Taking bone health seriously in menopause

If you’re lucky enough to live to your late seventies or eighties, you will face about a 9 percent chance of fracturing your hip — which will be painful and is potentially very serious, sometimes leading to surgery, blood clots, and even death. A more common but less serious vertebral fracture could also cause pain and lead to a gradual loss of height and a stooped appearance.

‘Little old ladies’ is usually intended as an affectionate term for women over a certain age, but there is no inevitability about turning into one. Although there’s nothing you can do about getting old, there are steps you can take to prevent osteoporosis (weakening of the bones, making them more likely to break) and loss of physical stature. All recommendations around ‘bone health’ are really about preventing osteoporosis. Any treatment offered for osteoporosis is simply an attempt to reduce your long-term risk of fracture — with the understanding, of course, that you could do everything right yet still have an osteoporotic fracture. There is no diet, lifestyle, supplement, or medication that can reduce your risk to zero.  

How menopause increases fracture risk

Menopause does not cause osteoporosis because menopause is a natural transition, not a disease. Instead, the shift from the high oestrogen of the reproductive years to the lower (but still normal) oestrogen of the post-reproductive years can accelerate the slow, steady bone loss that is an inevitable part of ageing.  

Specifically, a drop in oestrogen can temporarily increase the rate of bone remodelling or bone turnover, which is the rate of bone resorption compared to new bone formation. The temporary acceleration of bone turnover with menopause lasts about five years until the bones adapt to lower oestrogen levels and the rate of bone loss returns to baseline.  

Reassuringly, findings from a recent long-term study suggest that healthy menopausal women may lose only 10 percent of bone mass over 25 years, which is better than was expected based on previous studies.  

So yes, oestrogen is a big factor in bone health — but it’s not the only factor. The biggest determinant of future fracture risk is actually ‘peak bone density’ at age 30, which is when your bones were at their strongest. Peak bone density is affected by many factors including: 

• Smoking  
• Regular menstruation 
• General health 

Assessing menopause-related fracture risk 

If you’ve had a worrying result on a bone mineral test or DEXA scan, you might be surprised to learn that there is still some debate on the exact significance of such a result.   

Fun fact! DEXA (dual-energy X-ray absorptiometry) is a specialized X-ray that measures bone mineralisation and compares it to the expected bone mineralisation of a healthy young adult. 

The difference is calculated as a standard deviation and is called a T-score.

A T-score of -1 or less is osteopenia (indicating that your bone density is low but not low enough to be considered osteoporosis), while a score below -2.5 standard deviations is osteoporosis. 

The problem with bone density testing is that it measures only mineralisation and not other factors such as:  

• Bone quality  
• Bone strength  
• Muscle strength  
• Ability to balance 

This is why your doctor will also assess other factors that can affect your bone density and your risk for fractures. These risk factors include:

• Age (risk increases with age)
• Body mass index (BMI) (low BMI is a risk factor for hip fracture)
• If you have ever had a previous fracture
• If either parent has ever had a hip fracture
• Smoking
• Alcohol consumption (3 or more units a day increases risk of fracture)
• Oral glucocorticoid (steroid) medication (any dose taken for 3 months or more increases risk of fracture)
• Other medical conditions that may cause osteoporosis, such as inflammatory bowel disease, rheumatoid arthritis, hormonal disorders and diabetes (both type 1 and type 2)

If you have one or more of these risk factors, check with our doctor because you may need to think about treatment.  

Medications to reduce fracture risk in menopause

If you’ve been diagnosed with osteoporosis, you may not need to start medication for it. But if you’ve had a fracture because of osteoporosis then you should start treatment to try and reduce your risk of fractures in the future. Your doctor may prescribe:

Calcium and vitamin D supplements

Whether you have osteoporosis or not, having enough calcium is important for maintaining healthy bones. That’s because calcium is the main mineral found in your bones. Most people will be able to get enough calcium from a varied and balanced diet, but if you have osteoporosis, your doctor may recommend taking calcium supplements.

It’s also important to get enough vitamin D because it helps your body to absorb calcium.  For most of the year, most people should be able to get enough vitamin D from sunlight absorbed through the skin. However, when there is less sunlight in the autumn and winter months, everyone should consider taking vitamin D supplements because it’s difficult to get enough from food alone.

Bisphosphonates

These are a group of drugs that maintain your bone density by slowing down the rate at which bone is naturally broken down in your body. There are different bisphosphonates, including: 

• Alendronic acid
• Ibandronic acid
• Risedronate
• Zoledronic acid

Usually, it takes a minimum of 6 to 12 months for bisphosphonates to work, and you may need to take them for 5 years or more. Some people may also need to take calcium and vitamin D supplements with bisphosphonates – these will be prescribed in a special formulation.

Selective oestrogen receptor modulators (SERMs)

SERMs are a type of medication that act in a similar way as oestrogen and help to maintain your bone density. Raloxifene is a SERM used to treat osteoporosis after the menopause.

Hormone replacement therapy (HRT)

You may be receiving HRT, including oestrogen, for your menopause symptoms. The good news is that HRT can keep your bones strong and therefore reduce your risk of developing osteoporosis and fractures. 

Parathyroid hormone

Parathyroid hormone is naturally produced in the body and its job is to regulate the amount of calcium in the bone. 

It can be given as a hormone treatment to stimulate the cells that are responsible for creating new bone. Therefore, unlike the other medications we’ve mentioned, rather than slowing down the rate of bone mineral loss, parathyroid hormone can increase bone density.

Biological medicines

These are medications that are made from proteins or other substances produced in the body. They slow down the rate at which your body naturally breaks down your bones and increase the rate at which bone building-cells builds bone.

Denosumab and romosozumab are the names of two biological medicines.

Diet, lifestyle and supplement strategies to reduce fracture risk in menopause

Exercise

Regular movement or exercise is the single most important strategy for maintaining healthy bones and reducing the risk of fracture.  

According to a recent expert consensus statement published in the British Journal of Sports Medicine, this is true even if you have already had a fracture. In fact, one of the key expert recommendations is that women with osteoporosis should be ‘encouraged to do more rather than less.’   

The best types of exercise for bone health include: 

• weight-bearing activities: such as walking, hiking, jogging, climbing stairs, playing tennis, and,    
• movement that strengthens muscles: because strong muscles reduce the risk of falls and healthy muscle supports healthy bone remodelling. 

The great news is that introducing more exercise, particularly weight-bearing activities, into your life may also improve some of the symptoms of menopause. That said, if you’re new to exercise or have existing fractures, check with your doctor about a suitable osteoporosis exercise programme. 

Diet

Getting enough dietary calcium is important for bone health, and it can usually be obtained from foods such as:  

•  Seeds  
• Bony fish  
• Green vegetables  
• Dairy products

Of note, many products are fortified with calcium, particularly non-dairy milks, such as oat and soya - so also yoghurts and cheeses containing these milks - and breakfast cereals.

Getting enough vitamin D is also important because it helps our body to absorb calcium. Most people can get enough vitamin D when their skin is exposed to sunlight, but during the autumn and winter months, or if you are housebound, or cover yourself up for modesty, you should consider taking vitamin D supplements.

Foods that are rich in vitamin D include oily fish, egg yolks, meat offal, milk and fortified foods, such as margarines, fruit juices and cereals.

More broadly, on the topic of nutrition and bone health, it’s important to understand that bone is not a static repository of calcium. Instead, bone is dynamic living tissue that is connected to almost every other aspect of health.  

So, maintaining healthy bones is not just about calcium or medications to slow down natural bone breakdown, but is instead about all the ways you can improve your general health by looking after your bones!   

For example, smoking and excessive alcohol consumption can increase your risk of osteoporosis, so it’s best to keep these to a minimum or stop completely if possible. If you have chronic inflammation or insulin resistance, addressing these can also improve your bone health. And, finally, you need to be fully nourished with all the nutrients you need for healthy bones and for your general wellbeing.