Perimenopause Bone Health: How to Protect Against Osteoporosis Early
How estrogen decline accelerates bone loss in perimenopause, what DEXA scans show, and which strategies including strength training and HRT protect bone density.
Estrogen and Bone Turnover: The Fundamental Link
Bone is living tissue that is constantly being broken down by cells called osteoclasts and rebuilt by cells called osteoblasts. In healthy young adults, this remodelling process is in balance. Estrogen acts as a brake on osteoclast activity, slowing bone resorption. When estrogen declines during perimenopause, osteoclasts become more active relative to osteoblasts, and bone is broken down faster than it is replaced. This creates a deficit of bone mineral density over time. The rate of bone loss is not constant across the life course. It accelerates significantly in the perimenopausal and early postmenopausal years, with some estimates suggesting women can lose three to five percent of bone density per year in the years immediately surrounding the menopause transition. This is the critical window for protective intervention.
Understanding Your Fracture Risk: DEXA Scans
A DEXA (dual-energy X-ray absorptiometry) scan is the standard clinical measure of bone mineral density. It scans the lumbar spine and hip to produce a T-score, which compares your bone density to that of a healthy young adult. A T-score above minus one is considered normal; between minus one and minus 2.5 is osteopenia (low bone density); below minus 2.5 is osteoporosis. DEXA scan guidance varies by risk factors. Women with early menopause (before age 45), a family history of hip fracture, a history of eating disorders, long-term steroid use, or other risk factors for low bone density should discuss an earlier DEXA with their GP. Fracture risk calculators like FRAX, which incorporate bone density alongside clinical risk factors, give a more complete picture than T-score alone.
Calcium and Vitamin D: The Evidence
Calcium and vitamin D are the nutrients most commonly associated with bone health, and both matter, though their roles and the evidence around supplementation are nuanced. Calcium is the primary mineral in bone. Dietary calcium from dairy products, fortified plant milks, tinned sardines (with bones), broccoli, and almonds is the preferred source. Supplemental calcium at doses above 500 milligrams per day has been associated with slightly increased cardiovascular risk in some studies, which is why dietary sources are preferred when achievable. Vitamin D is essential for calcium absorption from the gut. Deficiency is extremely common in the UK due to low sun exposure. A blood test measuring serum 25-hydroxyvitamin D will confirm whether supplementation is needed. Most adults in the UK benefit from 10 micrograms (400 IU) daily from October to March at minimum, and many perimenopausal women need more.
Strength Training and Bone Density
Mechanical loading is one of the most powerful signals for bone formation. When bone is stressed by impact or muscle pull, osteoblasts respond by depositing new bone mineral. Weight-bearing exercise (any exercise where you are bearing your own weight through your skeleton, such as walking, jogging, dancing, or strength training) stimulates bone formation. Impact exercise provides greater stimulus than low-impact activities like swimming or cycling, which have minimal bone benefit. Resistance training is particularly effective because it loads multiple bone sites through muscle contraction forces. Progressive resistance training with progressively heavier loads provides a consistent bone stimulus. Research shows that consistent resistance training can increase or maintain bone density in perimenopausal women. Combining resistance training with some impact activity, such as jumping, running, or weighted carries, provides the broadest bone stimulus.
HRT as Bone Protection
HRT is highly effective at preserving bone density during perimenopause. It directly addresses the cause of accelerated bone loss (estrogen deficiency), reducing osteoclast activity and restoring the balance of bone turnover. Studies show HRT can prevent or significantly slow the bone loss of perimenopause, and it is associated with reduced fracture rates. For women who have early menopause (before 45), HRT is strongly recommended to protect bone as well as cardiovascular and cognitive health, and should typically be continued until the natural age of menopause. For women who start HRT in their forties or early fifties primarily for symptom management, bone protection is an important additional benefit. Bisphosphonates (medications that directly inhibit bone resorption) are used in women with osteoporosis who cannot take HRT or who need additional bone protection.
Lifestyle Factors: Smoking, Alcohol, and More
Smoking is directly toxic to osteoblasts and consistently associated with lower bone density and higher fracture rates. It also reduces estrogen levels, compounding hormonal bone loss. Quitting smoking at any age yields bone health benefits. Alcohol at high intakes impairs osteoblast function, reduces calcium absorption, and increases fall risk (which matters for fracture risk independently of bone density). Moderate alcohol intake has less clear impact, but exceeding UK guidelines of 14 units per week is associated with measurable bone harm. Adequate protein intake supports bone matrix formation. Very low protein intake, common in severely restrictive diets, impairs bone health. Body weight also matters: very low body weight is associated with lower bone density because fat tissue produces estrone (a form of estrogen) and because mechanical loading from carrying body weight stimulates bone formation.
Taking Action Now Rather Than Later
Bone density lost during the perimenopausal window is very difficult to recover fully. The most effective strategy is preservation, not restoration. Starting strength training, optimising vitamin D and calcium intake, reducing smoking and alcohol, and discussing HRT with your GP during perimenopause gives you the best chance of entering your fifties and sixties with bone density that supports an active life. Logging your workouts and symptoms using PeriPlan can help you track how consistently you are engaging in bone-protective activity over time. Bringing data about your exercise habits and symptom load to a GP appointment supports a more comprehensive conversation about your bone health alongside your overall perimenopause management.
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