The report is a product of the VA/HSR Evidence Synthesis Program.

Screening for Male Osteoporosis: A Systematic Review

Screening to identify individuals at highest risk of fracture-related morbidity is standard practice for women, but there remains uncertainty about universal screening for men. Despite a lower risk of fracture among men compared to women (21% vs 53%), men have higher rates of osteoporotic fracture-related complications and mortality than women. Thus far, the United States Preventive Services Task Force (USPSTF) has found insufficient evidence to recommend routine screening of men for osteoporosis. However, the issue of screening for osteoporosis among men is particularly relevant to VA because Veterans of both sexes are at higher risk for osteoporotic fractures, have more chronic medical conditions, have less bone-health knowledge, spend less time exercising, and have more falls than non-Veterans, contributing to a higher risk for bone health problems.

VA’s Evidence Synthesis Program (ESP) Center in Durham, NC, conducted a systematic review to examine:  

• Sensitivity/specificity of osteoporosis risk assessment tools among men;
• Individual factors associated with increased risk of osteoporosis among male Veterans; and
• System-level approaches for boosting osteoporosis screening.

Investigators searched MEDLINE®, Embase, and CINAHL for potentially relevant studies. Overall, they identified 9,287; of these, 598 received a full-text review, and 69 (19 were VA studies) were used for this review.

Summary of Findings

Most studies were too heterogeneous to perform quantitative synthesis; the majority of the analysis was conducted via narrative synthesis. Overall, investigators found few studies that directly compared osteoporosis risk assessment tools among male samples. Among the risk assessment tools assessed, the osteoporosis self-assessment tool (OST) was found to acceptably identify men with osteoporosis compared to bone density scan (DXA) using two easily obtainable variables. The prevalence of osteoporosis in the studies ranged from 5% to 24%.

Other tools evaluated by more than one study (i.e., FRAX, MORES, Garvan, and QFracture) generally had widely varying discrimination. Tools varied in their complexity ranging from only two risk factors (i.e., OST) required for calculations to more than 20 risk factors, such as QFracture. When considering tools and risk factors among male Veterans, specifically, investigators found that FRAX (Fracture Risk Assessment Tool) and OST were the two most commonly studied for the assessment of osteoporosis and/or fracture among male Veterans. Both performed similarly, with low-to-moderate discriminatory validity across osteoporosis and fracture outcomes.

Investigators also identified limited risk factors for osteoporosis and/or fracture risk, but the literature suggests that existing tools may underperform among persons with conditions such as HIV, ADT therapy, or rheumatoid arthritis. Among the many evaluated system-level interventions to increase uptake or screening, those that combine patient and provider targets may be more effective.

Clinical Implications

The Bone Health and Osteoporosis Foundation, the International Society for Clinical Densitometry (ISCD), and the Endocrine Society suggest screening for osteoporosis in men above the age of 70, and in those aged 50-69 years if additional risk factors are present (i.e., hypogonadism, smoking, and steroid use). In practice, clinical risk prediction tools can help identify patients at heightened risk of osteoporosis and/or fracture. Still, these tools (e.g., FRAX) have been developed primarily using female populations. Thus, the benefit of systematic screening in men is unclear. Factors that would affect the risks and benefits of routine screening, include increased demand on DXA utilization and interpretation, low-dose radiation with DXA, increased identification of low-bone density and osteoporosis, increased use of osteoporosis medication and potential adverse events, as well as the potential reduction in fracture risk.

Research Gaps/Future Research

Continued research is needed to support optimal choice and use of clinical risk assessment tools for male Veterans, including head-to-head comparisons of specific tools to help guide clinical decision-making. In addition, there are insufficient data to determine whether tools perform differently across under-represented racial/ethnic groups, as few studies include sufficiently diverse populations, and most studies do not consider race/ethnicity-specific reference data for bone mineral density (BMD).

VA is particularly well-suited to conduct research on system-level interventions aimed to increase appropriate screening for male Veterans at risk for osteoporosis and fracture. Given these findings, future work on system-level interventions may focus on combining patient- and provider-focused intervention strategies.

Sagalla N, Alexopoulos AS, Gordon AM, et al. Screening for Male Osteoporosis: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2022.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/male-osteo.cfm (Intranet only - If you have intranet acces, copy and paste the link into your browser.)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

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This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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