• Ruby Forbes

Osteoporosis and menopause: our best tips for better bone health

It might not be as hip as gut health, or as pressing as hot flushes, but osteoporosis should still be in your menopause vocabulary. Called a ‘silent disease’ by the American National Institute of Aging, this condition means you have weak and fragile bones that are more vulnerable to fractures. What’s more, osteoporosis mainly affects women over the age of 50, due to the hormonal changes associated with menopause.


hands
Osteoporosis is more likely to affect women over 50, due to hormonal changes in menopause.

It may sound worrying, but information and preparation is your best line of defence here. In this article, you’ll discover what good bone health actually looks like, as well as the link between menopause and osteoporosis. You’ll also discover our best tips on how to improve your bone health, with diet, exercise, medication and HRT all getting a look in.


What is bone health?

To have a bone to pick with someone, to stand bone idle, the bare bones of something… The skeletal stuff colours our everyday language, but how often have you thought about what bone actually is? Surely it’s just that hard, white substance that gives your body some structure…right?


Kind of. It might seem rigid and inanimate, but bone is actually a living tissue that houses nutrients, minerals and fats. Incredibly, bones are also in a constant state of self-renewal. This process is known as bone turnover, or remodelling, and it can be happening to 15% of bone surface at any one time. Cells known as osteoclasts break down and absorb damaged bone tissue before osteoblasts, another type of cell, build up and form new bone. The whole process takes between 3 to 6 months. Oestrogen plays a key role in the bone remodelling process - but more on that later.


A couple of things to remember, before we delve into what osteoporosis actually is:

  • Peak bone mass. The state at which your bones have reached their maximum density and strength, normally in your late twenties. Bone mass refers to the amount of bone tissue in your skeleton. It can be affected by sex, genetics, race, diet, smoking, physical activity and hormones. Having regular periods is a good indication that enough oestrogen is being produced to maintain adequate bone mass.

  • Bone density. This refers to the amount of mineral in the bone tissue itself. A bone density scan is used to check if you have osteoporosis.

What is osteoporosis?

Meaning ‘porous bones’, osteoporosis is a disease of the skeleton in which bones have weakened to the point where they fracture more easily. Anyone can develop osteoporosis, but it is mostly associated with women over the age of 50.


The most common injury associated with osteoporosis is a broken wrist, hip or spinal bone, although sometimes a simple cough or sneeze is enough to damage the rib bones. There are a number of risk factors that make you more likely to develop this disease:

  • Women are more likely to develop osteoporosis than men, especially those in early menopause (under the age of 45) or whose ovaries have been removed

  • If you’ve undergone 3 or more months of high-dose steroid medication

  • If you have certain medical conditions, for example inflammatory or hormonal issues

  • If you have a family history of osteoporosis

  • Long-term use of medication that affects bone strength or hormone levels, such as anti-oestrogen tablets (common after breast cancer)

  • If you have a history of eating disorders

  • If you have a small or petite frame

  • Lack of regular exercise

  • Excessive smoking or drinking

A bone density scan can show you what level of bone density you have (meaning, the amount of mineral in your bone tissue). Your doctor may also invite you to do an online questionnaire like FRAX which will calculate your likelihood of a possible fracture.


That women are more likely to develop osteoporosis than men is partly attributable to the fact that they have lighter bones. More importantly, however, is the role of menopause in the development of this disease.


Menopause and osteoporosis

Remember peak bone mass? That’s when your bones have reached their maximum strength and density, often by your late twenties, with levels remaining pretty consistent throughout your thirties. However, bone mass levels start to decline in your forties. Essentially, a loss of bone tissue is a natural part of ageing, and affects men and women at roughly equal rates.


Until menopause hits the scene.


As noted above, oestrogen is important for bone remodelling. It’s therefore no great surprise that declining oestrogen levels in menopause affect this process. The reduction of oestrogen is linked to an increase in the rate of bone resorption - the stage where bone gets broken down by osteoclasts. The problem is that the rate at which new bone is being formed doesn’t change. This results in an overall loss of bone over time.


This means that your bones both during and after menopause become weaker and more fragile, due to the loss of protective oestrogen. Having weaker bones makes it more likely that you will develop osteoporosis. Additionally, it is not uncommon for women to gain weight during midlife, again due to hormonal changes. This increase in body weight often occurs at the same time as bone is losing its density and strength, which can put the skeleton under additional pressure.


Preventing osteoporosis

Having weaker bones makes you more prone to suffering from a fracture. But why, exactly, is this such a bad thing?


A broken bone in old age doesn’t just cause a lot of pain. It can also have a profound physical and mental impact on your quality of life, due to a potential loss of mobility and independence. Recovery can often take months or years, if you are able to recover at all. A widely cited study from the 1980s found that one in three people died within twelve months of sustaining a hip fracture. Amongst those who survived, 60% still needed assistance a year later.


The study may be old, but the statistics are sobering. We cite these numbers not to frighten or alarm you, but rather to highlight just how important bone health is - it really shouldn’t be taken for granted. As with most things, prevention is the best cure, and exercise is the number one way to build up bone health. Diet, hormone replacement therapy and medication are also important factors to consider. Let’s have a look at how they all contribute to better bone health.


legs of person running
Weight-bearing exercise, such as running, is one of the best things you can do for bone health.

Movement

Aside from doing wonders for both your mental and physical health, exercise is an excellent way to strengthen your bones. And of course, the earlier you get started in life, the better.


But what if you’re already going through menopause, or you have osteoporosis? Fear not, there are still benefits to be had! One study of women with osteoporosis found that a 6-month long programme of 60 minutes of balance and strength training, three times a week, helped the participants gain strength and balance. A good sense of balance is important for preventing falls that lead to fractures. It’s undeniable, therefore, that exercise is important for both preventing and attenuating the effects of osteoporosis.


However, it’s important to choose the correct type of movement - even the most vigorous of breaststrokes won’t cut it here. Your best options are weight-bearing exercise, and strength/resistance training.

  • Weight-bearing exercise

This is any exercise where your feet and legs support your weight. High-impact weight-bearing exercise includes running, skipping, dancing, aerobics and jumping.


Weight-bearing exercise strengthens muscles, ligaments and joints, and all three help protect bone. Of course, frequency and intensity play a role here - an intense game of basketball is much more taxing, and therefore beneficial, than a gentle stroll through the local park. But there’s something to be said for starting slow and building up, too, especially if you’re new to these activities. Take care to wear supportive footwear, in order to protect your ankles and feet.

  • Strength/resistance training

This is where you use muscle strength to perform an exercise. Tendons pulling on the bones will increase bone strength.


Strength or resistance training can involve gym equipment, free weights, resistance bands or simply your own body weight. Maisie Hill, author of Perimenopause Power, recommends performing an exercise with a heavier weight and fewer repetitions, instead of many repetitions of a lighter load. She notes that this will have a better effect on your bone mass density.


However, if you’re a newbie to squat racks and kettlebells, it’s totally okay - and recommended - to start with lower weights and work your way up. Focus on getting the correct form first, before reaching for the barbell.


You can also read our guide to strength training here.


Diet

Diet also plays an important role in bone health - quelle surprise! Let’s have a look at why you need to optimise calcium, vitamin D and protein levels in order to protect bones.

  • Calcium

The big daddy of bone protection! We know that you know that calcium is important for bone health, but it would be remiss of us to leave out this wonder mineral. Nearly 99% of all the calcium in the body is found in your bones, and it combines with other minerals to make your skeleton strong.


Aim for 500mg a day, with calcium-rich foods including sardines, white beans, leafy green vegetables, dried fruit, tofu and dairy products.

  • Vitamin D

This vitamin is important for healthy bones and teeth, as it helps the body absorb calcium. Except - it’s not a vitamin. It’s actually a prohormone, meaning that the body turns it into a hormone. But let’s stick with ‘vitamin’ just to keep things simple! You need 10 micrograms a day of this stuff.


Good sources of dietary vitamin D include oily fish, red meat, liver, egg yolks, fortified foods and dietary supplements. However, it is difficult to meet all your vitamin D needs through diet alone, meaning you also need to get it from the sun. The NHS recommends 13 minutes of sunshine a day, though this figure is based on fair-skinned people. If you have a darker skin tone, you’re more likely to need 1-2 hours of sunshine.


But here’s the catch. The sunshine needs to be at a certain wavelength for your body to be able to manufacture vitamin D from it. This wavelength occurs when the sun is high enough in the sky for your shadow to be shorter than your body. For anyone living in the northern hemisphere, this is only really possible during the summer months.


It is therefore recommended for those of you in colder climates to take supplements to maintain your vitamin D levels during winter. For those with darker skin, you may not make enough vitamin D from sunlight even during the summer months, so consider taking a supplement year round. And of course, don’t forget to slather on the SPF!

  • Protein

Protein is highly important for maintaining both bone and muscle strength. Aim for 1g of protein per kilogram of body weight a day - which means that if you weigh 70kg, you need to aim for 70g of protein across breakfast, lunch and dinner. You will find 20g of protein in: 3 large eggs, one salmon fillet, one chicken breast and half a block of tofu.


vegetables in shop
Green leafy vegetables are an excellent source of calcium, an important mineral for bone health.

Hormone replacement therapy

Hormone replacement therapy can be a thorny issue, which you can read more about here. HRT is normally used to alleviate bothersome menopausal symptoms such as hot flushes. But did you know it can also protect your bone health too?


This is, of course, because it replenishes your oestrogen levels, which as you know are important for protecting bone health. Even short-term use of HRT is shown to lower the risk of fracture associated with osteoporosis. Conversely, if you stop taking HRT, the benefits are quickly lost.


Still unsure about HRT? The Royal Osteoporosis Society in the UK says that HRT is “safe and effective when used in the right way, by the women who need it”. In general, if HRT is started by women who are under the age of 60 and/or less than 10 years postmenopause, then the benefits are generally seen to outweigh the risks. Conversely, the risks are greater than the benefits (or simply cancel one another out) if you take HRT when you are over 60 and/or are more than 10 years postmenopause. The most important thing is to discuss HRT as an option with a trusted doctor or healthcare professional, in order to receive individualised treatment.


The Royal Osteoporosis Society have also noted that it’s important to consider taking HRT if you went through menopause early, i.e. before the age of 45. This is because you will have lost more bone on average, due to the loss of oestrogen at a younger age, so it’s important to protect yourself as well as you can against the risk of osteoporosis.


Medication

There are different medicines available to help prevent or treat osteoporosis. With all of these options, be sure to talk to a doctor or healthcare professional first to see if the medication is appropriate for you as well as to discuss any potential side effects. You can explore:

  • Bisphosphonates are a type of drug used to prevent the bone density loss that occurs with osteoporosis. They slow down the rate at which cells break down bone, which allows for more bone-building cell activity. Improvement can take 6-12 months. This drug should not be taken for more than 3-5 years. It is usually only prescribed if you have osteoporosis and have sustained a fracture or have a high risk of getting one.

  • Tibolone is a synthetic steroid. It seems to be effective for preventing bone loss of the spine and femur, though it is uncertain if it affects fracture risk.

  • SERMs (selective oestrogen receptor modulators) act as both an oestrogen blocker and promoter in various parts of the body. It can increase bone density.


So now you know just how important it is to take care of your bones. Whether it’s an extra jog round the park, some serious sumo squats, or even upping your calcium intake, there’s never been a better time to start optimising your bone health. Future you will be ever so grateful.



References

  • Daly, Robin. 2018. “Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription.” NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429007/.

  • Hill, Maisie. 2021. Perimenopause Power: Navigating Your Hormones on the Journey to Menopause. N.p.: Bloomsbury USA.

  • “HRT and bone health | Royal Osteoporosis Society.” n.d. NET. Accessed April 25, 2022. https://strwebprdmedia.blob.core.windows.net/media/auokc2hl/ros-hrt-and-bone-health.pdf.

  • JB, Andy -. 2016. “HRT is good for bones.” British Menopause Society. https://thebms.org.uk/2011/08/hrt-is-good-for-bones/.

  • Ji, Meng, and Qi Yu. 2015. “Primary osteoporosis in postmenopausal women - PMC.” NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5643776/.

  • Lorentzon, M. 2015. “Osteoporosis: the evolution of a diagnosis.” Wiley Online Library. https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12369.

  • “Osteoporosis.” n.d. National Institute on Aging. Accessed April 25, 2022. https://www.nia.nih.gov/health/osteoporosis.

  • “Osteoporosis - Prevention.” n.d. NHS. Accessed April 25, 2022. https://www.nhs.uk/conditions/osteoporosis/prevention/.

  • Otero, Montserrat. 2017. “The effectiveness of a basic exercise intervention to improve strength and balance in women with osteoporosis.” PubMed. https://pubmed.ncbi.nlm.nih.gov/28352163/.

  • “Overview - - - Osteoporosis.” n.d. NHS. Accessed April 25, 2022. https://www.nhs.uk/conditions/osteoporosis/.



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