Your Evidence-Based Guide to Protecting Bone Health
Through Perimenopause and Beyond
STRONG BONES AFTER 40 Your Evidence-Based Guide to Protecting Bone Health Through Perimenopause and Beyond (for a beautiful, downloadable PDF version, click here: |
Created by
Helen Stearns, DNP
Board-Certified Nurse Practitioner | Menopause Specialist| Sexual Medicine | San Diego, CA
helenstearnsdnp.com
PART ONE: WHAT’S HAPPENING TO YOUR BONES
Estrogen and Bone: The Connection Nobody Explained to You
Estrogen is not just a reproductive hormone. It is one of the primary regulators of bone metabolism in women. It works by keeping osteoclasts (the cells that break down bone) in check, while supporting osteoblasts (the cells that build new bone). When estrogen declines in perimenopause, that balance shifts dramatically.
Estrogen protects against bone loss. After menopause, the ovaries produce very little of it. This decrease triggers a period of rapid bone loss that starts approximately one year before the final menstrual period and continues for about three years.
The Numbers That Should Be on Every Provider’s Wall
International Journal of Basic & Clinical Pharmacology |
Endocrine Society |
1 in 2 postmenopausal women will have osteoporosis, and most will experience a fracture during their lifetime.
ScienceDirect |
Women with total estradiol levels below 5 pg/mL face a 2.5-fold increase in hip and vertebral fractures, independent of age and body weight.
Kaiser Permanente Center for Health Research |
Women ages 65 to 69 who break a hip are five times more likely to die within a year than women of the same age who do not break a hip.Let that last statistic sit for a moment. A hip fracture is not just a broken bone. It is a life-altering event with real mortality implications. This is why building and protecting bone now, while you still can, matters so much. |
The Perimenopausal Window: Why Now Is the Moment
Perimenopause is not just about managing symptoms. It is a biological window during which your interventions have the greatest impact on your long-term skeletal health. The bone loss that happens in these years cannot be fully recovered. Prevention is always more effective than treatment.
PART TWO: KNOW YOUR RISK FACTORS
You are at increased risk for osteoporosis and fractures if you:
- Are in perimenopause or postmenopause
- Have irregular or skipping periods (a sign of estrogen fluctuation)
- Have a family history of osteoporosis or hip fracture
- Are small-framed or have a history of low body weight
- Smoke or have a history of heavy smoking
- Drink more than 2 alcoholic beverages per day regularly
- Take corticosteroids, certain antidepressants (SSRIs), or thyroid medications long-term
- Have had previous fractures from minor trauma
- Have a history of an eating disorder, amenorrhea, or premature menopause (before age 45)
- Have a sedentary lifestyle
- Are noticing height loss (more than 1.5 inches since your 20s) or new upper back curvature
Risk is not destiny. But you need to know your starting point. That starts with a DXA scan. |
PART THREE: THE DXA SCAN — YOUR ROADMAP
What It Is and Why You Need One
A DXA scan (dual-energy X-ray absorptiometry) is a quick, painless, low-radiation scan that measures your bone mineral density at your spine and hip. It takes about 15 minutes. It is the gold standard for assessing bone health and estimating fracture risk.
Understanding Your T-Score -1.0 or above Normal bone density -1.0 to -2.5 Osteopenia (low bone mass) Below -2.5 Osteoporosis |
When Should You Get One?
- All women age 65 and older: routine DXA recommended by all major guidelines
- Women under 65 with risk factors: the updated USPSTF guidelines now recommend BMD screening (not just a risk calculator) for postmenopausal women younger than 65 who have risk factors
- Women in perimenopause with risk factors: ask your menopause provider about a baseline scan now
- Any woman with height loss, back pain, or a fragility fracture: do not wait
Your DXA also gives you a FRAX score, which calculates your 10-year probability of a major osteoporotic fracture. This helps your provider decide whether watchful waiting, lifestyle intervention, or medication is the right next step.
PART FOUR: THE FIVE PILLARS OF BONE PROTECTION
PILLAR 1: MOVEMENT |
Bone responds to mechanical load. When you put stress on bone, it remodels and strengthens. Exercise is one of the most powerful tools you have, and it costs nothing.
Resistance Training (Strength Training)
The most well-supported intervention for bone density. Lifting heavy things signals your bones to hold on to density. Aim for 2 to 3 sessions per week targeting major muscle groups, especially hips, spine, and legs. Combined types of exercise have shown significant positive effects on lumbar spine BMD and lower extremity strength in postmenopausal women.
Impact Exercise: The Bone Builder You Are Probably Skipping
Bone responds to ground reaction force. High-impact exercise creates a mechanical stimulus that signals bone-building cells to get to work. Studies show that just 10 to 15 minutes of heel drops, hopping, or jumping three days a week helps increase bone density and strength.
The Heel Drop: Start Here Today Stand barefoot near a wall for balance Rise up on your toes Let your heels drop firmly to the floor 10 to 20 repetitions, 3 times per week Progress to: single-leg heel drops, jumping jacks, hiking, dancing, tennis, pickleball |
Note: Swimming and cycling are wonderful for cardiovascular health but are non-weight-bearing and do not provide the mechanical load bone needs. They do not count for bone building. |
PILLAR 2: NUTRITION |
Calcium: Food First, Supplement the Gap
Calcium is the primary mineral in bone. Your body cannot make it. Recommended intake for women over 50 is 1,200 mg daily from all sources combined. Prioritize dietary calcium before supplements.
Food Source | Approx. Calcium |
Plain Greek yogurt (1 cup) | ~300 mg |
Sardines with bones (3 oz) | ~325 mg |
Whole milk (1 cup) | ~280 mg |
Fortified oat or almond milk (1 cup) | ~350 mg |
Cooked kale (1 cup) | ~180 mg |
White beans (1/2 cup) | ~130 mg |
Canned salmon with bones (3 oz) | ~180 mg |
Aged cheddar cheese (1 oz) | ~200 mg |
If supplementing: calcium citrate is better absorbed than calcium carbonate. Never take more than 500 to 600 mg in a single dose. Split doses are better absorbed.
Vitamin D: The Absorption Key
Vitamin D is required for calcium absorption. Without adequate levels, your calcium intake is largely wasted. The National Academy of Medicine recommends 600 IU for women ages 51 to 70 and 800 IU for women over 70. Many menopause specialists target serum levels of 40 to 60 ng/mL, which often requires 2,000 IU or more daily depending on your baseline.
Get your vitamin D level checked with a simple blood test (25-OH vitamin D). Do not guess.
Protein: The Most Underrated Bone Nutrient
Protein accounts for 50% of bone’s volume and a third of its mass. Without adequate protein, bone mass decreases much more quickly, even in women who are getting enough calcium and vitamin D.
Higher protein intakes are associated with higher bone mineral density, a slower rate of bone loss, and reduced risk of hip fracture. Aim for at least 100 grams of protein daily.
Helen Stearns, DNP Clinical Recommendation |
Aim for a minimum of 100g of protein per day. Prioritize protein at every meal.Magnesium
Magnesium works alongside calcium and vitamin D in bone metabolism. Many women are deficient. Good sources include leafy greens, pumpkin seeds, almonds, dark chocolate, and black beans. Aim for 320 to 420 mg daily.
Vitamin K2
Vitamin K2 helps direct calcium into bone rather than into soft tissue and arteries. Found in fermented foods (natto, aged cheese), grass-fed butter, and egg yolks. Look for MK-7 form in supplements.
What to Minimize
- Excessive alcohol (more than 1 drink per day significantly increases fracture risk)
- Smoking (one of the most modifiable bone risk factors)
- Very high sodium diets (increase urinary calcium loss)
- Excessive caffeine (moderate intake is generally fine)
PILLAR 3: HORMONE THERAPY |
The decline in estrogen is the primary driver of menopausal bone loss. Hormone therapy addresses that root cause directly.
Estrogen: The Foundation
PubMed, 2021 |
Hormone therapy reduces the risk of fracture at all bone sites by 20 to 40%. It is the only anti-osteoporotic therapy with proven efficacy regardless of baseline fracture risk level.
Women’s Health Journal, 2023 |
AAOS Annual Meeting, 2026 |
Progesterone: Estrogen’s Partner in Bone
Progesterone is not just a uterine protector. It plays an active role in bone formation by stimulating osteoblast activity, the cells responsible for building new bone.
Research shows that combined estrogen and progesterone therapy is more effective than estrogen alone for preserving bone density. Studies indicate that daily progesterone co-therapy with estrogen produces greater spinal BMD gains than estrogen alone, suggesting progesterone adds a meaningful anabolic (bone-building) effect on top of estrogen’s anti-resorptive (bone-protecting) effect.
Progesterone is estradiol’s partner hormone in bone. It appears to play important roles in preventing bone loss during the perimenopausal life phase, which is often when loss is most rapid.
Testosterone: An Emerging Piece of the Puzzle
Testosterone also has a role in bone health that is gaining increasing recognition in women’s health research.
Studies have found a statistically significant positive association between testosterone levels and bone mineral density in women ages 40 to 65. Women with lower testosterone levels show increased bone loss, and testosterone has both direct effects on bone via androgen receptors and indirect effects through conversion to estrogen.
Testosterone has been shown to improve bone mineral density in postmenopausal women, and the evidence base is growing. It is not currently first-line for bone protection, but it is absolutely worth a conversation with your menopause provider, particularly if you are already symptomatic from low testosterone.
The bottom line on hormones: Estrogen is the foundation. Progesterone adds to it. Testosterone may contribute further. A full hormone conversation with a knowledgeable menopause provider looks at all three, not just one. |
Timing matters. Hormone therapy is most effective for bone protection when started before age 60 or within 10 years of menopause. This is the window. — though you can STILL build bone back with HT when started later and especially when combined with lifestyle interventions!
PILLAR 4: BALANCE & FALL PREVENTION |
Fractures require two things: fragile bone AND a fall. Reducing fall risk is just as important as building bone density.
- Yoga, Pilates, tai chi, and single-leg exercises improve proprioception and stability
- Strong legs and hips are your best insurance against falls
- Remove throw rugs and loose cords from your home
- Ensure adequate lighting in hallways and bathrooms at night
- Use a bath mat and consider grab bars in the shower
- Wear supportive, non-slip footwear
- Have your vision checked regularly
Ask your provider to review your medication list. Many common medications including sedatives, certain blood pressure drugs, antihistamines, and some antidepressants increase fall risk. |
PILLAR 5: MONITORING |
Bone health is not a one-time check. It requires ongoing monitoring, especially in the perimenopausal years.
Warning Signs to Take Seriously
- Height loss of more than 1 to 1.5 inches compared to your young adult height
- New mid or upper back pain (could indicate a vertebral compression fracture)
- A fracture from a minor fall or everyday activity (fragility fracture)
- A DXA T-score in the osteopenia range, especially if you are early in perimenopause
Labs Worth Knowing
Vitamin D (25-OH) | Aim for 40 to 60 ng/mL |
Calcium (serum) | Should be within normal range |
Estradiol | Especially relevant for menopausal women |
Testosterone | Worth checking as part of full hormone picture |
Bone turnover markers (CTX, P1NP) | Help assess rate of bone loss and treatment response |
PART FIVE: YOUR ACTION PLAN
Here is what you can start this week:
7-Day Bone Health Kickstart Day 1 Track your protein intake for the day. Are you hitting 100g? Day 2 Look up your most recent vitamin D level. If you do not have one, call your provider. Day 3 Add heel drops to your morning routine while you brush your teeth. Ten reps. Day 4 Audit your calcium intake using food first. Supplement only the gap. Day 5 Schedule a DXA scan if you do not have a recent one. Day 6 Add one strength training movement. Squats count. Start where you are. Day 7 Book a consultation with a menopause specialist to discuss your full hormone picture. |
The Bottom Line
The healthcare system has failed many women by treating menopause as a symptom management problem rather than a long-term health event. Bone loss is happening right now, invisibly, in women who are being told their lab work is normal and they are fine.
You are not just managing today’s discomfort. You are building the foundation for who you will be at 70, 80, and 90. Whether you will still be hiking, traveling, picking up your grandchildren, and living independently. That future is worth protecting right now.
RECOMMENDED READING
Dr. Wright is an orthopedic surgeon and performance medicine pioneer whose work sits at the intersection of bone health, muscle preservation, and long-term vitality. This book is the logical next step if you want to go deeper. Highly recommended. |
Unbreakable by Dr. Vonda WrightABOUT YOUR GUIDE
Helen Stearns, DNP Board-Certified Nurse Practitioner | Menopause Specialist | Sexual Medicine Cash-Pay Concierge Women’s Health Practice | San Diego, CA I created this guide because I am in perimenopause myself. I know what it feels like to notice your body changing and to struggle to find a provider who takes it seriously. I built my practice specifically for women who are exhausted from being dismissed and who are ready for care that actually sees the whole picture. My practice is focused on hormone therapy, bone and metabolic health, sexual medicine, and preventive care for midlife women. I do not accept insurance. I do not rush appointments. And I will never tell you that what you are experiencing is just aging. Relief for today. Health for tomorrow. helenstearnsdnp.com |
This guide is for educational purposes and does not constitute individual medical advice.
Please work with a qualified healthcare provider to assess your individual bone health risk and develop a personalized plan.
