Lack of Bone Mineral Density Testing in Men With Hypogonadism

A Clinical Conundrum

Travis Goettemoeller; James Bena; Kevin M. Pantalone


J Endo Soc. 2022;6(10) 

In This Article

Abstract and Introduction


Context: The 2012 Endocrine Society Clinical Practice Guidelines recommend that men aged 50 years or older with a diagnosis of hypogonadism undergo bone mineral density (BMD) testing.

Objective: The objective of this study was to determine the frequency at which men aged 50 years or older with a diagnosis of hypogonadism undergo BMD testing, and if found to have low BMD, are subsequently treated with an osteoporosis medication.

Methods: A retrospective chart review was conducted at a large academic medical center. Inclusion requirements were an International Classification of Diseases (ICD)-9 or -10 code for hypogonadism at any time between July 1, 2012 and September 30, 2020. Patients were followed until the date of BMD assessment or censoring (September 30, 2021). BMD results and treatment with osteoporosis medication were recorded.

Results: A total of 10 169 men with hypogonadism were identified, of whom the mean age was 63.4 (± 9.2), 86.3% White, mean body mass index 31.3 with prevalence of chronic kidney disease, type 2 diabetes, and hypertension of 20.6%, 36.9%, and 68.2%, respectively. The percentage that underwent BMD testing was 7.2%, of which 352 (48.4%) and 87 (12.0%) had osteopenia and osteoporosis, respectively. Among the 87 patients with osteoporosis, 57.5% were treated with an osteoporosis medication.

Conclusion: Only 7.2% of hypogonadal men underwent BMD testing, and among them, 12.0% were found to have osteoporosis. Among those with osteoporosis, 57.5% underwent treatment with osteoporosis medication. Further studies are needed to determine why so few men with hypogonadism undergo BMD assessment and what systems can be put in place to overcome this clinical conundrum.


Previous studies have reported that osteoporosis in men is underdiagnosed.[1–7] Hypogonadism is a known risk factor for decreased bone mineral density (BMD) and increased risk of fractures in men.[8–11] In June 2012, the Endocrine Society issued clinical practice guidelines recommending that men aged 50 years or older with a diagnosis of hypogonadism undergo BMD testing.[12] To the authors' knowledge, since the publication of these guidelines, no studies have been performed investigating the rate at which older men with hypogonadism undergo screening with BMD testing.

In addition to the recommendation to screen for decreased BMD in men with hypogonadism, the Endocrine Society also provides guidelines for treatment. Current guidelines recommend that all men at high risk of fracture, regardless of whether they have hypogonadism, be treated with an agent with proven antifracture efficacy.[12] Guidelines suggest that hypogonadal men at high risk of fracture, who lack standard indications for testosterone replacement but who have contraindications to approved standard osteoporosis medications, be treated with testosterone therapy.[12] Moreover, in men with hypogonadism at borderline high risk of fracture, testosterone therapy is suggested in lieu of a "bone drug" if there are signs or symptoms of hypogonadism.[12]

While no studies have been performed looking specifically at the frequency of treatment in hypogonadal men with osteoporosis, previous studies have reported the undertreatment of men diagnosed with osteoporosis, even in those who have suffered a previous fracture.[3,4,6]

In this report, men aged 50 years or older with a diagnosis of hypogonadism that underwent BMD testing (dual-energy x-ray absorptiometry [DXA]) at a large integrated delivery system in the United States were identified. Among those men who underwent testing, the percentage of patients that were diagnosed with osteopenia or osteoporosis, and were subsequently treated with an osteoporosis medication, was recorded. The frequency of treatment with testosterone replacement therapy (TRT) during the study period was also recorded. Furthermore, the frequency of BMD testing between patients seen by providers from different specialties was also collected.