Preventing osteoporosis: what to start in perimenopause

Bone loss speeds up sharply about a year before the final period and stays fast for a couple of years after it, so perimenopause is the time to protect what you have. Most women do not need a bone density scan yet, but everyone benefits from enough calcium and vitamin D, regular weight-bearing and strength exercise, no smoking and modest alcohol. Women with risk factors should ask about a fracture risk assessment now rather than at 65.

Why bone loss speeds up around menopause

Bone is constantly broken down and rebuilt. Estrogen keeps that cycle in balance; when estrogen falls, breakdown outpaces rebuilding. The spine, which is rich in spongy (trabecular) bone, shows loss first, and the hip follows later.

SWAN repeatedly measured bone density in 862 women of four racial and ethnic groups as they went through menopause. Loss began about 1 year before the final menstrual period and slowed, but did not stop, about 2 years after it. Over 10 years:

Site	Total loss over 10 years	Lost from 1 year before to 2 years after the final period
Lumbar spine	10.6%	7.4%
Femoral neck (hip)	9.1%	5.8%

Women with a higher body mass index and African American women lost bone more slowly; Chinese and Japanese American women lost it faster. The practical point is that the three years around the final period matter more than any other window.

The numbers

• About half of white women over 50 in the US will have a fracture related to osteoporosis in their remaining lifetime, according to the Bone Health and Osteoporosis Foundation’s clinician guide.
• About 12.3 million Americans are estimated to have osteoporosis.
• Among US women 65 and older, the USPSTF reports an osteoporosis prevalence of 27.1%.
• Only 40% to 60% of people who break a hip recover their previous level of mobility.

Screening: who needs a bone density test and when

Bone density is measured with a DXA scan of the hip and spine, a quick, low-radiation test.

Who	USPSTF (2025)	Bone Health and Osteoporosis Foundation (2022)
Women 65 and older	Screen (grade B)	Test regardless of risk factors
Postmenopausal women under 65	Screen if risk assessment shows increased risk (grade B)	Test if clinical risk factors are present
Women in the menopausal transition	No specific recommendation	Test if clinical risk factors are present
Anyone with a fracture after 50, or on bone-depleting drugs	Not covered by screening advice	Test

For women under 65, the USPSTF describes two steps. First, check for risk factors such as low body weight, a parent with a hip fracture, smoking and excess alcohol. If any are present, use a risk tool such as FRAX, OST or ORAI to decide whether a DXA scan is worthwhile. FRAX also counts rheumatoid arthritis, long-term steroid use, a prior fracture and menopause before 40.

If your first scan is normal, the USPSTF notes that repeating it within 4 to 8 years does not improve fracture prediction for most women. For what a T-score between -1.0 and -2.5 means, read osteopenia.

What to start now

Calcium, mostly from food. The recommended intake is 1,000 mg a day through age 50 and 1,200 mg from 51. Dairy, fortified plant milks, canned fish with bones, tofu made with calcium and leafy greens all count. Supplement only the gap. Intakes above the recommendation have shown no added bone benefit, and supplemental calcium above 1,200 to 1,500 mg a day can raise kidney stone risk in susceptible people.

Vitamin D. The Bone Health and Osteoporosis Foundation recommends 800 to 1,000 IU a day for adults 50 and older; the national RDA is 600 IU through age 70. Large trials have not shown that extra vitamin D prevents fractures in people who are not deficient; see our vitamin D guide.

Protein. The Menopause Society lists adequate protein alongside calcium and vitamin D as part of basic bone care.

Load your bones. Weight-bearing and resistance exercise is part of every major prevention guideline. In the LIFTMOR trial, 101 postmenopausal women with low bone mass were randomized to 8 months of supervised, twice-weekly, 30-minute high-intensity resistance and impact training or a low-intensity home program. Spine bone density rose 2.9% with lifting and fell 1.2% with the home program, and hip bone density rose 0.3% versus a 1.9% drop, with a single adverse event reported in the lifting group. Our guide to weight training and bone density shows how to start safely.

Do not smoke, and keep alcohol modest. Both raise fracture risk; FRAX counts 3 or more drinks a day as a risk factor.

Review your medications. Long-term glucocorticoids, aromatase inhibitors, excess thyroid hormone, proton pump inhibitors, SSRIs and medroxyprogesterone acetate are among the drugs linked to bone loss. Do not stop anything on your own, but ask whether bone protection is needed.

Where hormone therapy fits

Estrogen therapy is FDA-approved for preventing postmenopausal osteoporosis. In the Women’s Health Initiative, 16,608 women aged 50 to 79 took estrogen plus progestin or placebo for an average of 5.6 years. Fractures occurred in 8.6% of the hormone group and 11.1% of the placebo group (hazard ratio 0.76), and total hip bone density rose 3.7% versus 0.14% after 3 years. The benefit was seen in every subgroup studied. However, when the trial’s other outcomes were added in, there was no overall net benefit, even in women at high fracture risk. The trial enrolled women up to age 79, and the balance of risks depends strongly on age at the start of treatment.

The Menopause Society’s 2021 statement says estrogen or other therapies can be used to prevent bone loss in women at high risk, especially perimenopausal women with low bone density and other risk factors. When hormone therapy would be used only to prevent fractures, the FDA advises carefully considering approved non-estrogen treatments first, such as bisphosphonates or raloxifene. Bone loss resumes after any osteoporosis drug is stopped, sooner with estrogen and other non-bisphosphonates than with bisphosphonates.

If you are weighing hormone therapy for hot flashes, bone protection is a real added benefit. Read is hormone therapy safe? for the risks by age and route.

When to see a clinician

• You broke a bone in a minor fall after age 40.
• Your periods stopped before 45, or you had both ovaries removed.
• You have taken steroids for more than 3 months, take an aromatase inhibitor, or have a condition such as rheumatoid arthritis, celiac disease or an eating disorder history.
• You have lost height, developed a rounded upper back, or have new back pain.
• A parent broke a hip.

Ask your clinician to run a FRAX estimate and tell you whether a DXA scan makes sense now. You can find a menopause-literate clinician in our directory.