The Menopause Clinic
Request

Condition

Osteoporosis and bone loss

Osteoporosis is bone that has lost enough density and structure to break from a fall or force that would not normally break it. Bone loss accelerates sharply in the years around the final menstrual period, and it causes no symptoms until a fracture happens. A DEXA scan is recommended for all women at 65, and earlier when risk factors are present — so the point of screening is to find and treat the problem before the first broken bone, not after.

What women describe

  • Usually none at all until a fracture happens — this is why screening matters
  • A broken bone from a fall from standing height or less
  • Losing height, more than about an inch and a half from your tallest adult height
  • A rounding of the upper back that is new
  • New mid-back pain that came on suddenly, which can be a spine compression fracture

What is happening

Bone is living tissue that is constantly torn down and rebuilt. Cells called osteoclasts remove old bone; osteoblasts lay down new bone. Through your thirties and forties the two roughly balance.

Estrogen is one of the main brakes on the tearing-down side. When it falls at menopause, resorption accelerates while formation does not keep pace. The result is a period of rapid loss — steepest in the year before the final period and the two years after — during which many women lose a meaningful percentage of their bone density. After that the loss continues, but more slowly.

What is lost is not just density. The internal architecture of trabecular bone thins and connections are lost, which weakens bone more than a density number alone suggests.

Why this belongs in a menopause visit

Bone loss is silent. There is no ache that tells you it is happening. The first sign, for too many women, is a broken wrist, a compressed vertebra, or a hip fracture — and a hip fracture after 65 carries serious consequences for independence and survival.

Meanwhile there is a well-defined window, right around menopause, where treatment decisions are most consequential and where a woman is likely to be in front of a clinician for another reason. Treating hot flashes and ignoring bone is a missed opportunity. So we ask about bone at every menopause visit, calculate risk when it is relevant, and order the scan when it is due.

How we approach it

We start with history: any fracture as an adult, when your periods stopped, steroid use, rheumatoid arthritis, family history of hip fracture, smoking, alcohol, weight, and medications that affect bone. We measure your height and compare it to your tallest adult height.

If you are due for screening, we order a DEXA, and where it is indicated we add vertebral fracture assessment — a low-dose image of the spine taken on the same machine — because silent vertebral fractures are common and change treatment.

We then calculate FRAX and put the numbers together. If you need treatment, we go through the options: bisphosphonates, denosumab including biosimilars, romosozumab, and teriparatide, plus hormone therapy where it fits. Each has a different profile, a different route, a different duration, and a different plan for what happens when you stop — which matters more than most people are told.

Then we set a follow-up interval and stick to it.

How we treat it

  • Bone health and DEXA

    Evidence for Bone health and DEXA: Strong evidence

    Screening with DEXA, fracture risk calculation with FRAX, and treatment with bisphosphonates, denosumab, romosozumab, or teriparatide depending on your risk.

  • Systemic hormone therapy

    Evidence for Systemic hormone therapy: Strong evidence

    A bone-protective option for women under 60 or within 10 years of menopause, especially when hot flashes need treating too.

  • Pelvic floor and bladder care

    Evidence for Pelvic floor and bladder care: Moderate evidence

    Strength and balance work reduces falls, and fewer falls means fewer fractures.

Common questions

When should I get a DEXA scan?

At age 65 for all women. Earlier if you have risk factors: a fracture after 50, menopause before 45, oral steroids for three months or more, rheumatoid arthritis, low body weight, a parent who broke a hip, current smoking, or heavy alcohol use. Medicare covers screening DEXA every two years when criteria are met.

What is FRAX?

FRAX is a calculator that estimates your chance of a major fracture in the next 10 years using your age, weight, height, fracture history, family history, steroid use, smoking, alcohol, rheumatoid arthritis, and, when available, your hip bone density. It matters because bone density alone underestimates risk — many fractures happen in women whose scans read as osteopenia rather than osteoporosis.

I have osteopenia. Do I need medication?

Not always. Osteopenia is a range, not a diagnosis, and treatment depends on your calculated fracture risk rather than the T-score alone. Some women with osteopenia have high enough FRAX scores to warrant treatment; many do not and are managed with calcium, vitamin D, weight-bearing exercise, fall prevention, and a repeat scan.

Can hormone therapy protect my bones?

Yes. Systemic estrogen preserves bone density and reduces fractures, including hip fractures, and that was demonstrated in randomized trials. It is a reasonable bone-protective choice for women under 60 or within 10 years of menopause, particularly when there are also hot flashes to treat. It is generally not started for bone protection alone in women well past that window.

Will calcium and vitamin D be enough?

They are necessary but rarely sufficient once osteoporosis is established. Aim for adequate calcium mostly from food and enough vitamin D to keep your level in range. On their own, supplements do not produce the fracture reduction that prescription treatment does in women at high risk.

Medically reviewed by PLACEHOLDER — Medical Director, MD · Reviewed · Updated
PLACEHOLDER: replace with the reviewing clinician before launch.

Ready to talk to someone who treats this every day?

Insurance-based visits across metro Atlanta. No membership, no cash-pay program, no obligation to start hormones.

Request an appointment Call (770) 800-0000