Why menopause changes bone

Bone is constantly remodelled by cells that remove old bone and cells that build new bone. Oestrogen restrains the removal side. When oestrogen falls during the menopause transition, removal outpaces formation and bone loss accelerates — most rapidly in the first several years around and after the final period, then continuing at a slower rate.

This is why osteoporosis is more common in women, and why the perimenopausal years are a useful moment to think about bone rather than waiting until a fracture happens.

  • Early menopause, before age 45, means more years of accelerated loss and higher risk.
  • Long gaps without periods at any age, including from low body weight or intensive training, also affect bone.
  • Trabecular bone in the spine and hip is affected earlier than dense cortical bone.

Exercise that actually loads bone

Bone adapts to mechanical load. The exercises that help are those that apply force to the skeleton, and specificity matters — loading the hips and spine is what protects the hips and spine.

  • Resistance training — progressive loading two or three times a week, working legs, hips, back, and arms.
  • Weight-bearing impact — brisk walking with hills or stairs, jogging, skipping, or hopping where joints and existing bone health allow.
  • Balance work — reduces falls, which is where most fractures come from.
  • Posture and back extensor strength — helps counter the forward curvature associated with spinal fractures.

Swimming and cycling are valuable for fitness but do little for bone. If those are your main activities, add loading work rather than replacing them. Women with established osteoporosis need a modified programme — high-impact work and loaded spinal flexion may be unsuitable, so get individualised guidance.

Calcium, vitamin D, and overall nutrition

Calcium guidance for adult women is around 1,000 mg a day, rising to roughly 1,200 mg after 50. Food sources are preferred: dairy, fortified plant milks, tinned fish with bones, calcium-set tofu, leafy greens, almonds, and beans. Very high supplemental doses have not clearly reduced fractures and raise other questions, so supplementing is best guided by a clinician.

Vitamin D is needed for calcium absorption. Deficiency impairs mineralisation. Whether routine supplementation reduces fractures in people who are not deficient is less clear, with large trials showing limited benefit. Testing and dosing are individualised.

Adequate protein and energy matter more than older advice suggested. Chronic under-eating, whether from dieting, disordered eating, or high training volume, harms bone directly and through disrupted menstrual cycles.

Screening, risk factors, and treatment

USPSTF recommends bone density screening with DXA for women aged 65 and older, and for younger postmenopausal women at increased risk identified by a formal risk assessment tool. Results are reported as a T-score comparing your density to a young adult reference.

Risk factors that may prompt earlier screening include a parental hip fracture, early menopause, long-term oral corticosteroid use, low body weight, smoking, heavy alcohol intake, rheumatoid arthritis, and conditions affecting absorption such as coeliac disease.

When density is low enough or a fragility fracture has occurred, medication may be considered. Several classes exist with different benefits, side effects, and monitoring needs, and any decision including dosing and duration is made with a prescriber. Menopausal hormone therapy also affects bone and is one part of a broader individual discussion.

Preventing the fall, not just protecting the bone

Most fractures in older adults follow a fall. That makes fall prevention as important as bone density, and often more immediately actionable.

  • Practise balance regularly — progressions near a counter, or tai chi, which has good trial evidence.
  • Keep leg and hip strength up; the ability to catch yourself depends on producing force quickly.
  • Have vision checked and keep prescriptions current; bifocals can complicate stairs.
  • Improve lighting, remove loose rugs and clutter, and add grab rails where useful.
  • Wear supportive footwear indoors rather than socks or loose slippers.
  • Ask for a medication review — several common medicines increase fall risk.
  • Report any fall even without injury; it strongly predicts the next one.