusive.

"There haven't been studies that look ... at a big population of men, select those who have osteoporosis or low bone density and see what proportion of them have secondary causes versus non-secondary causes and compare them to a female population," said Eric Orwoll, MD, professor of medicine at the Oregon Health and Science University in Portland and principal investigator of the multisite observational Osteoporotic Fractures in Men Study or Mr.OS. This project is funded by the National Institutes of Health and has been following since 2000 more than 6,000 men older than 65.

Also, many physicians are using testosterone as a treatment, but as in the case of women who were treated with estrogen before the release of results from the Women's Health Initiative, long-term safety and efficacy data are lacking.

"We know the issue as it relates to women and estrogen and that it was wrong to give all the postmenopausal women estrogen. We made a blunder there," Dr. Mulligan said. "We're trying not to make the same blunder as it relates to testosterone. We're trying to figure out who really does need it, who will benefit and who won't have the adverse effects."

Facing the challenges

While there are many unanswered questions, it is clear that there also are many known differences between men and women that make detection of osteoporosis more difficult. Much like women, men tend to have a decline in hormones as they age, which can lead to bone loss. But men have no defining event comparable to menopause that marks a need to pay attention.

"There isn't a time in life signaled by something dramatic like cessation of menses and hot flashes in men," said Robert Recker, MD, director of the osteoporosis research center at Creighton University in Omaha, Neb. "So they just happily go on until they fracture, and then they are labeled as having osteoporosis."

Specialists also say reimbursement is a hurdle, and that it is far more difficult to get third-party payers to pony up for the tests to detect this disease in men than in women. For instance, according to Medicare rules, most postmenopausal women will be covered for a bone mass assessment every two years. Men need to have a specific medical condition that puts them at higher risk for bone thinning to get the same deal.

"Third-party payers ... are not particularly generous when it comes to identifying men who have osteoporosis. This is a problem," said Robert Adler, MD, chief of endocrinology at the Hunter Holmes McGuire VA Medical Center and professor of internal medicine, epidemiology and community health at Virginia Commonwealth University in Richmond.

Debate also surrounds the accuracy of bone mineral density tests when it comes to men, because the values used are usually based on the bone density of healthy women.

"That's really a controversial issue," said Mark Nanes, MD, PhD, professor of medicine at Emory University School of Medicine and chief of the endocrine section at the VA Medical Center in Atlanta. "There are some who argue that we can use the [same] system because men are more likely to fracture at the same bone density as women. There are others who argue just the opposite depending on the study that you look at. Really, it's unclear."

Physicians say, though, that these matters must be dealt with to manage the burgeoning number of male baby boomers now hitting the age where bone thinning becomes a concern.

"It's there, and it's much more prevalent than we give it credit for, unfortunately," Dr. Corson said. "And if you keep an otherwise healthy male from dying from a hip fracture, it's worth it."