To Your Good Health: Osteoporosis screening for men remains controversial

My husband and I are confused about the guidelines concerning when older men should be screened for osteoporosis. All the information seems to suggest that it is only needed for men over 70 who have had a fracture. In my husband’s case, he was only told to get a dual-energy X-ray absorptiometry scan after he had back pain and several compression fractures of the thoracic spine, up to 70%, at the age of 72. His T-score was -2.8 for his spine. I can’t help feeling that because he is male, weighs 200 pounds, has an active lifestyle and was previously 6 feet, 2 inches tall, the issue of osteoporosis just never came up during his yearly primary care visits — even though his height had decreased since at least 2019, and he’s now only 6 feet tall. This is a potentially life-threatening condition for older women and men, but the risks for women seem to get all the attention. What’s the reluctance to order a simple, fast, painless, not-too-expensive test to screen men earlier?

In general, screening tests — by definition, a test done on a person with no symptoms of the condition — are done when there is good evidence that the screening will lead to an improved outcome in the screened group compared to an unscreened group.

The data in women is strong enough that all women over 65 and women younger than 65 with additional risks for osteoporosis should be screened with a DEXA scan, but there is not strong enough data to support screening in men.

Osteoporosis screening in men is controversial. While one of the most influential groups does not recommend screening in all men over 70, some groups do, despite an absence of proven benefit.

They base this recommendation on the fact that, as you say, it’s not a particularly dangerous test (the radiation dose is small), nor is it expensive (the average cost is $150, but can be higher in some states).

One major downside of testing in general is that no screening test is perfect. As such, an unexpected finding of osteoporosis in a man requires that the screening test be repeated to be sure the test result is accurate.

Even though men are not always recommended for screening, there are some medical findings that should prompt a test. One is a loss of height — losing more than 1.5 inches of height should have prompted a DEXA scan.

Strictly speaking, this is no longer a screening. It’s an evaluation of the cause of an unexpected medical finding.

A low testosterone level (either by itself — hypogonadism — or as a result of medical treatment for prostate cancer); primary hyperparathyroidism; inflammatory bowel disease; and long-term use of prednisone and similar drugs are all known risk factors for osteoporosis that should at least trigger a discussion of a DEXA scan.

Similarly, the finding of osteoporosis in a man should prompt consideration of the underlying reason behind it, which could include any of the risk factors listed above.

Have you ever heard of a low blood pressure stroke? That was my husband’s (incorrect) diagnosis several years back when he suddenly could not move his arms and legs. He was told that not enough oxygen was getting to his spine. His blood pressure is historically low, usually around 90/60. That lasted about seven months, and he was bedridden the entire time. He then went to a neurosurgeon and was (correctly) diagnosed with a spinal cord injury. He had C1-C2 surgery and had use of his limbs the next day. After months of physical therapy, he regained a lot of function. We’ve never heard of that diagnosis before or after his experience. Does it really exist?

The brain has tremendous ability to regulate its own blood flow under a very wide range of blood pressures, but there are some limits.

When a person is used to very high blood pressure levels, such as 200/110 for months or years, a sudden drop to 90/60, or even 120/80 sometimes, can cause a stroke.

That’s the main reason we don’t lower blood pressure too quickly in people who have had very high blood pressure levels for a long time. It takes weeks or months for the brain to recover its ability to regulate blood flow.

In a person who has a heart attack, prolonged low blood pressure, or no blood pressure, will also cause brain damage. That’s why starting CPR as quickly as possible is so critical in order to preserve brain function.

In both of these cases, not enough blood is getting to the central nervous system — the brain, the spinal cord and the retinas — which can lead to cell death, the hallmark of a stroke. But these are extreme cases.

A healthy person whose normal blood pressure is around 90/60 is at risk for fainting when suddenly standing. However, they are at a lower-than-average risk for heart disease and stroke.

The diagnosis of “a low blood pressure stroke” for your husband doesn’t make any sense at all to me, and advanced imaging of the brain should have made it abundantly clear that it was not the right diagnosis.

I’m shocked that he wasn’t treated correctly for that long. But I’m very happy to hear that his neurosurgeon did not assume the diagnosis of a stroke, instead making the correct diagnosis and performing the procedure to help him recover.

Your husband is fortunate that he still had neurological function to recover after such a long time, since spinal cord injuries generally heal better when treated promptly.

My primary care physician and blood specialist claim there is nothing that will increase white blood cell count. Are there any supplements that I can take or foods I can eat to improve the low count?

The question is, why is your white blood cell count low? Some people have low white blood cell counts for no reason; it runs in families, so there aren’t any health concerns there.

However, there are a large variety of blood diseases that cause low white cell counts. Some affect the lymphocytes, while others affect the granulocytes, the two main types of white cells.

Nutritional deficiencies are extremely rare in North America — vitamin B12, folic acid and copper are the exceptions that should be looked for — so neither diet nor supplements are usually helpful.

If there’s an absence of blood disease or symptoms, low white blood cell counts usually do not need treatment.