Bone health is one of the most under-recognized problems of menopause. Most women are worried about hot flashes and weight gain. However, the loss of bone mass that usually occurs during perimenopause continues to accelerate after menopause and can reach 2 to 2.5% annually around the final menstrual period. This loss accounts for a decrease in bone mineral density by nearly 50% compared to the period before menopause. In addition, by the time a woman knows she has osteoporosis, she has already lost a considerable amount of bone tissue. This is a serious public health problem since 20% of women over 50 years of age have osteoporosis, while another 40% have osteopenia. Moreover, 50% of women will suffer a fragility fracture, and one-third of women over 50 will suffer an osteoporotic fracture worldwide, resulting in a significant reduction in quality of life and even death in the case of hip fracture. One of the most common complications of osteoporosis is a hip fracture, since about 25% of people who have suffered it die within a year, and many of them lose their autonomy.
Osteoporosis is often asymptomatic until a fracture occurs, although there are various warning signs that should make a woman go to the doctor. However, women have comparatively little knowledge and understanding of their personal risks and frequently report inadequate counseling by their healthcare providers.
They significantly underestimate their risk of fracture because they do not consider many risk factors associated with osteoporosis. These include:
Previous fracture after age 50 increases the risk of subsequent fractures, with a wrist fracture being a predictor of hip fracture.History of parental hip fracture, low body weight, tobacco use, heavy alcohol consumption, premature menopause, rheumatoid arthritis, inflammatory bowel disease, celiac disease, diabetes mellitus, chronic kidney disease, hyperthyroidism, hyperparathyroidism, etc. Medications that can contribute to the development of osteoporosis are: long-acting glucocorticoids, aromatase inhibitors, proton pump inhibitors, selective serotonin reuptake inhibitors, antiepileptic drugs, excess thyroid hormone, drugs that enhance the effect of GABA, for example, benzodiazepines or opioids, which can lead to falls. The most important risk factor for hip fracture is falling, 90% of which occur after the age of 65. Preventive measures against falls are crucial, for example, walking exercises to strengthen the muscles and joints, vision checks, reducing the risk of slipping.
Prevention of osteoporosis is indeed possible, and there are several effective interventions. First of all, doctors recommend therapeutic physical culture, since clinical studies have shown that progressive resistance exercises combined with a choice of impact or weight-bearing physical activities most often have a positive effect on increasing bone mineral density. Such exercises should be done at least 150 minutes per week, and two or more times a week – training workouts to maintain muscle strength. In addition, to prevent osteoporosis, it is necessary to take calcium and vitamin D supplements, get rid of the harmful habits mentioned above, treat diseases that affect the hormonal balance and the absorption of minerals by the body, and provide the body with a balanced diet and a sufficient amount of protein.
Most women do not know that they should periodically visit a healthcare provider for a DXA scan after age 65 - or at a younger age if there are additional risk factors. Despite the availability of screening tests, few women get recommended to actually do them, and most who suffer a fragility fracture do not receive osteoporosis treatment.
Moreover, menopausal hormone therapy (MHT) is indicated for women with fractures of any severity: it reduces the risk of all-cause, clinical, and specific site fractures in postmenopausal women of any age with or without a history of fracture. Thus, for women who are candidates for MHT, this method is the only one proven to reduce the risk of fractures of all sites regardless of prior fracture and is indicated for the prevention of postmenopausal osteoporosis.
The Women’s Health Initiative showed that estrogen-containing drugs reduced the risk of clinical fractures, including vertebral, hip, and forearm fractures. In particular, estrogen plus progestin decreased the risk of clinical fractures by about 35% and hip fractures by 39%. In addition, meta-analyses of randomized trials confirm that MHT reduces the risk of vertebral fractures by 34% and hip fractures by 29%.
A promising direction in the fight against osteoporosis is the concept of the physiological threshold of estrogen. More than 30 years ago, scientists noticed that when blood estradiol levels exceed 60-90 pg/ml, markers of bone breakdown decrease. In addition, a 2026 comparative analysis of transdermal estradiol clinical trials and classic studies, such as KEEPS and ELITE, concluded that the optimal bone and cardiovascular function corresponds to serum estradiol levels of 60 pg/ml. MHT is prescribed considering the balance of benefits and risks for each patient, and the choice of dosage within the range of standard doses also remains open. Although discussions about the physiological level of estrogen are actively developing among menopause specialists, measuring estradiol levels continues to be an unproven practice.
To conclude, I want to emphasize that there is nothing inevitable about menopause-related bone loss. It is crucial to use the time before the first fracture to reduce the fracture risk. Therefore, women should view menopause as an opportunity to: assess overall fracture risk, optimize nutrition and exercise, identify secondary causes of bone loss, and decide whether to pursue pharmacologic options to reduce fracture risk. We cannot delay managing osteoporosis until the first fracture, as by then, the opportunity to prevent it will be lost.
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