The study of osteoporosis (OP) has long focused on women, and its presence in men has been underestimated despite the existence of important morbidity and mortality data.
Prevalence data in Spain reflect densitometric OP percentages of 6% in men aged between 60 and 69 years, 11.3% in the lumbar spine of men aged between 70-79 years, and 2.6% in the femoral neck of older men [1, 2].
Epidemiological data of vertebral fractures in a Spanish male population are difficult to calculate because 30% of these are symptomatic; however, a prevalence rate of 572 per 100,000 population was published by the EVOS study . Hip fractures are the easiest to document because most of them require hospitalization for treatment. Data from the Ministry of Health and Consumption  reports an annual incidence rate of these fractures among men of 270 cases per 100,000 people older than 64 years. Also to be emphasized is that the mortality rate after vertebral fracture seems to be higher in men as compared to women  in the older age groups.
Health-related quality of life (HRQOL)
Decreased HRQOL in women with osteoporotic fracture is well documented, as are the economic repercussions involved (the occurrence of fractures implies a loss of 0.3 HRQOL points on the EQ-5D health state classification ). Also, this worsening persists for years after sustaining the fracture . In contrast, little information is available in the male population. The purpose of this study is to objectively measure the degree of HRQOL worsening in men by validated questionnaires, complete with clinical aspects related to osteoporosis and bone density scan results (DXA).
OP-related HRQOL distinguishes between OP patients with or without fracture. These two categories worsen the patient's quality of life on account of fear to sustain new fall-related fractures, fracture-related pain, resulting vertebral deformity, respiratory compromise, limited hip mobility due to some fractures, and death of a relevant number of patients within one year after hip fracture surgery .
Patients may be evaluated by generic HRQOL instruments such as the SF-36 , the EuroQol , or the COOP/WONCA charts . The latter, however, may lack sensitivity to detect significant clinical changes within the scope of OP, such as morbidity caused by vertebral fractures and resulting pain or inability, impaired body image, possible isolation, or mood alterations. Accordingly, specific questionnaires to evaluate OP have been created, such as the QUALEFFO (Quality of Life Questionnaire of the European Foundation for Osteoporosis)  or the ECOS-16  questionnaires. A possible drawback of these specific questionnaires is the impossibility of making comparisons between different populations.
The EuroQol-5D (EQ-5D) is a generic HRQOL instrument that consists of 2 parts: one describes the different health dimensions and the other is a Visual Analogue Scale. The items assessed include mobility, self-care, daily activities, pain, and anxiety/depression. Each dimension is divided into 3 degrees of severity: none, moderate and severe (scored 1, 2 and 3, respectively). The order of dimensions must be the same at all times.
ECOS-16 is an OP-specific questionnaire validated in Spain, obtained from the generic SF-36 and the QUALEFFO questionnaires. It is a shorter questionnaire (16 items) and thus proves useful in the daily medical practice. The health state is divided into 4 dimensions: physical function (5 items), pain (5 items), fear of illness (2 items), and psychosocial function (4 items). Each dimension is divided into 5 degrees of severity, varying from 1 (best health state) to 5 (worst health state).
Both EQ-5D and ECOS-16 are readily administered questionnaires (< 5.0 minutes and 12.3 minutes, respectively) and accordingly these were selected for HRQOL evaluation in our study. Indeed, time is a major drawback when assessing the biopsychosocial context of our patients and, on the other hand, their briefness helps keep the patient's and the health care provider's interest awake.
OP and osteoporotic risk factors for fracture in men
While many studies conducted in different countries identify fracture-related risk factors , few data are available on the Spanish male population.
In the year 2004, Kanis et al  identified low BMI, smoking, family history of fragility fracture and glucocorticoid intake as risk factors for fracture in men. Other risk factors cited in the literature [14, 15] include old age (> 70 years), personal history of fracture, alcohol consumption, weight loss, lack of exercise and situations of decreased bone strength, such as androgen suppression, rheumatoid arthritis, diabetes mellitus, hypothyroidism, chronic obstructive pulmonary disease, symptoms of gastrointestinal malabsorption, and cardiovascular disease ; also, exposure to certain drugs other than typical corticosteroids, such as anti-androgen therapy, thyroid therapy, hypolipidemic drugs (statins), antidiabetic drugs (glytazones), and antacids (proton pump inhibitors ). The evidence for some of these is controversial.
There is consensus on the use of clinical risk factors for fracture in combination with bone mineral density (BMD) measurements in the evaluation and the decision-making process regarding OP patients. Reliable tools to evaluate the risk factor for fractures in both men and women, such as the FRAX™ algorithm designed by the WHO, are now available . This tool has proved to be very valuable to detect densitometric osteoporosis in a Spanish population [19, 20], and allows obtaining absolute 10-year probability of major or hip fracture by using clinical risk factors for fracture associated or not associated to bone density measurement by DXA. Recently, the evaluation of fracture risk factors other than those included in the FRAX™ is being advised . This study attempts to update knowledge on this subject, with focus placed on a Spanish male population.
To determine the loss of health-related quality of life in men with osteoporosis or osteoporotic fracture in a Spanish population.
To determine the relationship between questionnaire clinical risk factors for osteoporotic fracture (age, body mass index), personal and family history of fracture, comorbidity, risk of falls, pharmacological treatments, low bone mineral density) and health-related quality of life in a male population.