Bone is a complex tissue and its strength depends on genes, growth during puberty, historical and current nutrient intake, exercise levels, and hormones throughout life. Women reach peak bone strength in their early thirties and often sharply lose bone density starting at perimenopause and throughout the rest of their lives.
Osteoporosis is a skeletal disease which is characterized by low bone mineral mass and deterioration of bone tissue. Bone, as a living tissue, is continually replacing itself with new cells. In the case of osteoporosis and osteopenia, the creation of these new bone cells does not match the aging and dying of old bone cells. This can lead to weakened bones and increased risk of fracture from low impact trauma. It is a “silent” disease that often shows up only after a bad bone fracture in mid- to- late life.
Osteopenia is a condition of low bone mass and if left unmanaged, will become osteoporosis. In the event of a bone fracture from a low-impact injury or loss of height, notify a care provider and request a bone density test.
Osteoporosis is not a direct symptom of menopausal transition. However the reduction of estrogen and increase in follicle-stimulating hormone (FSH) during the menopausal transition can make osteopenia and osteoporosis worse. Post-menopausal women, and white and Asian women are at particular risk.
Factors that increase risk for osteoporosis:
Low-impact fractures often happen in people with osteopenia or osteoporosis, frequently from falls impacting hips, wrists and the spine.
There are many steps you can take at almost any age to help protect your skeletal system against osteoporosis.
If you do not already have a healthcare practitioner who is familiar with identifying and treating symptoms of menopause, the North American Menopause Society provides a list of menopause practitioners here.
A bone density scan is a good idea when entering perimenopause, if you notice you are losing height or following a bone fracture from a low-impact injury. Bone density, or bone mineral density (BMD), is a measure of how dense bones are relative to the average healthy young woman at peak bone density. It is measured via a DEXA scan (dual-energy X-ray absorptiometry), which uses two different, low-radiation X-ray beams to scan mineral content in bone. The result is called a T-score, and it is usually focused on your spine, wrist and hip bones as they are most likely to fracture.
FDA approved medications for osteoporosis fall into two categories. Antiresorptive medications such as bisphosphonates (many brands) and Denosumab protect against further bone loss and may increase bone density. Anabolic medications such as parathyroid hormone (Teriparatide) and Romosozumab rebuild bone and increase bone density.
Hormone therapy (HT) with estrogen is safe and often effective for treating osteopenia and osteoporosis during perimenopause.
Post-menopause, the selective estrogen receptor modulator (SERM) drug Raloxifene can reduce osteoporosis and help stabilize bone strength. Raloxifene mimics estrogen’s beneficial effects on bone density in postmenopausal women, with reduced risk relative to HT with estrogen. Users may have hot- flashes as a side effect.
Currently, HT with estrogen can’t be used by some women, including those with breast or ovarian cancer risk, or cardiovascular and stroke risk. Bisphosphonates may pose a risk to those with kidney disease.
There is ongoing research into therapeutic drugs which block FSH receptor molecules on bone cells or decrease active FSH in circulating blood. Eventually these therapies may also offer help for all individuals with osteopenia or osteoporosis.
Bone is a living tissue that is constantly remodeling. Cells called osteoblasts are embedded within bone and work at strengthening and reinforcing areas of bone that are under physical stress and strain. They store and secrete calcium and bone matrix proteins.
Meanwhile, other bone cells called osteoclasts remove calcium from the bone matrix and release stored calcium into the blood for purposes such as milk creation for nursing mothers.
Most women reach peak bone mass around age 30. As they age, bone mass, strength and density decrease.
A larger decrease in bone mineral density (BMD) and destruction of bone microarchitecture occurs at the start of perimenopause, correlating with a sudden rise in FSH. This bone breakdown occurs even while the ovaries are secreting estrogen and menstrual periods continue. The loss of bone continues to rise steeply through menopause and postmenopause as shown in the graph.
Estrogen is well understood to build and retain bone by stimulating osteoblasts (together with other signaling molecules). Estrogen hormone therapy helps retain BMD but it does not seem to reverse osteoporosis significantly. It isn’t known how long past menopausal transition HT with estrogen is therapeutic, since most estrogenic hormone therapy is stopped before a woman is 65 due to changes in cancer risk after this age.
Bone Health and Osteoporosis
Americans with osteoporosis who are women
Average reduction in bone mineral density during menopausal transition
to 40% Average decrease in bone mass by age 70
in 2 Women over age 50 will break a bone due to osteoporosis
Many women maintain adequate bone strength throughout their lives. Osteoporosis is a result of many life history factors including genes, puberty, diet, smoking, caffeine intake and physical activity.
Medical research has shown that decreasing estrogen and a steep rise in FSH during menopausal transition contribute to bone loss.
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