Menopause has a significant impact on bone health due to the decline in estrogen levels, which play a critical role in maintaining bone density. Women lose bone strength from their mid-30s onwards, but as estrogen levels drop during menopause this process accelerates rapidly. This means risk of fragility fractures (fractures that occur after a fall from standing height or less) starts to increase drastically. This can profoundly affect women's health, mobility, and quality of life.

What does estrogen do for bones?

Bones are constantly undergoing a process of breakdown and formation to keep them strong and healthy. Estrogen helps to regulate the balance between bone breakdown and bone formation by reducing the activity of the cells that break down bone. This helps maintain a balanced bone remodeling process that preserves bone density.

When estrogen levels decrease during menopause, this balance shifts towards increased bone breakdown, leading to loss of bone density. The first 5–7 years after menopause are critical, as women can lose up to 20% of their bone density during this time. This can lead to a condition called osteoporosis, which affects 1 in 3 women.

What is the significance of osteoporosis?

Osteoporosis is characterized by low bone density and structural deterioration of bone tissue, leading to increased bone fragility. With lower bone density, the risk of fractures, especially in the hip, spine, and wrist, increases substantially. Fragility fractures can lead to serious complications, including chronic pain, reduced mobility, and even increased risk of death.

Hip fractures tend to have the most impact, with research showing that around 50% of women who have a hip fracture never regain their previous level of independence. There is also evidence that risk of death is over twice as high for the year after a hip fracture in post-menopausal women, with risk remaining above normal levels for up to ten years after the fracture.

Fractures of the spine often go unnoticed at the time, as they can occur after minor trips or falls. However, they can lead to chronic back pain and spinal deformities which can have significant impact on mobility, mental health and quality of life.

Osteoporosis is much more common in post-menopausal women, and as a result women over the age of 50 are thought to have a 40-50% lifetime risk of fracture. Most cases of osteoporosis are preventable or treatable, but as it does not cause any symptoms until a fracture occurs it is often missed until it is too late. For this reason it is important to be aware of how to minimize risk of osteoporosis around menopause, and identify it early so preventative action can be taken.

How can I protect my bone health during menopause?

Osteoporosis is not an inevitability, and there are several strategies for women that can help prevent bone loss and reduce fracture risk.

Understand your risk: Among other things, factors such as a low body mass, a family history of osteoporosis, history of rheumatoid arthritis or steroid use, smoking, heavy drinking, or history of eating disorders all increase overall risk of osteoporosis. Understanding whether you may be at increased risk can help you take preventative measures at an earlier stage.

Identifying bone loss early: Bone density can be assessed by a DEXA (dual energy x-ray absorptiometry bone scan). This a non-invasive and quick test that compares your bone density against what would be expected for your age.

Managing risk factors: quitting smoking, reducing alcohol intake and maintaining a healthy diet are good steps to reduce risk of bone loss.

Physical Activity and Weight-Bearing Exercises: Weight-bearing exercises (e.g. walking, jogging, and resistance training) stimulate bone remodeling and improve bone density. Research shows that postmenopausal women who engage in regular exercise experience slower bone density loss, reducing the risk of osteoporosis. High intensity impact training has been shown to be more effective than regular exercise, with a 3% increase in bone density over 8 months compared with a 1% increase. Increasing muscle mass through resistance training will also prevent falls and reduce risk of fragility fractures.

Calcium and Vitamin D Supplementation: Adequate intake of calcium and vitamin D is essential for bone health. Even if your DEXA scan shows good bone strength, you should aim to eat 2-3 portions of calcium-rich food a day (e.g. a small yogurt or 200mL milk). If you struggle to get enough calcium from your diet, you might want to consider supplementing with calcium and Vitamin D tablets.

Hormone replacement therapy: The British Menopause Society supports the view that HRT is a good way to prevent fragility fractures and improve bone health, especially for women under the age of 60. Taking HRT for a few years around the time of menopause can have long-term effects on reducing fractures. HRT increases bone density by an average of 7% after just 2 years and seems to be particularly protective for the bones in the spine.

Other medications: Bisphosphonates (e.g., alendronate, risedronate), selective estrogen receptor modulators, and denosumab, are effective for preventing and treating osteoporosis in postmenopausal women. These medications work by slowing bone resorption and are a good option for helping increase bone density.

Bone health is a crucial part of maintaining health and wellbeing during menopause, and taking a proactive and preventative approach will help you optimize your risk profile and preserve bone density. To understand how we at NIA use a range of markers to make personalised recommendations that can help improve long term health, have a look at our sample dashboard here. 

Sources

• British Menopause Society consensus statement: Prevention and treatment of osteoporosis in post menopausal women. https://thebms.org.uk/publications/consensus-statements/prevention-and-treatment-of-osteoporosis-in-women/
• Riggs BL, Khosla S, Melton LJ. (2002). Sex steroids and the construction and conservation of the adult skeleton. Endocrine Reviews; 23(3): 279-302.
• Sambrook P, Cooper C. (2006). Osteoporosis. The Lancet; 367(9527): 2010-2018.
• Haentjens P, Magaziner J, Colón-Emeric CS, et al. (2010). Meta-analysis: excess mortality after hip fracture among older women and men. Annals of Internal Medicine; 152(6): 380-390.
• Kelley GA, Kelley KS, Kohrt WM. (2013). Exercise and bone mineral density in premenopausal and postmenopausal women: a meta-analysis of randomized controlled trials. American Journal of Physical Medicine & Rehabilitation; 92(3): 233-243.
• Wells, G., Tugwell, P., Shea, B., Guyatt, G., Peterson, J., Zytaruk, N., Robinson, V., Henry, D., O'Connell, D., Cranney, A., & Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group (2002). Meta-analyses of therapies for postmenopausal osteoporosis. V. Meta-analysis of the efficacy of hormone replacement therapy in treating and preventing osteoporosis in postmenopausal women. Endocrine reviews, 23(4), 529–539. https://doi.org/10.1210/er.2001-5002
• Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 33(2), 211–220. https://doi.org/10.1002/jbmr.3284

All the views expressed here are based on careful research conducted by the research team at Niahealth. However, in some places we have omitted certain details for the sake of clarity and simplicity. If you have any questions about our research or the content of this blog email our head of research Dr Robin Brown at: robin@niahealth.co