Bone loss and fracture risk after menopause

Summary

Bone is lost without any symptoms. During the menopause transition — especially in the year before and the two years after the final period — bone density falls far faster than at any other time of life. The bone lost in this window determines much of the later risk of osteoporosis and fracture. The good news: bone loss can be measured, slowed, and fracture risk lowered. The backbone of the approach is simple: risk assessment, measurement where needed, resistance exercise, enough protein, calcium and vitamin D, a smoke-free life, and medication if required. Which of these steps is right for you is your doctor's decision.

What is happening?

Bone is living tissue; it is constantly broken down and rebuilt. Estrogen puts a brake on the breakdown side of that balance. As estrogen falls, breakdown speeds up, rebuilding cannot keep pace, and bone tissue thins out: osteopenia (reduced density) and, at an advanced stage, osteoporosis.

The loss is greatest in the spine and hip, where spongy bone predominates. Osteoporosis does not hurt; the first sign is usually a fracture: the wrist, the spine (loss of height, stooping, sudden back pain) or the hip. A hip fracture is a serious cause of lost independence and of death in older age.

Factors that increase fracture risk: early menopause (before 45), low body weight, a parent who had a hip fracture, smoking, heavy alcohol use, long-term steroid use, rheumatoid arthritis, an overactive thyroid, vitamin D deficiency and inactivity.

What do we know?

• The loss accelerates in the menopause window: In SWAN, spine bone density fell by about 2-2.5% a year over the period covering the year before and the two years after the final period; the loss is close to zero premenopause and slows in late postmenopause ^{1 7}. This three-year window is the most critical period for bone.

• Risk can be calculated: Tools such as FRAX use age, fracture history, family history, smoking, steroid use and, where available, bone density measurement to calculate the 10-year probability of fracture, guiding decisions about scanning and treatment ⁴. A FRAX model specific to Türkiye exists and is based on national fracture data ⁶.

• Scanning is by risk, not for everyone: The Menopause Society recommends a bone density scan (DXA) for all women over 65, and for postmenopausal women under 65 who have risk factors ².

• HRT prevents bone loss and reduces fractures: In randomized trials HRT significantly reduced spine and hip fractures; within the first 10 years after menopause or under the age of 60, it is also an option for bone in women at high fracture risk. In early menopause and POI, HRT is recommended at least until the average age of menopause ^{3 2}.

• Other medicines: Bisphosphonates, denosumab, selective estrogen receptor modulators and bone-building medicines are evidence-based options in women with diagnosed osteoporosis or a high fracture risk; the choice is made by your doctor according to your level of risk and any other conditions ^{2 8}.

• Calcium and vitamin D are necessary but not sufficient: Adequate intake is a basic requirement for bone; but in healthy, low-risk women supplements alone do not prevent fractures. Getting calcium from food is preferred; vitamin D deficiency is widespread and is identified with a blood test ^{5 2}.

• Exercise protects bone and muscle together: Weight-bearing and resistance exercise preserves bone density; balance exercises prevent falls. Most fractures happen in a fall; preventing falls matters as much as strengthening bone ².

What does this give you?

• Talk about your risk: If you went through menopause before 45, if there is a hip fracture in your family, if you have taken steroids or if you smoke, ask your doctor about a bone density scan. There is no need to wait until you are 65.

• Start today: Resistance exercise 2-3 days a week, a daily walk, protein at every meal, calcium sources such as dairy, leafy greens and nuts, sunlight, and vitamin D if your doctor determines you need it. Smoking and heavy drinking are among bone's worst enemies.

• Prevent falls: Rug edges, slippery floors and poor lighting at home; checks on your vision and balance; the effect of sleeping pills. These are the cheapest steps in preventing fractures.

• Your doctor interprets the result: The "T-score" on a DXA scan means something only alongside your age, your risk factors and FRAX; on its own it is not a treatment decision. Lumia only records lab or scan values, it does not interpret them.

Sources

1. Finkelstein JS, et al. Bone mineral density changes during the menopause transition in a multiethnic cohort of women. J Clin Endocrinol Metab. 2008;93(3):861-868.
2. The Menopause Society. Management of osteoporosis in postmenopausal women: the 2021 position statement. Menopause. 2021;28(9):973-997.
3. The Menopause Society. The 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.
4. Kanis JA, et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19(4):385-397.
5. US Preventive Services Task Force. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures. JAMA. 2018;319(15):1592-1599; December 2024 draft update: against supplementation for fracture/fall prevention in community-dwelling postmenopausal women (vitamin D recommendation).
6. Tuzun S, et al. Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study. Osteoporos Int. 2012;23(3):949-955 (the basis of the Türkiye FRAX model).
7. Greendale GA, et al. Bone mineral density loss in relation to the final menstrual period in a multiethnic cohort: results from SWAN. J Bone Miner Res. 2012;27(1):111-118.
8. Panay N, et al. International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause. Climacteric. 2025;28(6):634-656.

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