According to a new position paper from the North American Menopause Society (NAMS), despite all the new drugs that are available, diet and lifestyle should remain the first osteoporosis management tool. Only after diet and lifestyle has failed should any of the newly approved treatment options to prevent osteoporosis be considered.

Although osteoporosis is usually thought of as a problem of older women, older men and especially men who are on hormone deprivation therapy (ADT) can quickly fall victim to osteoporosis. Not only does osteoporosis endanger men on ADT because of the increase in fracture risk they will face, but it also leaves their bones at an increased risk for bone metastasis. Given the failure of the research community to study men and osteoporosis, we can only operate on the assumption that the recommendations for the care and treatment of women will be similar for men.

NAMS’s latest position statement on osteoporosis management appeared in the January/February issue of Menopause. It stated that all postmenopausal women should be encouraged to reduce their risk of bone loss and osteoporotic fractures by:

• Maintaining a healthy weight

• Eating a balanced diet

• Obtaining adequate calcium (1,200 mg per day at age 50 and beyond) and vitamin D (800 to 1,000 IU vitamin D3 per day)

• Participating in appropriate exercise

• Avoiding excessive alcohol consumption

• Not smoking

• Taking measures to prevent falls

This latest statement from NAMS included the results from the 10-year fracture risk calculator, called FRAX. FRAX is based on a World Health Organization meta-analysis of more than 60,000 patients and over 5,000 fractures.

The factors included in the FRAX calculator were: age, sex, weight, height, low femoral neck bone mineral density, prior fragility fracture, parental history of hip fracture, current smoking, long-term corticosteroid use, rheumatoid arthritis, other causes of secondary osteoporosis (such as hyperthyroidism or type 1 diabetes), and more than two servings of alcohol per day.
“This tool, used with guidelines for treatment thresholds, is very helpful in identifying candidates for pharmacotherapy,” the position statement said.

NAMS recommended osteoporosis drug therapy for all postmenopausal women with the following:

• An osteoporotic vertebral or hip fracture

• Bone mineral density T-scores of -2.5 or worse at the lumbar spine, femoral neck, or total hip region.

• Bone mineral density T-scores under the osteoporotic threshold — from -1.0 to -2.5 — if accompanied by a 10-year FRAX-calculated risk of at least 20% for major osteoporotic fracture, or of at least 4% for hip fracture alone.

Among available treatments, the statement recommended bisphosphonates as the first-line option for osteoporosis in postmenopausal women.

The statement then continued by recommending additional alternate drug treatments which I do not believe would be appropriate for men on hormone therapy.

Bone health is a very under studied for men, especially for men on ADT. In the mean time we should all incorporate diet and exercise into out normal life routine, especially if we are on ADT.

North American Menopause Society “Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society” Menopause 2010; 17: 25-54.

Joel T Nowak, MA, MSW