Osteoporosis is considered a women's disease. The clinical system is largely built around screening and treating women. But men make up 1 in 5 osteoporosis cases in Canada, experience higher post-fracture mortality than women, and are diagnosed far less often — frequently not until after a serious fracture. This guide covers what Canadian men specifically need to know about bone health, from risk factors and screening recommendations to the testosterone question and treatment options.
The fixation on osteoporosis as female has a historical reason: the link between menopause, estrogen decline, and rapid bone loss was identified first and studied most extensively. That's a legitimate risk — postmenopausal women do lose bone faster in early menopause. But the framing has stuck long past its usefulness, causing real harm to men.
Bone loss in men is more gradual than the post-menopause drop women experience, but it starts earlier than most men realize and accumulates. By age 50, the average Canadian man has lost measurable bone mass. By 70, fracture risk is significant — and after a hip fracture, men have worse survival odds than women, largely because they tend to be older and frailer when the fracture finally occurs, and because fewer of them were being monitored and treated beforehand.
Osteoporosis Canada's position: male osteoporosis is underdiagnosed, undertreated, and under-researched. This is a public health problem that isn't going to fix itself unless men start asking their doctors the right questions.
Most men know testosterone plays a role in muscle mass and libido. Fewer know it's directly involved in bone maintenance. Testosterone promotes bone formation, stimulates osteoblasts (bone-building cells), and helps maintain the geometry of cortical bone — the dense outer shell of bones like the femur.
But testosterone doesn't work alone. A significant portion of its bone-protective effect comes from aromatase — an enzyme that converts testosterone to estradiol (a form of estrogen) directly in bone tissue. Men who lack functional aromatase develop severe osteoporosis early in life. This means bone health in men depends on both hormones being present, even though estrogen is typically associated with women's physiology.
Testosterone decline in aging men is gradual (unlike menopause) — roughly 1–2% per year after age 30. Low testosterone (hypogonadism) — defined as serum testosterone below about 8–10 nmol/L — is an established risk factor for osteoporosis in men. It can arise from testicular failure, hypothalamic-pituitary disorders, or as a consequence of medications or medical treatment.
The most acute testosterone-related bone risk in Canadian men is androgen deprivation therapy (ADT) for prostate cancer. ADT medications (LHRH agonists like leuprolide, or anti-androgens) suppress testosterone to castrate levels — typically below 0.5 nmol/L. Bone density drops at 2–4% per year in the first year of ADT, faster than postmenopausal bone loss in women.
Osteoporosis Canada recommends that all men starting ADT have a baseline DEXA scan, with repeat imaging at 1–2 year intervals. Most men on ADT will meet criteria for bone-protective medication (bisphosphonates or denosumab), particularly Prolia, which has Health Canada approval specifically for bone loss prevention in men on ADT for prostate cancer.
If you or someone you know has started ADT and hasn't been offered a DEXA scan, this is a conversation worth having with their oncologist or GP — it's an explicit gap in care.
Men's osteoporosis is more frequently secondary — caused by another underlying condition or behaviour — than women's. In men, secondary causes account for roughly 40–60% of osteoporosis cases, vs. approximately 30% in women. This matters because identifying and treating the underlying cause can slow bone loss and reduce fracture risk beyond medication alone.
Alcohol use disorder is more prevalent in men than women, and it's one of the most potent suppressors of bone health. Heavy alcohol use (more than 14 standard drinks per week in Canada, or consistent daily use above 2 drinks) reduces osteoblast activity directly, elevates cortisol (which interferes with calcium absorption), and suppresses testosterone production. Men with significant drinking histories consistently show lower BMD on DEXA than non-drinkers.
Even moderate heavy drinking — 4+ drinks in a day, regularly — is associated with increased fracture risk. This isn't about abstinence, but it is a legitimate clinical risk factor that should be part of any bone health conversation with your doctor.
Smoking reduces bone density through several mechanisms: it inhibits osteoblasts, accelerates estrogen and testosterone catabolism, reduces intestinal calcium absorption, and impairs circulation to bone. Smokers have approximately 10–15% lower bone density than non-smokers on average. The risk is dose-dependent — heavy long-term smokers have the worst outcomes — and it's partially reversible. Bone density begins recovering after quitting, though the full recovery takes years.
Body weight provides mechanical loading to the skeleton. Men with a BMI below 20 have significantly higher fracture risk than those at normal weight. Low weight in men is also often associated with low muscle mass (sarcopenia), which independently increases fall risk. Men who have lost significant weight — from illness, malabsorption, or intentional extreme dieting — should consider a DEXA scan.
Long-term corticosteroid use (prednisone and equivalents) is the most common drug-induced cause of osteoporosis in both sexes. Men on corticosteroids for conditions like rheumatoid arthritis, COPD, asthma, inflammatory bowel disease, or organ transplant are at high risk. Osteoporosis Canada guidelines recommend initiating bone-protective therapy in any adult expected to be on ≥7.5 mg prednisone equivalent per day for more than 3 months, or in those with additional risk factors at lower doses. See our dedicated guide on steroid-induced osteoporosis.
Osteoporosis Canada's current guidelines recommend bone mineral density testing for men in the following situations:
| Indication | Recommendation |
|---|---|
| Age 65 or older | Offer BMD testing, especially with additional risk factors |
| Any fragility fracture after age 40 | BMD testing recommended — men frequently missed here |
| On androgen deprivation therapy (prostate cancer) | Baseline DEXA, then every 1–2 years |
| Long-term corticosteroids (≥3 months cumulative) | BMD at initiation of therapy |
| Diagnosed hypogonadism / low testosterone | BMD testing recommended |
| BMI < 20 or significant unintentional weight loss | Consider BMD testing |
| Heavy alcohol use or current smoking with other risk factors | Consider BMD testing before age 65 |
Provincial health plans (OHIP, BC MSP, AHCIP, RAMQ, etc.) cover DEXA scans when clinical criteria are met. Your GP or specialist issues the referral. If you believe you meet criteria but haven't been offered a scan, ask directly. See our detailed guide on how DEXA scanning works in Canada for information on what to expect and how to interpret your results.
DEXA T-scores are calculated against a reference population of young adults at peak bone mass. The same cutoffs apply to men as to women: T-score below −1.0 is osteopenia; below −2.5 is osteoporosis. However, there's an important nuance: the reference database used for comparison matters. Some older densitometers use female reference data by default. Ensure your report specifies male reference norms.
Your T-score alone doesn't determine treatment. Osteoporosis Canada recommends the FRAX fracture risk tool — which incorporates T-score along with age, BMI, family history, secondary causes, and other clinical variables — to estimate your 10-year probability of a major osteoporotic fracture. This gives a more complete picture than T-score alone and is what most Canadian physicians use to make treatment decisions.
The major osteoporosis medications available in Canada are effective in men. Health Canada has approved the following for male osteoporosis:
Generic bisphosphonates are covered by most provincial drug plans. Coverage for Prolia and newer medications requires meeting specific criteria. See our full guide to osteoporosis medications in Canada for dosing, coverage details, and side effects.
Canadian men are less likely than women to track calcium intake, and also less likely to supplement with vitamin D in winter. The specific targets for men according to Osteoporosis Canada and Health Canada:
The average Canadian man gets about 700–800 mg of calcium from diet. Three servings of dairy (or fortified plant-based equivalents) or including canned fish with bones (sardines, salmon) would close most of that gap. See our calcium-rich foods guide for practical strategies.
Men who have been active in their 20s and 30s sometimes coast on the assumption that their bones are fine. Bone responds to mechanical loading in the present — what you did 20 years ago matters less than what you're doing now. Two to three sessions of resistance training per week, prioritizing compound lower-body and spinal loading (squats, deadlifts, rows), is the most evidence-backed approach. Impact activities like running, jumping, and racquet sports add benefit.
Swimming and cycling — popular among men in middle age — don't load the skeleton and don't stimulate bone formation. If they're your primary activities, add weight training. After age 60, balance training becomes equally important; most hip fractures occur from falls, and fall prevention is as valuable as bone density improvement.