When I raise the topic of bone health with male patients, the response is almost always the same: "Isn't that a women's thing?" It's a reasonable assumption, because most of the public messaging around osteoporosis has focused on postmenopausal women. But the data tells a different story.
Men account for approximately 30% of all hip fractures worldwide. The lifetime risk of fracture in men over 60 is roughly comparable to the lifetime risk of prostate cancer. And when men do fracture, the outcomes are significantly worse. Despite all of this, men are far less likely to be investigated or treated.
Why men get missed
The treatment gap for men with osteoporosis is striking. Australian data shows that only 7% of high-risk men receive a DXA bone density scan after a fracture, compared with 17% of women. Only 14% of men are started on medication, compared with 22% of women. An estimated 90% of men who are eligible for osteoporosis treatment remain untreated.
There are several reasons for this gap. The perception that osteoporosis is a women's disease affects both patients and clinicians. Men are less likely to think of bone health as something relevant to them, and GPs may be less likely to consider it after a male patient fractures. There's also a structural issue: screening guidelines have historically focused on postmenopausal women, and many of the large fracture prevention trials were conducted predominantly in female populations.
The result is that men tend to present later, with more advanced disease, and with worse outcomes after fracture.
How male bone loss is different
Men and women lose bone differently. Women experience a rapid phase of bone loss around menopause, driven by the sharp drop in oestrogen. Men don't have that equivalent. Instead, male bone loss is gradual: approximately 0.5 to 1% per year from around age 50, driven by slowly declining testosterone and free oestradiol.
Men also start with a larger bone bank. Higher peak bone mass (due to larger bone size and greater cortical thickness) means men typically reach the fracture threshold about 10 years later than women. But that advantage can be misleading, because by the time a man fractures, he's often older and more medically frail, which partly explains why outcomes are worse.
There's another important difference. Men can fracture at a higher bone density than women at non-vertebral sites. This means that DXA T-scores may underestimate fracture risk in men. A man with a T-score of -2.0 may be at higher risk than the number suggests.
The mortality gap
Australian data from the Dubbo Osteoporosis Epidemiology Study found that after a hip fracture, the age-adjusted mortality ratio was 3.51 in men compared to 2.43 in women. Five-year post-fracture mortality was 51% in men and 39% in women. If a second fracture occurred, those figures rose to 75% and 50% respectively. Men who fracture have worse outcomes at every stage.
Risk factors that matter for men
Between 50% and 80% of men with osteoporosis have an identifiable secondary cause. That's a much higher proportion than in women, where postmenopausal bone loss is the primary driver. In men, it's worth looking for underlying contributors.
- Prior fracture from a minor fall or bump
- Family history of osteoporosis or hip fracture
- Low testosterone (hypogonadism, from any cause)
- Long-term corticosteroid use
- Prostate cancer treatment (androgen deprivation therapy)
- Alcohol excess (more than 2 standard drinks per day)
- Smoking
- Low body weight or significant weight loss
- Physical inactivity
- Vitamin D deficiency
- Conditions affecting absorption (coeliac disease, inflammatory bowel disease)
- Chronic kidney disease
If several of these apply to you, it's worth having the conversation with your GP, even if you feel fine. Osteoporosis has no symptoms until a fracture happens.
The prostate cancer connection
One of the most significant and underrecognised risk factors for osteoporosis in men is androgen deprivation therapy (ADT), used in the treatment of prostate cancer. ADT works by suppressing testosterone, which is effective against the cancer but has a direct impact on bone.
Research shows that bone density can decline by 2.5% at the hip and 4% at the spine in the first year of ADT. Around 35% of men on ADT meet the criteria for osteoporosis on DXA. The fracture risk increases by 34 to 65%, and men who fracture while on ADT have roughly twice the mortality rate of those who don't.
Despite clear guideline recommendations, fewer than 20% of Australian men starting ADT receive a bone density scan within the first 12 months. Current guidelines recommend a baseline DXA before or at the start of ADT, lifestyle advice, calcium and vitamin D optimisation, and consideration of bone-protective medication if bone density is already low or fracture risk is elevated.
If you're on ADT and haven't had your bone health assessed, raise it with your treating team or your GP.
When men should be screened
The 2024 RACGP/Healthy Bones Australia guideline recommends fracture risk assessment for the following groups of men.
- Men aged 50 and over with one or more clinical risk factors (prior fracture, family history, corticosteroid use, ADT, low testosterone, low BMI, smoking, excess alcohol, falls)
- All men aged 70 and over (fracture risk assessment using FRAX)
- All men starting androgen deprivation therapy (baseline DXA)
- Any man who has had a fragility fracture at any age
DXA uses the same T-score thresholds for men as for women: -2.5 or below for osteoporosis, -1.0 to -2.5 for osteopenia. The FRAX fracture risk calculator works for men and uses the same 10-year probability thresholds. For men with a high risk of falls, the Garvan Fracture Risk Calculator may be preferable because it includes falls as an input (FRAX does not).
What can be done
The treatment approach for male osteoporosis is broadly the same as for women: a combination of lifestyle measures, calcium and vitamin D optimisation, exercise, falls prevention, and medication when indicated.
Exercise
Resistance training and weight-bearing exercise are the most effective forms of exercise for building and maintaining bone density, regardless of sex. The same principles apply: load the skeleton through gravity and resistance, challenge your balance, and do it consistently. An exercise physiologist or physiotherapist can design a program appropriate for your current level.
Medication
The same classes of medication used in women are approved and available for men in Australia. The evidence base from male-specific trials is smaller, but it supports similar effectiveness. Your GP can assess your individual fracture risk and advise whether medication is appropriate.
Addressing the underlying cause
Because secondary causes are so common in men, identifying and treating the underlying contributor can make a real difference. If low testosterone is a factor, your GP can investigate and manage it. If a medication is contributing to bone loss, alternatives may be available. If alcohol or smoking is playing a role, addressing these will benefit both your bones and your broader health.
The key message is that osteoporosis in men is common, underdiagnosed, and treatable. If you have risk factors, or if you've had a fracture that wasn't followed up, it's worth raising with your GP. The conversation takes a few minutes. The consequences of not having it can be significant.
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Common questions about men and osteoporosis
Clinical information in this article is informed by the 2024 RACGP/Healthy Bones Australia guideline, the Dubbo Osteoporosis Epidemiology Study (Bliuc et al., JAMA 2009; JBMR 2013), Bliuc et al. 2023 (PLoS Medicine), Ebeling et al. 2022 (Endocrine Reviews), and the Healthy Bones Australia Burden of Disease Report 2024. This is general information only. Your GP can advise on what's relevant for your individual situation.
