No Such Thing As a Lucky Break

Osteoporosis in menopause

Make no bones about it, when it comes to osteoporosis, there’s no such thing as a lucky break.

Osteoporosis is a threat to all women in postmenopause.

It’s characterized by weakened bones that become fragile and more susceptible to breaks. Serious fractures, like those in the hip and spine, in women can lead to becoming bedridden and even death. Therefore, understanding this disease is crucial in avoiding the unfortunate and often far-reaching consequences of a fracture and low bone density.

This article discusses general information about osteoporosis in an easy-to-understand, non-clinical way. I highly suggest that if you’ve already had a fracture, are concerned about osteoporosis, have a family history, or have a concerning bone density scan result, speak with your physician. This article doesn’t include treatment options because it’s drug therapy dependant, however I include prevention tips.

Do You Have a Funny Bone?

We build and strengthen our bones up until our 20s, but by our late 20s and 30s, our bone density starts to decrease gradually over time. In your 20s, you have what’s called “peak bone mass,” which is your strongest bones.

By the time we reach 65, we have a 30% risk of having osteoporosis (this assumes we reached menopause around age 52), and the risk increases the older we get.

In our lifetime, women have a 40% risk of a fracture due to osteoporosis.¹ Why women? The issue is that estrogen and bone health are linked. Menopause hastens the rate at which we lose bone density, which makes our bones more porous and our skeleton weaker, especially in the first two years post menopause.

Hip fractures are serious fractures in the elderly. The average age of a broken hip is 82. However, I’ve known women much younger who fell and broke their hip. “Hip fractures cause up to a 25% increase in mortality within 1 year of the incident.”²

Here’s a story highlighting this statistic: A 78-year-old woman gets her foot caught on the edge of a rug, trips, and falls, breaking her hip. She goes to the emergency room, and it’s decided she needs a hip replacement. She’s prescribed rehabilitation post-surgery to build her strength and regain mobility, but she’s afraid of falling again and finds it difficult or painful to do the things she needs to in order to get better. If she doesn’t get better or refuses to do rehab, she gets transferred to a nursing home or home care as a bedridden woman. From there, things can get more dire due to a number of health issues from being bedridden.

The Burden on Women When It Comes to Bones

Estrogen is directly related to bone density, which is why more women than men³ get diagnosed with osteoporosis and why our bone density rapidly declines postmenopause.

In your 50s, fractures can start to be a real concern, especially in the forearm, usually from falling. If you have a fracture postmenopause, you have a 10% chance of having another fracture in the next 1 or 2 years, and a 20% chance if you’ve had a spinal fracture.⁴

Dr. Michael McClung, MD, FACP, FACE, FASBMR, who is the Director of the Oregon Osteoporosis Center in Portland and a leading physician, researcher, and educator in osteoporosis, says that if you’re over 50 and you’ve experienced a fracture, you’ve had a “bone attack.” That’s an effective way to express the necessity of follow-up and assessment for osteoporosis post-fracture.

How is Osteoporosis Diagnosed?

Diagnosing osteoporosis is more complex than we imagine, and we need a physician who understands the intricacies of this disease.

You may have heard your friends mentioning their DEXA (also called DXA, either way it’s pronounced “Dex-ah”) scan results and T-scores and had no idea what they were talking about.

Let’s clarify these terms.

DEXA Scan, aka “the bone density test”

A DEXA scan is a type of X-ray that measures bone density in different places around the body. Getting a scan is non-invasive and only takes a few minutes. You lie down on the machine, and it takes pictures of the internal structure of your body.

Some doctor offices have DEXA scan machines in their office, but if not, you’ll need to go to an imaging center or hospital to get the scan done. Some fitness facilities also offer this as a service (more on this below).

There has been some confusion about who is eligible for a DEXA scan, which was clarified at the last Menopause Society member meeting last month. As patients in the U.S., we may think that insurance won’t cover it until we turn 65 because we hear that information floating around, but that may not be the case.

The 2021 Osteoporosis Position Statement of The Menopause Society states that several categories of women should be considered for a bone density test. You’ll still need to check insurance coverage first.

This includes:

• Postmenopause women who have a history of one or more fractures, regardless of age

• Women with a known medical cause of bone loss or fracture (which includes other diseases that lead to bone loss or medications that affect bone density)

• All women aged 65 and older

• Women under 65 with additional risk factors that include a body weight less then 127lbs (57.7 kg) or BMI less than 21 kg/m²), or a history of a parent with a hip fracture, or is a current smoker, or stopped estrogen hormone therapy

Dr. McClung recommended that women get a baseline DEXA scan around menopause, maybe even a few years prior to menopause, to measure their bone density; however, your insurance company may not cover it, and your doctor may not order one.

He also said it’s a good idea to get a scan when going off hormone therapy because of the connection between estrogen and bone density, but also because there’s a rapid decline in bone density in the 2 years of stopping estrogen therapy, and this rapid decline can be more damaging than a gradual decline. The benefits gained while taking estrogen hormone therapy are lost once it’s stopped.

Although the information I’m presenting here came from a private lecture he presented last month, you can watch an interview he gave last year for the International Menopause Society.

DEXA scans also measure body fat percentage. Several years ago, I went to a DEXA scan “store” and paid $99 out-of-pocket. The bone density results were a bonus for me, as I really wanted to know my body fat percentage more than I did my bone density. However, I’m glad I did this in 2021 because now I have a baseline bone density test.

T-Score

When you get your DEXA results back, bone density is measured as a T-score, which is a statistical term. A T-score measures the distance away from normal, with normal being “0”. Normal in the case of osteoporosis is based on young, healthy, white women in their 20s, so your DEXA T-score compares you to this population’s bone density, even though you may be of a different race.⁵

A T-score of -2.5 or lower in the lumbar spine, femoral neck, or total hip helps to make a diagnosis of osteoporosis. If these sites are unavailable, forearm may be considered to assist in the diagnosis.

If your DEXA T-score is between -1.0 and -2.5 in these locations, you may be told you have osteopenia, which is a potential pre-warning to osteoporosis, much like pre-diabetes. It doesn’t mean that you have or will develop osteoporosis because your risk needs to be further evaluated as low or high fracture risk (more on this below).

A DEXA scan and T-score are not the only criteria that are used to diagnose osteoporosis, but these tend to be very clear. Doctors also use a history of spine or hip fractures postmenopause that were not caused by major physical trauma, as well as some other factors. Dr. McClung says, “We don’t treat T-scores, we treat patients,” and that means looking at all of the risk factors and tools together.

In postmenopausal women, there is another tool that is used alongside a DEXA scan to determine a diagnosis for osteoporosis, especially when osteopenia is present.

Osteopenia needs further evaluation, and one of the tools doctors use is called a FRAX™ or Fracture Risk Assessment Tool. It’s not meant to be used with perimenopausal women, only postmenopause, and does not provide a value for future risk (probability), only the current risk of fracture. With the advent of AI, more tools like this for younger women may become available.

Risk Factors for Low Bone Density and Fractures

Some studies suggest⁶ that women with a higher body weight are at a lower risk of osteoporosis; however, they have a higher risk of developing other conditions like diabetes and cardiovascular issues, so it’s a tradeoff. It’s thought that fat and bone are interrelated (just like muscle and bone), and/or that carrying around more weight may help maintain bone density.

Some considerations for low bone density:⁷

• Thinness (frail, weak muscles)

• Premature menopause

• Genetics

• Smoking

• Diseases and drugs (for example: diseases like celiac or hyperthyroidism; steroid use > 3 month, protein pump inhibitors that help with acid reflux)

• Age

Some considerations for fractures:⁸

• Prior fracture

• Low bone density

• Age

• Parental history of hip fracture

• Smoking

• Excessive alcohol intake (more than 3 servings daily raises your risk by 38% for osteoporosis and 68% for hip fractures.)

• Dementia

• Diseases and drugs (see some examples above)

• Balance issues

• Low physical activity

• Height loss greater than 1.5 inches (While loss of height happens in aging, a loss of 1.5 inches or 3.8cm should be evaluated for osteoporosis and a potential spine fracture, especially if there is chronic pain in the back.)⁹

Not Just Teen Problems

There are several issues we associate with teenagers, such as anorexia and other disordered eating patterns, suicide, and unexpected pregnancies, which are also quite common during midlife. Another example is scoliosis, which can sometimes develop around the time of menopause and postmenopause.

As luck would have it, I was attending a hospital event around the time I was writing this article, and got to chatting with an older woman who had spine surgery at the hospital after dealing with years of osteoporosis and scoliosis issues. She was so grateful for the hospital and the surgery. She went from being in a wheelchair back to her normal active life. I would have never known she had been so incapacitated just a short while ago.

No Boneheads Here: Prevention Tips

Perimenopause is still a great time to address bone health - it’s not too late. I started lifting weights at 45 and still do 10 years later. Your goal should be to slow down bone loss by maintaining a healthy lifestyle.

1. The Menopause Society recommends eating foods high in calcium and Vitamin D. Dr. Suzanne Gilbert-Lenz, GYN and author of Menopause Bootcamp, also suggests foods high in magnesium. She says these three elements work together for bone health.

2. Estrogen hormone therapy has been approved in the U.S. by the FDA to help PREVENT osteoporosis, not treat it. The longer we can keep estrogen circulating, the stronger our bones may remain. This only includes estrogen hormone therapy products purchased at a commercial pharmacy like CVS or Walgreens. Compounded estrogen purchased at a compounding pharmacy has not been proven to have the same protection.

3. While we all know that weight lifting and resistance exercises are helpful to our health, we should also incorporate coordination, agility, and balance exercises. Exercise researchers also recommend plyometrics, which are jumping exercises. However, these can be dangerous for people at risk of fractures or who have osteoporosis.

4. Be mindful of slippery or uneven surfaces that can cause a fall. A few weeks ago, I wrote about walking around with my mother-in-law in my article Mother-in-Laws In Menopause and how mindful she was of cracks in the sidewalk.

5. If you feel like midlife has also affected your vision, it’s time to get your eyes checked. Correcting vision problems is essential to being able to move safely.

6. Improve muscle strength by lifting weights and doing resistance exercises. Dr. McClung wasn’t yet convinced that weighted vests did much for bone health, but he said he doesn’t see any harm in them if used correctly. He felt the same about vibration plates.

7. Get regular check-ups and schedule an appointment to discuss any bone health concerns with your physician. There are many drug treatment options if you are diagnosed with osteoporosis.

“To succeed in life, we need four things: a wishbone, a backbone, a funny bone, and strong bones.” - Adapted from a quote I found online.

✨Special Offer! FREE premium month for sharing!

To celebrate The Periprofessional’s anniversary, share this article on your favorite social media platform and earn a free month of The Periprofessional premium paid subscription, which includes:

• The Period Break newsletter filled with my personal advice, opinions, and expert tips to start your week feeling supported. Emailed every Monday.

• Ask Away Wednesday every first Wednesday of the month to get your questions answered (private option available). Next event Wednesday, June 4!

• Discounts on 1:1 calls with me

Once you’ve shared the article (forwarding this email to a friend counts too!), come back here and complete the form below. No credit card required; this is my gift to the first 75 people.

This offer is available until May 31, 2025.

---

Be well, stay cool…

Shelby Tutty, MHA
Certified Perimenopause Educator
Founder of The Periprofessional, LLC

Disclaimer, Content Use Policy, Privacy Policy

1. The Menopause Society. The Menopause Guidebook, 10th Edition. 2024

2. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.

3. In the US, about 8 million women have osteoporosis as compared to 2 million men. 80% of osteoporosis cases are in women, according to the U.S. Department of Health and Human Services.

4. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.

5. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.

6. Here is one: Migliaccio S, Greco EA, Fornari R, Donini LM, Lenzi A. Is obesity in women protective against osteoporosis? Diabetes Metab Syndr Obes. 2011;4:273-82. doi: 10.2147/DMSO.S11920. Epub 2011 Jul 4. PMID: 21792326; PMCID: PMC3139535.

7. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.

8. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.

9. The Menopause Society. The Menopause Guidebook, 10th Edition. 2024