When most people hear the word “osteoporosis,” they think of an older woman who may have fractured her hip or vertebrae as a result. What you may be surprised to learn is that this is not a gender-specific condition – men too, can develop osteoporosis and suffer from osteoporotic fractures. Evaluation, management and treatment are identical, but the key to reducing the risk of complications is early identification of osteoporosis before symptoms occur. Through regular bone density screenings and follow up visits, we can address these problems head-on. Non-invasive, proactive measures – such as daily doses of vitamin D and calcium supplements, engaging in weight-bearing exercises and activities, and prescription bisphosphonates – have proven highly effective in reducing the likelihood of suffering an osteoporotic fracture for male and female alike.
As you’ll see in the stories of two male patients, aged 75 and 84, a heightened awareness that these type of issues can, and often do, present in men, along with early identification and care is vital to optimal outcomes. Both patients were suffering from considerable back pain as a result of a vertebral compression fracture. However, the younger male benefited from much earlier diagnosis and subsequent treatment.
Both male patients reported experiencing new back pain which was not triggered by any recent, acute injury. The pain had lasted 10 to 14 days and was not improved with routine home treatments such as acetaminophen, ibuprofen, heat, ice or stretching. While both could find positions of comfort at rest, they experienced significant pain with most movements. A physical exam pinpointed the location of the pain, in the lower thoracic spine for one patient, and in the upper lumbar spine for the other. X-rays subsequently revealed both had suffered a new vertebral compression fracture, the same spontaneous or “fragility” fractures commonly seen in women. These happen when the bone matrix has weakened to the point that a vertebral body cannot support the body weight above it. A partial collapse occurs, which causes severe pain that can last from weeks to months and results in an irreversible slight decrease in a person’s height. Additionally, if the compression fracture is more prominent in the front, a change in posture of slightly stooping forward is seen.
Diagnosis and testing
If no trauma has occurred, the most likely reason for these types of fractures is osteoporosis, and our next step is to confirm the diagnosis and rule out other possible causes: metastatic cancer which can weaken bones, metabolic bone or kidney disease, vitamin D and/or calcium
deficiency or severe malnutrition. In women, we would also consider hormonal shifts of menopause, and in men, decreased testosterone production. Tests can include an MRI scan of the fracture to evaluate for possible cancer, a bone density scan to identify osteoporosis, blood tests to measure levels of Vitamin D (an essential building block in bone formation), TSH (thyroid function) and PTH (parathyroid glands function). A comprehensive metabolic panel is done to evaluate for diabetes, liver and kidney function, and total calcium stores in the body (also key to building bones). If abnormalities in protein or albumin levels are seen, additional tests may be ordered.
If osteoporosis is confirmed, there are a number of ways to retain current bone mass and slow down future loss. First, we turn to bisphosphonates, a group of drugs that have proven very effective over the last three decades in reducing the likelihood of a second vertebral fracture in the initial 24 months after a first compression fracture. While bisphosphonates cannot eliminate or cure osteoporosis, they can significantly delay the loss of bone matrix which weakens bones and leads to fractures. To this, we usually add 1,000 to 2,000 units of oral vitamin D and 1,000 to 2,000 mg of oral calcium daily. We also recommend weight-bearing exercise, important for stimulating and strengthening bones.
Following the protocols above, our two patients experienced markedly different outcomes, underscoring the importance of early diagnosis and treatment. The 75-year-old had been diagnosed with osteoporosis at age 60 when an unusual ankle fracture led to an extensive metabolic workup and a bone density scan. Carefully followed and treated with a bisphosphonate over the last 15 years, the latest scans document an actual increase in his bone density, most significantly in the vertebrae. No new metabolic abnormality was revealed in testing done after the new vertebral fracture occurred, and he will continue to be treated and monitored in the same way.
Unfortunately, the experience was not the same for the 84-year-old, whose vertebral fracture resulted in a similar diagnosis of osteoporosis after an MRI, bone density scan and metabolic lab testing. Prompt treatment with a bisphosphate and vitamin D and calcium supplements was not enough to prevent two more compression fractures just weeks after his first one. We will continue this medical regimen and initiate weight-bearing exercises as his symptoms permit.
I share these patient’s outcome with you as a reminder that many of the problems we confront in Internal Medicine can be identified, evaluated, managed and treated, but we cannot make them go away entirely – especially when diagnosed at more advanced stages of a disease. We can, however, work diligently to reduce the risk of serious complications by identifying osteoporosis in both men and women at its earliest, most treatable point. As a guideline, the National Osteoporosis Foundation recommends bone mineral density testing in all women over 65 and all men over 70; and if indicated by individual risk factors, for postmenopausal women younger than 65 and men aged 50 to 69. To determine what’s right for you, there is no better place to start than by consulting with your primary care physician or healthcare provider.