When we think of osteoporosis, we rarely consider the hormonal changes women experience years before a diagnosis. Although the condition is often associated with advanced age, noticeable frailty, or fractures, the biological processes that weaken bone begin much earlier.
Bone is constantly being remodeled, and hormones like estrogen play a critical role in this process. Estrogen slows osteoclasts (the cells that “CHEW” bone) while stimulating osteoblasts (which “BUILD” new bone), helping to maintain bone density. During menopause, estrogen levels drop, tipping the natural balance of bone remodeling and causing bone loss to outpace the body’s ability to rebuild1. This process is silent and painless, which is why many women remain unaware of their risk until significant deterioration has occurred. Additionally, most women do not receive a DEXA scan before age 65 unless they have risk factors such as early menopause, a family history of fractures, a history of an eating disorder, or certain medical conditions such as celiac disease.
Menopause hormone therapy (MHT or MRT) is an important option for postmenopausal women at higher risk for osteoporosis. Research shows that combined estrogen and progesterone therapy is generally more effective at maintaining bone density than estrogen alone, and that lower doses over longer periods tend to preserve bone better than higher doses for shorter periods2. Because hormone therapy carries potential risks, including breast cancer, blood clots, and cardiovascular complications, decisions should always be individualized2.
Of note, MHT is most effective when paired with lifestyle strategies that support bone health. The American College of Sports Medicine (ACSM) recommends engaging in at least two days per week of comprehensive resistance training that incorporates progressive overload3. Regularly loading the muscles and bones through resistance and weight-bearing exercise stimulates bone remodeling, while also improving strength, stability, and balance—key factors in reducing the risk of falls and fractures. In post-menopausal women specifically, Zhao et al. found that weight-bearing exercise at an intensity of >70% 1 RM (3 days per week) improved bone mineral density (BMD) in the lumbar spine, femoral neck, and hip4.
Another important point is that serum calcium levels on standard blood tests do not reflect dietary calcium intake. Blood calcium is tightly regulated by hormonal mechanisms (including parathyroid hormone and vitamin D), so levels will often appear normal even when dietary intake is inadequate. As a result, assessing calcium intake requires evaluating diet rather than relying on routine lab values.
Finally, ensuring adequate intake of calcium and vitamin D is an important component of bone health. Vitamin D supports intestinal calcium absorption and overall bone metabolism. Food sources of vitamin D are limited; therefore, when supplementing, vitamin D should be taken with a meal that contains fat to improve absorption, since it is a fat-soluble vitamin. Together with resistance training, adequate nutrition, and, when appropriate, MHT, these strategies work synergistically to support bone density and reduce fracture risk.
References:
- Wawrzyniak A, Balawender K. Structural and Metabolic Changes in Bone. Animals. 2022;12(15):1946. doi:https://doi.org/10.3390/ani12151946
- Platt O, Bateman J, Shagaf Bakour. Impact of Menopause Hormone therapy, exercise, and Their Combination on Bone Mineral Density and Mental Wellbeing in Menopausal women: a Scoping Review. Frontiers in Reproductive Health. 2025;7. doi:https://doi.org/10.3389/frph.2025.1542746
- Currier BS, D’Souza AC, Fiatarone MA, et al. American College of Sports Medicine Position Stand. Resistance Training Prescription for Muscle Function, Hypertrophy, and Physical Performance in Healthy Adults: An Overview of Reviews. Medicine and Science in Sports and Exercise. 2026;58(4):851. doi:https://doi.org/10.1249/MSS.0000000000003897
- Zhao F, Su W, Sun Y, Wang J, Lu B, Yun H. Optimal Resistance Training Parameters for Improving Bone Mineral Density in Postmenopausal women: a Systematic Review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2025;20(1). doi:https://doi.org/10.1186/s13018-025-05890-1
