Dr. Keith Roach

DEAR DR. ROACH: My husband and I are confused about the guidelines concerning when older men should be screened for osteoporosis. All the information seems to suggest that it is only needed for men over 70 who have had a fracture. In my husband’s case, he was only told to get a DEXA (dual-energy X-ray absorptiometry) scan after he had back pain and several compression fractures of the thoracic spine (up to 70%) at the age of 72. His T-score was -2.8 for the spine.
I can’t help feeling that because he is male, weighs 200 pounds, has an active lifestyle and was, previously, 6 feet, 2 inches tall, the issue of osteoporosis just never came up during his yearly primary care visits (even though his height had decreased since, at least, 2019, and he is now just 6 feet). This is a potentially life-threatening condition for older women and men, but the risks for women seem to get all the attention. What’s the reluctance to order a simple, fast, painless, not-too-expensive test to screen men earlier? — B.W.
ANSWER: In general, screening tests (by definition, a test done on a person with no symptoms of the condition) are done when there is good evidence that the screening will lead to an improved outcome in a screened group compared with an unscreened group. The data in women is strong enough that all women over 65, and women younger than 65 with additional risks for osteoporosis, should be screened for osteoporosis with a DEXA scan, but there is not data strong enough to support screening in men.
Osteoporosis screening in men is controversial. While one of the most influential groups does not recommend screening in all men over 70, some groups do, despite an absence of proof of benefit. They base this recommendation on the fact that, as you say, it’s not a particularly dangerous test (the radiation dose is small), nor is it expensive (the average cost is $150, but can be higher in some states). One major downside of testing in general is that no screening test is perfect. As such, an unexpected finding of osteoporosis in a man should be repeated to be sure that the test result is accurate.
Even though men are not always recommended for screening, there are some medical findings that should prompt a test. One is a loss of height — losing more than 1.5 inches of height should have prompted a DEXA scan. (Strictly speaking, this is no longer screening; it’s an evaluation of the cause of an unexpected medical finding.)
A low testosterone level (either by itself — hypogonadism — or as a result of medical treatment for prostate cancer); primary hyperparathyroidism; inflammatory bowel disease; and long-term use of prednisone and similar drugs are all known risk factors for osteoporosis that should, at least, trigger a discussion of a DEXA scan. Similarly, the finding of osteoporosis in a man should prompt consideration of the underlying reason behind it, which could include the risk factors listed above.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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