Early intervention during perimenopause can prevent long-term osteoporosis through timely screening and intermittent therapy strategies.
At The Menopause Society's 2025 Annual Meeting, Michael McClung, MD, FACP, FACE, FASBMR, founding and emeritus director of the Oregon Osteoporosis Center in Portland, Oregon, discussed prevention and management strategies for perimenopausal bone loss.1
McClung explained that estrogen deficiency beginning during perimenopause leads to upregulation of a molecule called RANK ligand, which stimulates osteoclasts—the bone-resorbing cells—to work harder. “That’s the mechanism of the rapid bone loss,” he said. This phase of accelerated bone loss lasts about 5 to 6 years, during which approximately half of all the bone loss between menopause and age 80 occurs.
Because bone loss begins before menopause is diagnosed—defined as 12 months after the last menstrual period—McClung emphasized that “much bone loss has already happened by the time women become menopausal.”
Women at increased risk for osteoporosis, such as those who are thin, have a family history of the condition, or have medical problems that adversely affect the skeleton, should be screened for bone density as they enter perimenopause. “We’ve got multiple studies that we all did 30 years ago documenting that estrogen given in early menopause preserves bone density for as long as it’s given,” McClung said.
For women who cannot or should not receive estrogen, he noted that “low-dose bisphosphonate therapy is as effective as estrogen.”
Menopausal hormone therapy—whether oral or transdermal estrogen—effectively prevents bone loss during use, but the benefit diminishes rapidly once therapy is stopped. “If for whatever reason it’s stopped, the benefit goes away very quickly, within a year or 2,” McClung said. To prevent this rebound loss, transitioning from estrogen to a bisphosphonate such as low-dose alendronate for 2 years or a single intravenous dose can help maintain bone density.2
After this transition, McClung recommends what he terms “maintenance therapy,” which involves using low-dose alendronate for 2 years out of every 5 years, cycling between treatment and rest periods. Alternatively, “recent studies from New Zealand show that giving one dose of intravenous alendronate every 5 years maintains bone density for a long, long time,” he said.
This intermittent, low-dose approach minimizes the long-term risks associated with continuous bisphosphonate therapy, such as atypical femoral fractures. “Up to 3 or 4 years of therapy, there’s an improving benefit,” McClung said, “but after that, there’s no additional benefit and an increasing risk.”
McClung concluded that the perimenopausal period is critical for preventing future osteoporosis. “It’s more effective, easier, and actually less expensive to prevent osteoporosis in the first place than to try to correct or treat it once it’s found,” he said. Regular bone density monitoring and proactive intervention during this stage can help preserve skeletal health and reduce fracture risk later in life.
McClung reports no relevant disclosures.
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