Strong Bones, Strong Life:Preventing Osteoporosis for Better Bone Health

For women, the story of bone health extends beyond the bones themselves. It is greatly influenced by several hormones, a slight imbalance of which can put you at risk of developing osteoporosis.

In this article, we will look at the effect of hormones on bone health, help you evaluate your risk of osteoporosis, and outline prevention strategies and treatment options so you can live your best life even after menopause.

What Is Osteoporosis?

A healthy bone is a living tissue that’s constantly being remodeled. Two specialized cells in the body called osteoclasts and osteoblasts control this process. Osteoclasts break down old/ damaged bones (bone resorption), and osteoblasts produce new bone cells to replace them. The ratio of bone resorption and replacement is called bone turnover. When this balance is lost, it can result in osteoporosis.

Osteoporosis is the gradual decline in bone density and mass. A healthy bone has a structure like a honeycomb under the microscope. With osteoporosis, the holes in your bone become larger (porous bone). Porous bones are fragile and more likely to fracture, especially in the hips, spine, and wrists. You could break a bone from a minor fall, or even when sneezing or lifting a child. A mother recounted her day-to-day impact of osteoporosis as experiencing lumbar and hip pain while driving her car and not finding a comfortable seat position.  

According to studies, women make up 80% of osteoporosis cases. In addition, around one in two women over the age of 50 will break a bone because of osteoporosis.

Source: American Medical Association; Bone Health & Osteoporosis: A Comprehensive Look from Causes to Treatment

Osteoporosis shouldn’t be confused with osteopenia. Osteopenia means a lower-than-normal bone density, but not as severe as seen in osteoporosis.

Causes of Osteoporosis

There are several factors that make women more susceptible to developing osteoporosis.

The uncontrollable risk factors include:

• Age (over 50 years)

• Genetics

• Low body weight (having a smaller and thinner body frame)

• Menopause (associated with a sharp decline in estrogen levels)

• Being Caucasian or Asian

The controllable risk factors include:

• Smoking

• Drinking too much alcohol

• A sedentary lifestyle

• A diet low in calcium

• Decreased sun exposure that leads to vitamin D deficiency

• Long-term therapy with steroids (such as prednisone) interferes with bone formation, making the bones weaker over time.

How Estrogen Affects Bone Health

Estrogen is a female hormone with several important functions, including protecting bones and keeping them strong and healthy. During menopause, the estrogen levels fall, which negatively impacts osteoblast function. When osteoblasts don’t produce new bone tissue, it can lead to osteoporosis. This is why women start to experience accelerated bone density loss after menopause. [2]

Studies suggest that women experience a rapid decline in bone density within the five to seven years following menopause. Women can lose up to 20% of their bone density during this time. [1]

However, bone density starts declining in women long before menopause. Women have peak bone mass in their third decade, after which the density slowly starts deteriorating. Perimenopause is a phase of transition before menopause when estrogen levels keep fluctuating. The bone mass may diminish more quickly during this time, but most people notice the sharpest decline after menopause.

However, menopause-related estrogen loss isn’t the only hormonal change that can affect bone health.

Endometriosis is a condition where women have higher levels of estrogen that cause the endometrial tissue to grow outside the uterus, leading to inflammation and pain. Treatments used for endometriosis could cause hypo-estrogenism, increasing the risk of osteoporosis. [3]

Estrogen-containing oral contraceptives, on the other hand, are thought to help protect against osteoporosis. [4]

Other Hormones Affecting Bone Health

Parathyroid Hormone (PTH)

PTH regulates blood calcium levels in your body. When calcium levels drop, the parathyroid glands release PTH. Your body reacts to the PTH by absorbing calcium from the food and preventing it from being excreted through urine. However, if your diet doesn’t contain enough calcium, or if your parathyroid glands don’t stop secreting PTH (hyper-parathyroidism), the osteoclasts start breaking down bone tissue to release calcium into your bloodstream. Over time, excessive PTH activity can lead to bone loss. [5]

Testosterone & Progesterone

Testosterone is a precursor to estrogen in women. It also contributes to skeletal development. So adequate levels of testosterone help support overall bone strength and mass. [6]

Just like estrogen, progesterone supports bone health by stimulating osteoblasts. Shifts in progesterone levels during menstrual cycles or menopause can lead to a decrease in bone density. [7]

Thyroid Hormones

Thyroid hormones are essential for skeletal maturation and normal bone metabolism. Excess thyroid hormones can cause increased osteoclast activity, leading to bone loss. Over time, this can result in osteoporosis. [8]

Cortisol

Known as the stress hormone, cortisol blocks calcium absorption which hinders osteoblast activity. When present in high levels over a long period, cortisol can significantly decrease bone density and increase the risk of osteoporosis. [9]

Signs & Symptoms of Osteoporosis

Osteoporosis is often called a “silent disease” because it can progress without obvious symptoms until a fracture occurs. However, there are several warning signs that might suggest the presence of this condition:

• Fractures from minor falls or even routine activities

• Persistent lower back pain

• A noticeable decrease in height

• Stooped posture (a hunchback appearance)

These signs are often subtle, which is why regular bone density screenings, especially for those at risk, are crucial.

How Is Osteoporosis Diagnosed?

After considering your medical history, age, risk factors, and findings of physical examination, your healthcare provider may recommend a bone mineral density (BMD) test. This test measures calcium and other minerals in the bone and helps determine your bone strength and density.

Central dual-energy x-ray absorptiometry (DXA or DEXA) is the most common BMD test. It measures bone density around the hip and spine because these are weak bones that tend to break most often.

For postmenopausal women and for men over age 50, your BMD test results are given as a T-score. This score compares your BMD to that of a healthy young adult. The lower your T-score, the higher your risk of bone fracture.

• -1 or higher    🡪  healthy bone

• -1 to -2.5        🡪  osteopenia

• -2.5 or lower  🡪  osteoporosis

Source: American Medical Association; Bone Health & Osteoporosis: A Comprehensive Look from Causes to Treatment; diagnostic criteria from WHO.

On the other hand, for pre-menopausal women, for men under age 50, and for children, a Z-score is used. This score compares your BMD to what is typical for healthy people your age, sex, and ethnicity. If the Z-score is -2 or lower, it suggests that your BMD is lower than expected, which may point to underlying issues such as osteoporosis caused by certain medications, or health conditions.

BMD tests are safe, noninvasive, and painless. The U.S. Preventive Services Task Force suggests that women over the age of 65 should get their BMD checked. [10] In addition, the National Osteoporosis Foundation (NOF) recommends a BMD test for [11]:

• Post-menopausal women under 65 who have risk factors for osteoporosis

• Women going through menopause with known risk factors

• Women who have suffered a bone fracture after age 50

• Women with certain medical conditions or on medications that can affect bone health

• Post-menopausal women who have stopped estrogen therapy (ET) or hormone replacement therapy (HRT)

Source: American Medical Association; Bone Health & Osteoporosis: A Comprehensive Look from Causes to Treatment

How To Prevent Osteoporosis?

Preventing osteoporosis starts with building strong bones early in life and maintaining bone health throughout adulthood. Nonetheless, it’s never too late to take steps to improve your bone health at any age. 

The American Medical Association recommends the following practices to prevent or manage osteoporosis: [13]

• Get enough calcium daily. If you’re under age 50, about 1000 mg of calcium daily is recommended, and for women over age 50, increase intake to about 1200 mg. [12]  Dairy products like milk, yogurt, and cheese are a rich source of calcium. If you’re lactose intolerant, lactose-free dairy, tofu, leafy greens, almonds, or fish with edible bones can be great alternatives. If you can’t get enough calcium from your food, consider taking calcium supplements.

• Get enough vitamin D to absorb calcium and protect bones. Women under 50 should aim to get about 400-800 IU daily of Vitamin D, whereas women over 50 should aim for 800-1,000 IU daily [13]. Sunlight is the primary source of vitamin D, but supplements can help too.

• Eat a healthy, well-balanced, and nutrient-rich diet that includes plenty of fruits, vegetables, and lean proteins. Avoid consuming high amounts of protein, sodium, or caffeine as they can contribute to bone loss.

• Weight-bearing and muscle-strengthening exercises, such as lifting weights, using resistance bands, dancing, brisk walking, aerobics, can help maintain and prevent bone loss. Aim for at least 150 min of activities every week.

• Avoid smoking and excessive alcohol consumption to reduce the risk of osteoporosis. 

Managing Your Life With Osteoporosis

While there’s no cure for osteoporosis, lifestyle changes like those mentioned above can help you manage the condition and reduce its impact on your quality of life.

For many women, medication might be necessary for preventing further bone loss and decreasing the risk of fractures. The most notable medications are estrogen therapy (ET) and hormone replacement therapy (HRT) which have been approved by the Food and Drug Administration (FDA) for the prevention of osteoporosis in post-menopausal women. [14]

However, ET is not suitable for every woman because taking estrogen alone has been shown to increase the risk of uterine cancer. For this reason, estrogen is often prescribed in combination with progesterone as part of the recommended HRT therapy to minimize this risk. 

FDA also recommends looking at other medicines for osteoporosis before considering ET or HRT. These options primarily include selective estrogen receptor modulators (SERM) drugs, which either stimulates estrogen receptors in bone and blocks estrogen receptors in the uterus. In the case of bone health, they would either encourage osteoblasts to build new bone or prevent osteoclasts from reabsorbing bone. [15]

Always consult with your healthcare provider and osteoporosis specialist, such as an endocrinologist, to choose the right treatment option for your health profile and risk factors. Furthermore, it is a good preventative plan to annually assess your bone density and get your treatment plan adjusted as needed.