I followed with great interest the data reported by Kiebzak et al1 regarding the underdiagnosis and undertreatment of osteoporosis in men. Only 7% of their male patients had a diagnosis of osteoporosis prior to hip fracture, and fewer than 5% were taking treatment of any kind at hospital discharge. Moreover, in their medical chart review, the authors stated that osteoporosis risk factors were not consistently documented in patients' medical records. Specifically, there was no mention of hypogonadism, a well-established risk factor for osteoporosis in men. Clearly, the previous data unravel the profound unawareness of risk factors and treatment of osteoporosis in the male sex. In fact, hypogonadism is the commonest cause of secondary osteoporosis in men, occurring in up to 20% of men with symptomatic vertebral fractures and 50% of elderly men with hip fractures.2 In the series of Kiebzak et al,1 only 5 of the 110 male patients with hip fracture had a documented diagnosis of hypogonadism, a finding that underscores the lack of awareness of gonadal failure being an important risk factor for osteoporosis in men. In this regard, I disagree with the authors for not considering testosterone as a treatment for osteoporosis in males, and in their claim that there is little information in the literature to support its use as an osteoporosis treatment (page 2218 of the article). Indeed, testosterone supplementation in hypogonadal men with osteoporosis increases bone mineral density,3 decreases bone resorption, and stimulates bone formation.4 In addition, such therapy can ameliorate concomitant abnormalities that contribute to the pathogenesis of hypogonadal male osteoporosis, such as low circulating levels of estrogen, calcitonin, 1,25 dihydroxyvitamin D, and negative calcium balance.4 Furthermore, the improvement of muscle strength as result of testosterone administration may potentially decrease the risk of falls. Although long-term randomized studies specifically designed to assess the effect of testosterone replacement on the incidence of fractures are lacking, this should not be a reason to overlook routine screening for gonadal failure in men with osteoporosis. Until such studies become available, it is worthwhile to offer testosterone replacement therapy to patients with proven hypogonadism in addition to the standard treatment of osteoporosis. It should be emphasized that hip fracture in men is a true public health problem. Multiple studies,5 including that of Kiebzak et al,1 have repeatedly shown higher mortality following hip fracture in men than in women. Thus, it is vitally important to identify and correct any remediable cause of skeletal deterioration in the male population.
Mikhail N. Hypogonadism and Osteoporosis in Men. Arch Intern Med. 2003;163(10):1237. doi:10.1001/archinte.163.10.1237-a