Amidst an aging population, the importance of osteoporosis prevention and management is becoming increasingly critical. Osteoporosis, a systemic disease marked by low bone mass, deterioration of bone microarchitecture, and skeletal fragility, poses significant health risks. Traditionally, preventive screening for osteoporosis has focused primarily on women, yet we have advocated that men should also be screened for osteoporosis and fracture risk. If screening leads to decreased fracture incidence (and consequences), a proactive approach is essential.

Fragility fractures are the most serious complication of osteoporosis; osteoporosis (defined by bone mineral density) affects approximately 10 million people in the USA, including 2 million men [1]. In 2019, based on emergency room visits, there were just over 200,000 hip fractures in women, but almost 100,000 in men [2]. Case detection, assessing risks, conducting screenings, and initiating treatment discussions are fundamental steps in managing osteoporosis and preventing fractures. These measures are pivotal in reducing the personal and socioeconomic impacts of osteoporotic fracture.

Although 25% of men over the age of 60 will sustain osteoporotic fractures during their lifetime, data suggest that male osteoporosis is underdiagnosed and undertreated. This was observed in a group of > 13,000 adults, especially among those ≥ 70 years old and those at very high risk for osteoporosis [3]. Compared with older women, fewer older men underwent dual‐energy X‐ray absorptiometry (DXA) (12% vs 63%, respectively), and in older men with higher risk (including having already sustained a hip fracture), few men underwent DXA screening (27% versus 36% of women) and 25-OH D measurements (23% versus 28%) and received fewer calcium/vitamin D (40% versus 50%) and bisphosphonate prescriptions (13% versus 24%). The lack of testing and treatment was striking and put these men at significant risk for future bone health complications.

In a recent study [4], hip fracture incidence was found to be increasing among male veterans, and only 6% of those who experienced a fracture had ever undergone DXA. The study suggested that many fractures could have been prevented had a diagnosis of osteoporosis been made earlier. Using the Optum Research Database (which covers persons with commercial insurance or Medicare Advantage plans), a recent study [5] found the fracture rate in men ≥ 65 years old initially declined from 2007 to 2013, but then increased annually with the trend in the fracture rate for the 2014–2017 time period 4.8% higher than the annual trend from 2007 to 2013. This is consistent with the data on male veterans [4].

Another study of older male veterans found that 43% were never treated with an osteoporosis agent, and 90% of those who had received an osteoporosis medication discontinued it [6]. Targeted DXA testing of older men in the largest U.S. integrated health system (the VA) is associated with a lower risk of subsequent fractures in subgroups of men based on clinical characteristics (Fig. 1) [6]. In this observational study using the VA database and Medicare data, the authors found that screening with DXA led to fewer fractures in men on glucocorticoids or androgen deprivation therapy, men at least 80 years of age (with or without other risk factors), men over 65 years old who met a previously published set of criteria for screening veterans [7], or men who were at increased fracture risk based on FRAX calculated without bone density. (FRAX thresholds were ≥ 3% for hip fracture and ≥ 20% for major fracture.) This last-mentioned category is similar to the SCOOP study in women [8]. In this large study done in the UK, only those women at increased risk for fracture based on FRAX without bone density underwent DXA testing. Compared to women not screened at all, this stepwise screening program led to fewer hip fractures. There were more than 12,000 women in the SCOOP study; a similar one in men would likely require 40 to 50 thousand men, which would be prohibitively expensive.

Targeted screening for osteoporosis in men