What is bone health?

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:

  • Family history of broken bones or osteoporosis, which has a strong genetic influence
  • Prior bone break from a low impact fall, indicating you may already have low bone density
  • Early menopause or ovary removal before perimenopause 
  • Inadequate calcium and/or vitamin D in diet
  • Physical inactivity
  • Smoking, which decreases absorption of dietary calcium
  • A small body frame 
  • A history of stress fractures,  indicating you may already have low bone density
  • Vitamin D deficiency, including from limited sunlight exposure
  • History of liver disease
  • Thyroid disorder

Low-impact fractures often happen in people with osteopenia or osteoporosis, frequently from falls impacting hips, wrists and the spine.

Doctor checking a senior female patient's x-ray image during a visit at the hospital, injury and osteoporosis concept

Self-care for bone health and osteoporosis

There are many steps you can take at almost any age to help protect your skeletal system against osteoporosis.

  • Eat a quality diet including adequate calcium and vitamin D. Aim for a daily minimum of about 800 mg Calcium and 2000 IU of Vitamin D3. Vitamin K2 is helpful as well.
  • Exercise by doing weight-bearing activities such as brisk walking, crossfit, hiking, running, weight training, jump rope and brisk dance. Weight training twice a week will build both bone and muscle density and strength. Balance exercise can help prevent falls.
  • Consult with a physiotherapist to develop a personalized bone-building recreational exercise routine.
  • To help maintain bone strength, quit smoking and decrease alcohol and caffeine intake. Alcohol and caffeine both reduce bone calcification, the process by which bones are hardened.
Happy seniors and mature couples exercising with dumbbells. Healthy multiethnic people exercising using dumbbells outdoor.

Therapy for bone health and 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.

Osteoporosis hip bones

The science

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.

Medical illustration of healthy bone and bones with different stages of osteoporosis.

Most women reach peak bone mass around age 30. As they age, bone mass, strength and density decrease. 

Bone mass for male and female. Age and osteoporosis. Chart. healthy lifestyle. Vector illustration for educational, science and medical use

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

Bone Health and 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.


New therapies are under development for managing the decline in follicle-stimulating hormone (FSH) during the menopausal transition.

Compiled References


1. Bulan, S. E. (2019). Physiology and Pathology of the Female Reproductive Axis. In Melmed, S., Koenig, R., Rosen, C., Auchus, R. & F. Goldfine (Eds.), Williams Textbook of Endocrinology (14th ed., pp. 574-641). Elsevier.

2.Chapurlat, R. D., Garnero, P., Sornay-Rendu, E., et al. (2000). Longitudinal study of bone loss in pre- and perimenopausal women: evidence for bone loss in perimenopausal women. Osteoporosis International, 11(6), 493–498. https://doi.org/10.1007/s001980070091

3. El Khoudary, S. R., Aggarwal, B., Beckie, T. M., et al. (2020). Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation, 142(25), e506–e532. https://doi.org/10.1161/CIR.0000000000000912

4. Gera, S., Sant, D., Haider, S., et al. (2020). First-in-class humanized FSH blocking antibody targets bone and fat. Proceedings of the National Academy of Sciences of the United States of America, 117(46), 28971–28979. https://doi.org/10.1073/pnas.2014588117

5. Minkin M. J. (2019). Menopause: Hormones, Lifestyle, and Optimizing Aging. Obstetrics and Gynecology Clinics of North America, 46(3), 501–514. https://doi.org/10.1016/j.ogc.2019.04.008

6. Santoro, N., Lasley, B., McConnell, D., et al. (2004). Body size and ethnicity are associated with menstrual cycle alterations in women in the early menopausal transition: The Study of Women’s Health across the Nation (SWAN) Daily Hormone Study. The Journal of Clinical Endocrinology and Metabolism, 89(6), 2622–2631. https://doi.org/10.1210/jc.2003-031578

7. Santoro N. (2016). Perimenopause: From Research to Practice. Journal of Women’s Health (2002), 25(4), 332–339. https://doi.org/10.1089/jwh.2015.5556

8. Seifert-Klauss, V., Link, T., Heumann, C., Luppa, P., Haseitl, M., Laakmann, J., Rattenhuber, J., & Kiechle, M. (2006). Influence of pattern of menopausal transition on the amount of trabecular bone loss. Results from a 6-year prospective longitudinal study. Maturitas, 55(4), 317–324. https://doi.org/10.1016/j.maturitas.2006.04.024

9. Sowers, M. R., Finkelstein, J. S., Ettinger, B., et al. (2003). The association of endogenous hormone concentrations and bone mineral density measures in pre- and perimenopausal women of four ethnic groups: SWAN. Osteoporosis International, 14(1), 44–52. https://doi.org/10.1007/s00198-002-1307-x

10. Sun, L., Peng, Y., Sharrow, A. C., et al. (2006). FSH directly regulates bone mass. Cell, 125(2), 247–260. https://doi.org/10.1016/j.cell.2006.01.051

11. Randolph, J. F., Jr, Sowers, M., Gold, et al. (2003). Reproductive hormones in the early menopausal transition: relationship to ethnicity, body size, and menopausal status. The Journal of clinical endocrinology and metabolism, 88(4), 1516–1522. https://doi.org/10.1210/jc.2002-020777

12. Zaidi, M., Lizneva, D., Kim, S. M., et al. (2018). FSH, Bone Mass, Body Fat, and Biological Aging. Endocrinology, 159(10), 3503–3514. https://doi.org/10.1210/en.2018-00601

12. National Institute on Aging. Health Topics: Menopause. https://www.nia.nih.gov/health/topics/menopause

13. National Institute on Aging. (2017, June 26). Health Information: Osteoporosis. https://www.nia.nih.gov/health/osteoporosis