Funny bones: who's laughing?

Older women with bad backs or fractures are treated for osteoporosis. Why has it taken so long for men to be given the same treatment? Cherrill Hicks reports

Keith McInnes used to be a strapping 5ft 10in, but in the past 15 years he has shrunk eight inches in height. The indomitably cheerful former printer has also suffered numerous broken bones in his spine, ankle, fingers, toes and shoulder. He can neither walk nor stand for longer than 15 minutes at a stretch.

Mr McInnes, 65, suffers from osteoporosis. Fit and active during his thirties and forties, long days spent skin-diving, fishing and camping on the south coast where he grew up were favourite pursuits. Today any exercise is out of the question. Mr McInnes' bones have become so porous that they easily break, and his vertebrae have squashed together, hence the loss of height. The first signs of the disease, he recalls, occurred in 1980. "I was sitting in the car and reached over to pick up something from the passenger seat. It felt like someone sticking a knife into my ribs. Because of the shrinking process, my ribs had started to compress. At that time, the idea of osteoporosis in men was laughed off - the disease wasn't diagnosed until 1988.

"I had an X-ray in 1984, which failed to show any sign of bone disease. If I'd had a bone scan, on the other hand, the disease probably would have shown up, the treatment would have been started and I wouldn't be like I am now."

Doctors believe low testosterone levels, from which Mr McInnes has suffered since he was a teenager, may have caused the bone loss. "My voice didn't break and I had no facial hair until I was 16, when I had to have a testosterone implant," he recalls. "Later, when I was married, I had problems with fertility and had to take testosterone.

"Now I'm on it again and hoping it will prevent the condition getting worse. There is one problem, however - it does make you feel lecherous."

Osteoporosis, or brittle bones, is normally associated with elderly women and the "dowager's hump" caused by damaged vertebrae. But the disease also afflicts one in six men, with 10,000 suffering spine fractures and a further 12,000 suffering hip fractures every year. And although osteoporosis is often linked to lifestyle factors such as lack of exercise and smoking, it can strike the fittest of men living the most blameless of lives. Mr McInnes, for one, has never smoked and rarely drinks.

Despite the suffering this disease can cause, there is evidence of a widespread failure to tackle the problem. A nationwide survey published last week found that more than half of all UK health commissions are failing to provide screening, treatment and prevention strategies.

While both sexes suffer bone loss as they get older, post-menopausal women have always been thought especially vulnerable, as their bodies no longer secrete the oestrogen hormones which help maintain bone mass. However, osteoporosis in men is on the increase, says Dr Roger Francis, consultant physician at the Bone Clinic in Freeman Hospital, Newcastle. He estimates that the fracture rate among 50- to 60-year-old men has doubled in 30 years, "probably because men are leading less active lifestyles with more heavy smoking and alcohol consumption."

Studies carried out by Dr Francis have shown that in men, the disease causes depression, severe pain, loss of sleep and loss of energy. It can also reduce height dramatically, sometimes by as much as a foot. Yet until recently, the disorder in men has been virtually ignored. "Little research has been carried out into men and osteoporosis," says Rosemary Rowe from the National Osteoporosis Society. "Many men may not even know they have it - even if they have had a fracture."

In one in five men with the disorder, the cause is lack of testosterone, the male sex hormone which stimulates bone growth. This may be brought about by mumps or an injury to the testicles and can be rectified by testosterone replacement therapy. In a further one in five, bone loss follows treatment with costicosteroid drugs, used increasingly in the treatment of conditions such as asthma and rheumatoid arthritis. Excess alcohol, lack of exercise and smoking raise the risk.

But in nearly half of men with the disease, there is no known underlying cause - and no successful treatment so far.

"With women, we know the reason, and we know that hormone replacement therapy can prevent osteoporosis," says Rosie Rowe. "With men, it's not that simple."

Because research has so far concentrated on women, few trials have been carried out into what may work for men. But doctors are hopeful that etidronate, a non-hormonal drug that strengthens bone mass, may be useful. Alendronate (brand name Fosamax), launched as a "wonder drug" last September, may also be effective in men, although, like etidronate, it is at present only licensed for use by women.

Dr Francis is also planning a study to find out if additional testosterone can halt bone loss, not only in men with a hormone deficiency but also in those with normal hormone levels.

How does a man know if he has osteoporosis? Fracturing a bone after a minor bump or fall is often the first sign, while very fragile bones may break with a cough or an awkward stretch. Men who wish to avoid the disorder would do well to cut down on alcohol, stop smoking, eat calcium- rich foods (milk, green vegetables, citrus fruits and sardines) and do weight-bearing exercises which stress the bones, such as tennis or walking.