The underlying cause for bone loss is not always
A 68-year-old man presented for an initial visit. He had
previously seen a different endocrinologist who retired several months ago.
He had been diagnosed with idiopathic secondary
hypogonadism in 2002 and was treated with testosterone injections until 2009,
at which time he was diagnosed with prostate cancer. The patient received
external beam radiation and was taken off testosterone supplementation at that
The patient had been told he had osteopenia and had a
bone mineral density measurement 6 months before the visit.
At the visit, he complained of decreased libido,
erectile dysfunction (SHIM score 2/25) responsive to sildenafil (Viagra,
Pfizer) and weight gain during the past 2 to 3 years. He shaves once a day,
entered puberty around age 13 and denied changes in body hair or gynecomastia.
He had a history of two fractures of the left foot at
ages 22 and 29 years.
His medical history included obstructive sleep apnea
requiring continuous positive airway pressure, chronic obstructive pulmonary
disease, hypertension, hyperlipidemia, impaired fasting glucose, coronary
artery disease with s/p coronary artery bypass grafting, vitamin D deficiency,
hyperhomocysteinemia, umbilical hernia repair, cervical discectomy and lumbar
- Ramipril 5 mg by mouth twice a day;
- Metoprolol succinate XL 50 mg by mouth twice a day;
- Amlodipine 5 mg by mouth daily;
- Digoxin 250 mcg by mouth daily;
- Hydrochlorothiazide 12.5 mg by mouth daily;
- Budesonide/formoterol (Symbicort, AstraZeneca) 80 mcg to 4.5
mcg/actuation HFA inhaler 2 puffs by mouth twice a day;
- Atorvastatin (Lipitor, Pfizer) 20 mg by mouth daily;
- Tamsulosin (Flomax, Boehringer Ingelheim) 0.4 mg by mouth
- Vitamin D2 (Drisdol, Sanofi-Synthelabo) 50,000 U by mouth once a
- Zolpidem tartrate (Ambien, Sanofi-Aventis) 10 mg nightly as
- Fluticasone propionate (Flonase, GlaxoSmithKline) 50 mcg/actuation
Nasl SpSn one spray in each nostril daily;
- Aspirin 81 mg by mouth daily;
- Omega-3 fatty acids (fish oil) 500 mg oral twice a day;
- Coenzyme Q10 10 mg by mouth twice a day;
- Calcium carbonate-vitamin D2 1,200-400 mg-unit by mouth twice a
- Cyanocobalamin/folic acid (folic acid plus B12 oral) daily;
- Psyllium oral daily;
- Lactobacillus rhamnosus gg (probiotic oral) daily; and
- L-glutamine daily.
The patient is married, rarely consumes alcohol and quit
smoking more than 20 years ago.
Family history is remarkable for heart disease in his
mother and Hodgkin’s disease in his father.
The patient’s blood pressure was 138 mm Hg/68 mm
Hg; pulse: 56; height: 6 feet; weight: 95.255 kg (210 lb). His estimated BMI is
There was no gynecomastia. The phallus was normal in
shape and size, with normal male-pattern hair distribution and testicular size
approximately 20 mL bilaterally. The patient has a sternal scar after CABG.
Physical exam is otherwise unremarkable.
Recent labs drawn by his primary care provider
- Low testosterone level of 159 ng/dL;
- Normal comprehensive metabolic profile and CBC;
- Calcium: 10 mg/dL;
- Albumin: 4.2 g/dL;
- Phosphorous: 3.8 mg/dL;
- 25-hydroxyvitamin D: 52 ng/mL; and
- Prostate-specific antigen was 1.05 ng/mL and has been rising during
the past year.
Bone density performed 6 months before the visit showed:
- Femoral neck: T-score –1.8 / z score –0.7;
- lumbar spine: T-score –0.9/ z score 0; and
- Left radius 1/3: T-score –4.3 / z score –3.1.
What is the next best step in the workup and management of this
A. The results for the bone density of the radius
are out of sync with the BMD at other sites and therefore represent an
erroneous report. Contact the site of the DXA and insist on a repeat
B. Order a parathyroid hormone level for
suspected primary hyperparathyroidism.
C. Recommend the patient double up on his calcium
to address his osteoporosis.
D. Restart testosterone supplementation with
testosterone cypionate IM 100 mg weekly to reverse hypogonadism-induced
Despite the normal calcium and phosphorous levels, the
emphasis on cortical bone loss (as seen in the radius) is highly suspicious of
primary hyperparathyroidism. Indeed, this patient had a parathyroid hormone
level of 105 ng/dL in the setting of normocalcemia and a parathyroid adenoma
Male hypogonadism is a common cause of osteoporosis in
men. In the setting of rising PSA after external-beam radiation for prostate
cancer, testosterone supplementation may, however, be ill-advised (D). The
quality of a bone density report should never be taken for granted —
patients can be poorly positioned, and radio-dense objects or reactive changes
may distort the measurement, or the wrong database may have been applied to
calculate T-scores and z scores. Although scrutiny is always
appropriate, there was nothing in this instance to indicate any flaw in the
bone density report provided (A). Finally, increasing calcium supplementation
in this setting will not address the underlying problem (C).
For more information:
- Ronald Tamler, MD, PhD, MBA, is clinical director of the Mount Sinai Diabetes Center in New York. He is also an Endocrine Today Editorial Board member.
- Dr. Tamler reports that he has received research support from Abbott.