Menopause and Osteoporosis: What's Your Risk?

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Around menopause, the decline in ovarian estrogen production is associated with numerous changes in your body - including things that impact the health of your bones.

One of the biggest changes women experience during midlife is the progressive loss of bone quality and strength, often leading to osteoporosis: an increased risk for fragility fractures. As bone density decreases, osteoporosis risk increases. Osteoporosis is a chronic disease in which your bones become porous, spongy, and prone to breaking.

Here’s how menopause influences your bone health and how you can understand - and decrease - your risk.

How does menopause affect your bones?

The attainment of peak bone mass and density occurs in your mid-twenties and thirties. Once the menopause transition begins with perimenopause and estrogen levels decline, women initially experience a quick decline in bone density for about five to eight years, which then slows down and continues through postmenopause.

In your premenopausal years, there is typically a natural balance of bone break-down to remove old, damaged bone and bone buildup to replace bone that has been lost. However, because bone breakdown accelerates in the face of low estrogen levels, and bone buildup can’t keep up, there is a net loss of bone tissue. Bone loss is sped up by the lack of estrogen for a period of 5-8 years for most women. Without normal amounts of estrogen, your body is unable to produce bone at a rate that keeps up with bone loss. This results in weaker, more porous and fragile bones, which can lead to osteoporosis and an increased risk of bone fractures.

Women lose up to 200 mg of calcium daily during the first 3-4 years of menopause, gradually decreasing to around a 45 mg loss per day. Once you reach your sixties, intestinal calcium absorption and vitamin D production can drastically decrease. As you can guess, this contributes to the menopausal decline in bone quality.

What affects your chance of getting osteoporosis?

Many women don’t know they have osteoporosis until they experience a bone fracture. There are often no signs of bone loss or early osteoporosis, making it essential to understand your risk.

Below are some of the most significant risk factors that increase a woman’s osteoporosis risk:

  • Being Caucasian or Asian. Caucasian women are twice as likely as African American women to experience a hip fracture, but African American women are more likely to die following a hip fracture.

  • Having a petite and thin body frame.

  • Having a family history of osteoporosis, such as parents or grandparents who have had the disease.

  • Being over age 50.

  • Engaging in behaviors like smoking and excessive alcohol consumption or being sedentary.

  • Experiencing calcium deficiency as a young woman.

  • Having an early menopause, or prolonged duration of low estrogen levels, which is often signified by missed periods, as these can lead to loss of bone mass.

  • A history of eating disorders like anorexia or bulimia.

Tools to help evaluate your risk for bone fracture and osteoporosis 

The American Bone Health Fracture Risk Calculator can be used to assess risk for postmenopausal women. By inputting your answers to questions regarding your age, lifestyle habits, medical and fracture history, the calculator aims to tell you your risk for bone fracture in the next ten years. Give it a shot here.

A more hands-on way to understand your osteoporosis risk is to have your bone mineral density (BMD) measured. These are simple X-rays taken to examine the density and strength of your bones. If you have osteoporosis, this can also tell you how severe it is.

 
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It’s recommended that the following postmenopausal women have a BMD test done: 

  • Those who experience a fragility fracture. A fragility fracture is a fracture you can get after exposure to a low trauma, or sustaining a fracture that normal people would not have. Low traumas are those occurring from a fall from a standing height or less, without major trauma like being in a car accident.

  • Those under the age of 65 who have at least one risk factor for osteoporosis.

  • Those over the age of 65, regardless of additional risk factors.

How to understand your bone density test results 

Bone density tests provide what are called T-scores, which show how your bone density compares to the average bone density of a 30-year-old. The lowest T-score at the spine or hip is used to diagnose osteoporosis.

According to the National Osteoporosis Foundation, here’s how to interpret your T-score: 

  • -1.0 or above: normal bone density

  • -1.0 to -2.5: low bone density (osteopenia)

  • -2.5 or below: osteoporosis

If your T-score is below -2.5 and you have no other risk factors for osteoporosis, or your T-score is below -1.1 and you do have other risk factors, it’s recommended to consider further evaluation and treatment to prevent fractures.  

Ways to make your bones stronger

The good news is that there are things you can do to help keep your bones strong as you age.

One of the best ways is to stay active. Find a weight-bearing exercise that you enjoy, like walking, running, weight lifting, dancing, playing tennis, or climbing stairs, and engage in this activity regularly. Other exercises like swimming and biking have other health benefits but don’t offer much benefit to your bones directly. As your health permits, increasing the amount of weight bearing you do can help maintain your bones. For example, if you are walking for exercise, try to increase your pace. If you are running, consider adding weight lifting. It takes a certain "load" to stimulate the bone-building cells. Find out from American Bone Health if your favorite exercise is maintaining or building bone density.

 
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Your diet is also an important factor. Eating a balanced diet rich in calcium and vitamin D can help keep your bones strong. For example, green leafy vegetables, almonds, navy beans, oranges, calcium-set tofu, and sardines are high in calcium. Women over age 50 should aim to consume at least 1,200 mg of calcium per day.  

Vitamin D can be found in fortified foods like milk and dairy alternatives. Women over age 50 should consume at least 600 IU of vitamin D daily. Vitamin D is also made by your skin, so exposure to sunlight can boost your body’s natural production.

Prevention is key. Find some great downloadable resources for maintaining bone health from American Bone Health here

How can you prevent and treat osteoporosis?

In addition to weight-bearing exercise and maintaining adequate calcium and vitamin D intake, several medications are commonly prescribed to prevent and treat osteoporosis.

Hormone therapy can reduce bone loss that leads to osteoporosis. It may be recommended for women who experienced early menopause, have a low measured bone mass, suffer from menopause symptoms like hot flashes, or have osteoporosis risk factors such as a strong family history or are of a small frame. However, some types of hormone therapy may increase the risk for things like gallbladder disease, breast cancer, blood clots, and high blood pressure for some women.

The most common class of drugs used to treat osteoporosis are bisphosphonates. Like hormone therapy, these drugs slow down the accelerated bone loss. They include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast). ).  Some of these are taken orally, while others are administered as intravenous infusions (into your veins) by your healthcare provider.  

Denosumab (Prolia) is another bone-preserving medication, and is given as a twice-yearly subcutaneous injections (shots) .

There are also medications that promote faster bone build-up including teriparatide (Forteo) and abaloparatide (Tymlos).  Both of these are given as daily subcutaneous injections.

The newest medication to market is Romosozuma (Evenity), which was FDA-approved in 2019 for the treatment of postmenopausal women with osteoporosis at high risk for fracture.  It is given as monthly subcutaneous injections.

Your healthcare provider will be able to determine the best treatment and maintenance plan for you based on your individual medical and health history.

It’s essential to take good care of your bones, especially throughout the menopause transition when physiology sometimes works against us. If you’re in perimenopause or postmenopause and are unsure about the health of your bones, have a conversation with your healthcare provider to make sure you’re not at undue risk and create a lifestyle plan that supports your bone health.

For more tips for maintaining bone health and preventing bone loss during menopause, join us over at Lisa Health!

Dr. Aimee Shu, MD, is a medical endocrinologist with particular interests in reproductive and bone health.  She enjoys treating patients with menstrual disorders, menopause, fractures, osteoporosis, parathyroid imbalance, and calcium imbalance.  As a Clinical Associate Professor of Medicine at Stanford University, she is active in teaching students and physicians-in-training. She is a certified clinical densitometrist (International Society for Clinical Densitometry) and a certified menopause practitioner (North American Menopause Society). Aimee is also a member of the Medical & Scientific Advisory Board for American Bone Health, a national non-profit. Dr. Shu completed her undergraduate studies at Princeton University, medical degree at Harvard University, internal medicine residency at Brigham and Women’s Hospital in Boston, and endocrinology fellowship at Columbia University Medical Center in New York.

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