More men are now living long enough to develop osteoporosis, but few are aware of the risk, and fewer still are screened and treated – and worst of all, men don’t have as good a recovery rate as do women, reports The New York Times.
Osteoporosis occurs so much more commonly in women, for whom medical guidelines recommend universal screening after age 65, that a man who was not a healthcare professional might not have thought about a scan after a fall.
Yet about one in five men over 50 will suffer an osteoporotic fracture in his remaining years, and among older adults, about a quarter of hip fractures occur in men.
“When they do, men have worse outcomes,” said Dr Cathleen Colon-Emeric, a geriatrician at the Durham VA Health Care System and Duke University and the lead author of a recent study of osteoporosis treatment in male veterans.
“Men don’t do as well in recovery as women,” she said, with higher rates of death (25% to 30% within a year), disability and institutionalisation.
“A 50-year-old man is more likely to die from the complications of a major osteoporotic fracture than from prostate cancer,” she said.
In her study of 3 000 veterans ages 65 to 85, conducted at Veterans Affairs health centres in North Carolina and Virginia, only 2% of those assigned to the control group had undergone bone-density screening.
“Shockingly low,” said Dr Douglas Bauer, a clinical epidemiologist and osteoporosis researcher at the University of California-San Francisco, who published an accompanying commentary in JAMA Internal Medicine. “Abysmal. And that’s at the VA, where it’s paid for by the government.”
But establishing a bone health service, overseen by a nurse who entered orders, sent frequent appointment reminders and explained results, led to dramatic changes in the intervention group, who had at least one risk factor for the condition.
A total of 49% of them said yes to a scan. Half of those tested had osteoporosis or a forerunner condition, osteopenia. Where appropriate, most of them began medications to preserve or rebuild their bones.
After 18 months, bone density had increased modestly for those in the intervention group, who were more likely to stick to their drug regimens than osteoporosis patients of either sex in real-world conditions.
The study didn’t continue long enough to determine whether bone density increased further or fractures declined, but the researchers plan a secondary analysis to track that.
The results revive a long-time question: given how life-altering, even deadly, such fractures can be, and the availability of effective drugs to slow or reverse bone loss, should older men be screened for osteoporosis, as women are? If so, which men and when?
Such issues mattered less when lifespans were shorter, Bauer said. Men have bigger and thicker bones and tend to develop osteoporosis five to 10 years later than women do. “Until recently, those men died of heart disease and smoking before osteoporosis could harm them,” he said.
“Now, men routinely live into their 70s and 80s, so they have fractures,” he added. By then, they have also accumulated other chronic conditions that impair their ability to recover.
With osteoporosis testing and treatment, “a man could see a clear-cut improvement in mortality and, more importantly, his quality of life”, Bauer said.
Both patients and many doctors still tend to regard osteoporosis as a women’s disease, however.
“There’s a bit of a Superman idea,” said Dr Eric Orwoll, an endocrinologist and osteoporosis researcher at Oregon Health and Science University.
“Men would like to believe they’re indestructible, so a fracture doesn’t have the implication that it should,” he added.
Another obstacle to screening: “Clinical practice guidelines are all over the place,” Colon-Emeric said.
Professional associations like the Endocrine Society and the American Society for Bone and Mineral Research recommend that men over 50 who have a risk factor, and all men over 70, should seek screening.
But the American College of Physicians and the US Preventive Services Task Force have deemed the evidence for screening of men “insufficient.” Clinical trials have found that osteoporosis drugs increase bone density in men, as in women, but most male studies have been too small or lacked enough follow-up to show whether fractures also declined.
So it may fall to older male patients themselves to ask their doctors about a DXA (pronounced DECKS-ah) scan, widely available.
Otherwise, because osteoporosis is typically asymptomatic, men (and women, who are also under-tested and under-treated) don’t know their bones have deteriorated until one breaks.
“If you had a fracture after 50, you should have a bone scan – that’s one of the key indicators,” Orwoll advised.
Other risk factors: falls, a family history of hip fractures, and a fairly long list of other health conditions including rheumatoid arthritis, hyperthyroidism and Parkinson’s disease. Smoking and excessive alcohol use increase the odds of osteoporosis as well.
“A number of medications also do a number on your bone density,” Colon-Emeric added, notably steroids and prostate cancer drugs.
When a scan reveals osteoporosis, depending on its severity, doctors may prescribe oral medications like Fosamax or Actonel, intravenous formulations like Reclast, daily self-injections of Forteo or Tymlos, or twice-annual injections of Prolia.
Lifestyle changes like exercising, taking calcium and vitamin D supplements, stopping smoking and drinking only moderately will help, but aren’t sufficient to stop or reverse bone loss, Colon-Emeric said.
Although guidelines don’t universally recommend it, at least not yet, she would like to see all men over 70 be screened, because the odds of disability after hip fractures are so high – two-thirds of older people will not regain their prior mobility, she noted – and the medications that treat it are effective and often inexpensive.
But informing patients and healthcare professionals that osteoporosis threatens men, too, has progressed “at a snail’s pace,” Orwoll said.
Study details
Remote Bone Health Service for Osteoporosis Screening in High-Risk MenA Cluster Randomised Clinical Trial
Cathleen Colón-Emeric, Richard Lee, Kenneth Lyles, et al.
Published in JAMA Internal Medicine on 25 August 2025
Abstract
Importance
Evidence supporting osteoporosis screening in men is limited. Efficient models that promote osteoporosis screening and adherence in primary care are needed.
Objective
To test the impact of a centralised, remote bone health service (BHS) on screening, treatment, adherence, and bone density in older men with fracture risk factors.
Design, Setting, and Participants
This cluster randomised clinical trial involved 39 primary care teams in 2 Veterans Affairs (VA) Health Systems that included 3112 male veterans aged 65 to 85 years who had at least 1 fracture risk factor but had no prior fractures. Data were analysed from July to November 2025.
Intervention
Eligible men in medical teams randomised to BHS were invited to undergo dual-energy x-ray absorptiometry (DXA) scan, followed by an electronic consult to their primary care clinician with additional recommendations. A nurse care manager entered orders, obtained test results, provided patient education, and monitored adherence over the phone. Primary care teams randomised to usual care received osteoporosis education and VA practice guidelines.
Main Outcomes and Measures
DXA screening rates, osteoporosis treatment, persistence, and adherence were compared between patients in BHS and usual care. A random subset of patients in each team had a DXA 24 months after team enrolment, regardless of whether they had been screened during the intervention.
Results
Of the 3112 randomised participants (mean [SD] age, 73.3 [5.3] years; 1260 [40.4%] were black; and 1748 [56%] were white), 49.2% (830 of 1688) in the BHS group were screened vs 2.3% (33 of 1424) in the usual care group (P < .001). More than half of those screened (441 [51.1%]) had osteopenia or osteoporosis. One hundred fifty-seven patients (84.4%) in the BHS group initiated osteoporosis treatment and achieved high levels of adherence with a mean of 91.7% of subsequent days covered and a high persistence with a mean 657 (SD, 366) days over two years of follow-up. The mean femoral neck T-score 2 years after team initiation in a random subset favoured BHS vs usual care (−0.55 vs −0.70, P = .04).
Conclusions and Relevance
This cluster randomised clinical trial found that the BHS model was associated with significantly improved osteoporosis screening, treatment, and adherence compared with usual care, with high patient and clinician acceptance. Selecting men for osteoporosis screening based on clinical risk factors before a fracture has occurred has a high screening yield. This approach requires validation in other clinical settings and with longer follow-up to determine impact on fractures.
The New York Times article – Why Brittle Bones Aren’t Just a Woman’s Problem (Restricted access)
See more from MedicalBrief archives:
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Intense physical activity in adolescence may prevent osteoporosis later
New treatment improves bone density in osteoporosis
Older male smokers at risk of osteoporosis