Menopause and Bone Loss: Timing, Tests and Options

Most midlife changes announce themselves. Hot flashes wake you up. Joints complain on the stairs. Bone loss makes no sound at all. For many women, the first sign is a wrist that breaks in a fall that should have meant a bruise.

That is the hard part. The good part is that bone loss around menopause follows a known timetable, it can be measured with a quick scan, and several things change its course in trials.

This guide walks through when the loss happens, who should be scanned, and what each option can and cannot do.

SWAN (the Study of Women’s Health Across the Nation) scanned the spine and hip of 862 women every year through the transition. Loss began about one year before the final period and was fastest from then until two years after it. After that it slowed, but it did not stop (PMID: 21976317).

Source: SWAN, Greendale and colleagues, 2012. The pace differed between women. A higher body weight and Black heritage were linked with slower loss; Japanese and Chinese heritage with faster loss.

So roughly two-thirds of a decade’s spine loss happens in about three years. That window often overlaps the late perimenopause, well before most screening starts. Our guide to menopause stages by age shows where it usually falls.

Something to ask: if your periods are getting irregular and you have risk factors, ask whether it makes sense to talk about bone now rather than at 65.

Low bone density (osteopenia, then osteoporosis) is a risk, not an event. What matters is the chance of a fracture, and density is only part of that.

A DEXA scan gives a T-score: how your bone compares with a healthy young adult. A score of minus 2.5 or lower defines osteoporosis. Clinicians then combine it with age, past fractures, parental hip fracture, smoking, alcohol, steroid use and other conditions to estimate a 10-year fracture risk. The common tool is FRAX (PMID: 18292978).

A 2025 JAMA review sets out the thresholds most guidelines use. Medicines are generally advised for a T-score at or below minus 2.5, a past hip or spine fracture, or a high 10-year risk (PMID: 40587168).

Falls are the other half of the equation. Most hip and wrist fractures happen in a fall from standing height, so balance, leg strength, eyesight and medicines that cause dizziness all count as much as the scan result.

The US Preventive Services Task Force updated its advice in 2025 (PMID: 39808425):

• All women 65 and older: screening recommended (grade B).
• Postmenopausal women under 65 at higher risk: screening recommended (grade B), with risk judged by a clinical tool such as FRAX first.

Higher risk usually means things like low body weight, a parent with a hip fracture, smoking, heavy drinking, long steroid use, early menopause, or conditions such as rheumatoid arthritis.

The Menopause Society’s osteoporosis statement adds that the risk review, not age alone, should decide who is scanned, and that every postmenopausal woman benefits from the basics: protein, calcium, vitamin D, activity, and less smoking and alcohol (PMID: 34448749).

Something to ask: if you are under 65 and in postmenopause, ask your clinician to run a FRAX score and tell you whether it crosses the scanning threshold.

Calcium and vitamin D are the building blocks, and running short of either is bad for bone. The harder question is whether supplements on top of a normal diet cut fractures.

The largest test is the Women’s Health Initiative trial of 36,282 postmenopausal women. Supplements raised hip density by about 1% over placebo. They did not significantly lower hip fractures (hazard ratio 0.88, a range that included no effect). Kidney stones rose by 17% (PMID: 16481635).

There was one hopeful signal. Among women who actually took the pills, hip fractures were 29% lower. That is a weaker kind of evidence, but it suggests the supplements help most where intake was low to begin with.

For years, women with low bone density were told to avoid heavy lifting. An Australian trial tested that advice.

LIFTMOR randomly assigned 101 postmenopausal women with low bone mass, average age 65, to eight months of supervised high-intensity lifting and impact work, twice a week for 30 minutes, or to a gentle home program. Spine density rose 2.9% with lifting and fell 1.2% at home. Hip density rose 0.3% against a 1.9% fall. Height, strength and balance all improved. There was one minor injury, a back spasm (PMID: 28975661).

The key word is supervised. Every session had a trained coach who built up the loads slowly.

Something to ask: if you want to try this, ask for a referral to a physiotherapist or exercise physiologist who works with bone. Our guide to strength training after menopause for bone covers how to start, and the review of vibration plates covers a popular shortcut.

In the Women’s Health Initiative, estrogen plus progestin cut fractures: 8.6% of women on HT had one over the trial, against 11.1% on placebo. That is about 25 fewer fractures for every 1,000 women. But the trial’s overall measure of benefit and harm showed no net gain, even in women at high fracture risk (PMID: 14519707).

That is why estrogen labels list prevention of postmenopausal osteoporosis but say that, when bone is the only reason, non-estrogen medicines should be considered first. HT makes most sense when it is also helping hot flashes or other symptoms. Our article on HRT risks by age sets out the trade-offs.

Sources: Endocrine Society guideline update 2020 (PMID: 32068863) and JAMA review 2025 (PMID: 40587168). In trials of high-risk patients, the first-line bone medicines cut spine fractures by about 52 per 1,000 person-years and hip fractures by about 6 per 1,000 person-years.

Something to ask: what your 10-year risk is, which class fits it, and how long you would take it before a review.