EAA clinical guideline on management of bone health in the andrological outpatient clinic

Background: Male osteoporosis is now a well-recognized medical disorder with established clinical guidelines for both diagnosis and management. Prevention as well as management of osteoporosis in men consulting the andro- logical outpatient clinic because of low testosterone, how- ever, is not well established. This gap of knowledge is -at least partly- explained by the controversy with respect to the threshold of testosterone needed for skeletal mainte- nance. However, testosterone deficiency may be clearly associated with bone loss as well frailty in men. The aim of the guideline was to provide andrologists with the most updated, evidence based advices on the management of bone disease in men and to make them aware of the potential silent presence of osteoporosis in hypogonadal men. Methods: The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system for grading the quality of evidence and the strength of recom- mendations was used to grade recommendations. Results: A total of 32 recommendations were provided concerning clinical evaluation, diagnosis and therapy of male osteoporosis in the andrological patient. Conclusion: Therefore, the management of patients with potential hypogonadism should include a complete bone health assessment, besides clinical and biochemical evalu- ation of gonadal status. Such bone health assessment should include specific items in medical history and phys- ical examination related to fracture risk. Furthermore, dual-energy absorptiometry is indicated to evaluate frac- ture risk in men with confirmed clinical hypogonadism. Regarding treatment, besides general measures to prevent or manage male osteoporosis testosterone replacement can be initiated (as described in guidelines for hypogo- nadism), but data on its efficacy in preventing fractures are lacking. Thus, additional anti-osteoporotic may be needed, especially in men with very low testosterone who are at high risk for bone loss and/or in men not able to receive testosterone replacement.