How to manage bone health in midlife women


Michael E. Lewiecki, MD, discusses risk factors of osteoporosis in midlife women, and how clinicians can measure and manage bone health.

Michael E. Lewiecki, MD:

Well, I think some key points about osteoporosis that are new are stratifying fracture risk when we first see a patient who's concerned about bone health and individualizing treatment decisions. Now, the time of risk for women begins around the menopause transition, and typically increases over the lifetime of that woman. We know that bone loss can begin at the time of perimenopause and post menopause, some women with an accelerated rate of bone loss can lose as much as 3% to 5% of bone mass per year in the first five years of this time. So, a woman could possibly enter menopause with normal bone density and conceivably have osteoporosis 5 years later. So, I think we need to consider that whenever we see women of this age, we need to consider menopausal symptoms, whether estrogen might be possibly something to consider at this time in life. And as life goes on, in a woman, it's typical that bone density will decline if no treatment is instituted. Now, some women may have normal bone density going into menopause, and it may still stay pretty good. And for those women, nonpharmacological therapy is important. And that may just be adequate intake of calcium, sufficient vitamin D, physical activity, and all the things that all of us need to pay attention to.


  • Osteoporosis risk in women starts around menopause, and some may experience rapid bone loss, losing 3% to 5% of bone mass per year in the first five years of this period.
  • Osteoporosis is a lifelong condition, and even with treatment, the diagnosis persists, emphasizing the need for continuous care and monitoring.
  • The two most significant risk factors for osteoporosis are previous fractures and advancing age, suggesting the importance of evaluating fractures, even minor ones, in older women.
  • Routine tests for calcium, phosphorus, kidney function, and vitamin D levels are important in assessing bone health. Lifestyle factors like smoking, excessive alcohol consumption, and medications that harm bone health should also be considered.
  • Individualized treatment decisions are crucial, with nonpharmacological approaches like calcium intake, vitamin D, physical activity, and lifestyle changes being appropriate for some women, while others may require medication to reduce fracture risk.

Michael E. Lewiecki, MD:

I think an important thing to recognize is that osteoporosis is a lifetime disease. So, once we make a diagnosis of osteoporosis, that diagnosis persists, even if we treat the patient, and even if the bone density gets up above the range that we call osteoporosis, the patient has treated osteoporosis, the disease has not gone away. And this has important implications in terms of physicians and patients understanding this disease. So, we can treat it, but we can't cure it, and we need to follow the patient through the course of a lifetime to be sure they're getting the appropriate care that they need.

Michael E. Lewiecki, MD:

The 2 most important risk factors by far are having a previous fracture and advancing age. So, if a woman is 55 years old, and has a fracture of the wrist, we can't just dismiss that and say oh that was a bad fall, anybody would have broken a wrist. We need to think differently, we need to think this could be a sentinel event in that woman's life. It could be a harbinger of future adverse skeletal events to happen, and the next fracture could be much more serious than a wrist fracture. So, that woman with a wrist fracture needs to be evaluated and probably should have a bone density test, a few simple laboratory tests, her risk of future fracture should be evaluated, and possibly getting onto medication to reduce that risk.

Michael E. Lewiecki, MD:

Well, normally, we measure a few simple things such as calcium level, phosphorus level, we measure kidney function, often a serum 25 hydroxy, vitamin D is worthwhile to get, and we need to evaluate the patient's overall lifestyle. Are they smoking? If so, they should stop. Are they drinking an excessive amount of alcohol? If so, that should be moderated. Are they taking a medication such as prednisone that might be harmful to bone? Are they taking an aromatase inhibitor for breast cancer? If so, we have medications that help to mitigate the adverse skeletal effects of that medication.

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