Bone health in older men

Senile osteoporosis in men remains under-recognized despite substantial fracture-related morbidity and higher post-fracture mortality than in women. Age-related bone loss in men involves progressive trabecular thinning, cortical deterioration, and declining sex steroid levels, while secondary causes, including hypogonadism, medications, and chronic diseases, account for up to 60% of cases. Current guidelines recommend assessment of bone mineral density (BMD) in men aged ≥70 years and earlier screening in those with clinical risk factors, complemented by fracture-risk assessment and evaluation for secondary causes. Management includes lifestyle and fall-prevention measures, with pharmacological treatment according to fracture risk. Bisphosphonates remain first-line therapy, with zoledronic acid demonstrating vertebral fracture reduction. Denosumab and anabolic agents increase BMD, although male-specific fracture data remain limited. Testosterone replacement improves BMD in hypogonadal men, but has not been shown to reduce the risk of major osteoporotic fractures. Despite effective therapies, fewer than 20% of men receive treatment following a fragility fracture. This review summarizes current evidence on the epidemiology, pathophysiology, diagnosis, and management of osteoporosis in men, emphasizing male-specific evidence and persisting knowledge gaps. It identifies important gaps in the management of osteoporosis in men and highlights the need for improved screening and secondary prevention, male-specific fracture trials, long-term safety data, and evidence on optimal treatment sequencing.