EAA clinical guideline on management of bone health in the andrological outpatient clinic

Abstract

Male osteoporosis is now a well-recognized medical disorder with established clinical guidelines for both diagnosis and management. Prevention as well as management of osteoporosis in men consulting the andrological outpatient clinic because of low testosterone, however, is not well established. This gap of knowledge is-at least partly-explained by the controversy with respect to the threshold of testosterone needed for skeletal maintenance. However, testosterone deficiency may be clearly associated with bone loss as well as frailty in men. If anything, andrologists should therefore be aware of the potential silent presence of osteoporosis in men with confirmed hypogonadism. Therefore, the management of patients with potential hypogonadism should include a complete bone health assessment, besides clinical and biochemical evaluation of gonadal status. Such bone health assessment should include specific items in medical history and physical examination related to fracture risk. Furthermore, dual-energy absorptiometry is indicated to evaluate fracture risk in men with confirmed clinical hypogonadism. Regarding treatment, besides general measures to prevent or manage male osteoporosis testosterone replacement can be initiated (as described in guidelines for hypogonadism), but data on its efficacy in preventing fractures are lacking. Thus, additional anti-osteoporotic may be needed, especially in men with very low testosterone who are at high risk of bone loss and/or in men not able to receive testosterone replacement.

European Academy of Andrology (EAA) guidelines on investigation, treatment and monitoring of functional hypogonadism in males

“…TRT may improve bone quality in hypogonadal men with low or moderate fracture risk . TTrials also showed that TRT improves volumetric bone mineral density, more in the spine than (but also significantly) in the hip, confirming earlier data that TRT increases areal spinal bone mineral density as measured by dual‐energy X‐ray absorptiometry (DEXA) .…”

“…TTrials also showed that TRT improves volumetric bone mineral density, more in the spine than (but also significantly) in the hip, confirming earlier data that TRT increases areal spinal bone mineral density as measured by dual‐energy X‐ray absorptiometry (DEXA) . However, there are no data on the effects of TRT on fracture risk or incidence in men, unlike several bone‐specific medical therapies (eg bisphosphonates) …”

“…Fracture risk rather than bone density is the more important outcome . Fracture risk (estimated by FRAX or similar scores) remains the key metric for determining appropriate treatment option and assessment of efficacy in hypogonadal patients at high risk of osteoporosis …”

Bone mineral density is preserved in men with idiopathic infertility

“…It is well-known that testosterone deficiency is a risk factor for bone loss and osteoporosis in men (Rochira et al, 2018). Low testosterone levels are associated with increased bone resorption, though the effect of testosterone on bone is largely mediated by its conversion to estradiol (Rochira et al, 2006).…”

“…Testosterone deficiency is a well-known risk factor for bone loss and osteoporosis in men (Rochira et al, 2018). Infertile men have a higher risk of developing testosterone deficiency , and a positive association between sperm counts and Leydig cell capacity for testosterone production has been observed (Andersson et al, 2004;Jørgensen et al, 2016;Olesen et al, 2018).…”