Men's Bone Health: The Overlooked Risk

When most people hear "osteoporosis," they think of postmenopausal women. That association is not wrong — women do lose bone density faster after menopause, and they are more likely to be diagnosed and treated. But this framing has created a blind spot that costs men their health and, in some cases, their lives. Approximately 2 million American men have osteoporosis, and an estimated 12 million more have osteopenia (reduced bone density that has not yet reached the osteoporosis threshold). One in four men over 50 will experience an osteoporotic fracture in his remaining lifetime.

Perhaps most concerning: when men do fracture, the outcomes are worse. Men who suffer hip fractures have a higher mortality rate than women with the same injury. This is partly because men tend to be older and sicker when they fracture, and partly because they are less likely to have been screened, diagnosed, or treated beforehand.

How Bones Work: A Brief Overview

Bone is living tissue that is constantly being remodeled. Specialized cells called osteoblasts build new bone, while osteoclasts break down old bone. In youth, bone formation outpaces resorption, and bone density increases. Peak bone mass is typically reached by the late twenties. After that, a slow net loss begins as resorption gradually outpaces formation.

This process is regulated by hormones, mechanical loading (exercise), nutrition, and other factors. When the balance tilts too far toward resorption, bone becomes progressively thinner and more porous, increasing fracture risk.

The Role of Testosterone (and Estrogen)

Testosterone contributes to bone health in men through two pathways. First, androgen receptors on osteoblasts and osteocytes respond directly to testosterone, stimulating bone formation and reducing bone resorption. Second, testosterone is converted to estradiol (a form of estrogen) by the enzyme aromatase. Estradiol is actually the more potent regulator of bone density in men, which surprises many people.

Studies have shown that estradiol levels, rather than testosterone levels per se, are the strongest hormonal predictor of bone mineral density in older men. However, testosterone is the primary substrate for estradiol production in men, so testosterone deficiency ultimately leads to reduced estradiol and accelerated bone loss.

Men with clinically low testosterone are at significantly increased risk for osteoporosis. The Testosterone Trials showed that one year of testosterone treatment in older men with low levels increased bone mineral density and estimated bone strength, particularly in the spine and hip. This confirms that testosterone deficiency has a direct, measurable effect on bone and that treatment can partially reverse it.

Other Risk Factors for Bone Loss in Men

Testosterone deficiency is an important risk factor but not the only one. The following factors also contribute to reduced bone density in men:

Age

Bone loss accelerates after age 65 to 70 in men, even in those with adequate testosterone levels. Age-related changes in bone cell function, calcium absorption, and vitamin D metabolism all contribute.

Glucocorticoid Use

Chronic use of glucocorticoid medications (such as prednisone) is the most common cause of secondary osteoporosis in both men and women. Glucocorticoids suppress osteoblast function, increase osteoclast activity, reduce calcium absorption, and suppress testosterone production. Men on long-term glucocorticoids should be monitored for bone loss.

Alcohol Excess

Heavy alcohol consumption is toxic to osteoblasts and suppresses bone formation. It also increases fall risk, creates nutritional deficiencies, and suppresses testosterone. More than two alcoholic drinks per day is associated with significantly increased fracture risk.

Smoking

Smoking reduces bone density through multiple mechanisms, including direct toxic effects on bone cells, reduced testosterone, impaired calcium absorption, and increased cortisol. Smokers have measurably lower bone density than non-smokers and higher fracture rates.

Sedentary Lifestyle

Bone responds to mechanical loading. Weight-bearing exercise and resistance training stimulate bone formation by signaling osteoblasts through mechanical stress. Men who are sedentary, particularly those who are bedridden or wheelchair-bound, lose bone density rapidly. Even among ambulatory men, low levels of physical activity are associated with reduced bone density.

Low Body Weight

Men with a BMI below 20 are at increased risk for osteoporosis. Low body weight means less mechanical loading on bones and may be associated with nutritional deficiencies and lower hormone levels.

Calcium and Vitamin D Deficiency

Inadequate calcium and vitamin D intake contribute to bone loss. Vitamin D is essential for calcium absorption in the gut, and deficiency is common, particularly in northern latitudes and in men who spend limited time outdoors. The recommended daily intake of calcium for men over 50 is 1,000 to 1,200 mg per day, and vitamin D intake should be sufficient to maintain a serum 25-hydroxyvitamin D level of at least 30 ng/mL.

Other Medical Conditions

Conditions that increase bone loss risk include hyperparathyroidism, hyperthyroidism, celiac disease and other malabsorptive conditions, chronic kidney disease, rheumatoid arthritis, and type 1 diabetes.

Screening: When Should Men Be Tested?

Current guidelines from the Endocrine Society and the International Society for Clinical Densitometry recommend DEXA scans (dual-energy X-ray absorptiometry, the gold standard for measuring bone mineral density) for:

• All men aged 70 and older
• Men aged 50 to 69 with risk factors for osteoporosis (glucocorticoid use, low body weight, smoking, excess alcohol, testosterone deficiency, history of fracture)
• Men of any age with a fragility fracture (a fracture from minimal trauma such as a fall from standing height)
• Men on medications or with conditions known to cause bone loss

Despite these guidelines, screening rates in men remain low. Many primary care providers do not routinely consider bone density testing in their male patients, and many men are not aware that they are at risk.

What a DEXA Scan Tells You

A DEXA scan measures bone mineral density at the hip and spine and reports results as a T-score, which compares your bone density to that of a healthy 30-year-old of the same sex:

• T-score of -1.0 or above: Normal bone density
• T-score between -1.0 and -2.5: Osteopenia (reduced bone density)
• T-score of -2.5 or below: Osteoporosis

The test is quick (about 10 to 15 minutes), painless, and involves minimal radiation exposure. If your provider has not mentioned it and you have risk factors, it is reasonable to ask.

Prevention and Treatment

Bone health in men is best addressed through a combination of lifestyle measures and, when appropriate, medical treatment:

Exercise

Weight-bearing exercise (walking, jogging, stair climbing) and resistance training (weightlifting) are the most important non-pharmacological interventions for bone health. The mechanical loading from these activities directly stimulates bone formation. Aim for resistance training at least two to three times per week, incorporating exercises that load the spine and hips.

Nutrition

Ensure adequate calcium intake (1,000 to 1,200 mg per day from diet and supplements if needed) and vitamin D (typically 1,000 to 2,000 IU per day, adjusted based on blood levels). Adequate protein intake also supports bone health.

Lifestyle

Stop smoking. Limit alcohol to no more than two drinks per day. Both are modifiable risk factors with strong evidence.

Address Testosterone Deficiency

If testosterone is genuinely low, treatment may improve bone density, as demonstrated in the Testosterone Trials. This should be part of a broader evaluation and treatment plan.

Pharmacological Treatment

For men diagnosed with osteoporosis, medications such as bisphosphonates (alendronate, risedronate, zoledronic acid) and denosumab are approved and effective. These medications reduce fracture risk by slowing bone resorption. Teriparatide, a parathyroid hormone analog, is an anabolic agent that stimulates new bone formation and is used in severe cases. Treatment decisions should be made with a provider experienced in bone health.

The Bottom Line

Osteoporosis in men is common, underdiagnosed, and undertreated. The consequences of ignoring it — fractures, disability, and increased mortality — are serious and largely preventable. Men should be aware of their risk factors, proactive about screening when appropriate, and engaged in the lifestyle measures that protect bone health.

If you are a man over 50 with risk factors, or if you have been diagnosed with low testosterone, ask your provider about bone density screening. It is a simple test that could prevent a life-altering fracture.