Male osteoporosis: pathophysiology, risk assessment, and evidence-based management

Osteoporosis in men is a common yet underrecognized condition associated with substantial fracture-related morbidity and excess mortality. Although men generally attain higher peak bone mass than women, age-related changes in bone microarchitecture, progressive cortical bone loss, declining sex steroid bioavailability, and a high prevalence of secondary causes contribute to a significant lifetime fracture risk. Importantly, a large proportion of fragility fractures in men occur at bone mineral density (BMD) values above the osteoporotic threshold, highlighting the limitations of BMD-based diagnosis alone. This review provides a comprehensive overview of the epidemiology, pathophysiology, and clinical characteristics of osteoporosis in men, with particular emphasis on sex-specific skeletal aging, hormonal regulation, and secondary osteoporosis. Current strategies for fracture risk assessment are critically examined, including the roles and limitations of dual-energy X-ray absorptiometry, vertebral imaging, the Fracture Risk Assessment Tool, and alternative risk prediction tools. We further summarize evidence-based approaches to management, encompassing lifestyle measures, correction of reversible risk factors, and pharmacological therapies. Antiresorptive agents remain the first-line treatment for most men, while anabolic therapies and sequential treatment strategies are increasingly recognized for those at very high risk of fracture. Overall, effective care in cases of male osteoporosis requires an integrated risk-based approach that extends beyond BMD to include clinical risk factors, secondary causes, and functional status. Improved recognition and sex-specific management strategies are essential to reduce the fracture burden and improve long-term outcomes in men.