Hormones play an essential role in bone health for women. With a decline in estrogen and progesterone at menopause, women can lose up to 20% of their bone mass. Resulting bone fractures can lead to pain, disability, hip replacements and, in some cases, death. Right now, in the US, 10 million people have osteoporosis (abnormal thinning of the bone), and 52 million have osteopenia (the stage just before osteoporosis). By the age of 85, 1 in 2 women will suffer from an osteoporotic bone fracture. The best way to prevent this from happening is to replace hormones before the damage is done.
The period of greatest bone loss starts 1 year before menopause and continues up to 3 years after the last period. Furthermore, researchers can detect signs of increased bone thinning via blood markers starting 2 years before the final menstrual period. This is likely because of the loss of progesterone which we know builds bone, and the drop in estrogen which prevents bone breakdown and facilitates calcium absorption from our diet.
While there are numerous medicines available to treat bone loss, a better strategy is to prevent the bone loss from happening. This is where perimenopause and menopause hormone treatment comes into play. Hormone replacement can increase bone density by as much as 5% and decrease fracture by 34% compared to placebo in women with low bone mass. Estrogen is FDA approved for the prevention of osteoporosis in women who have osteopenia (early stage of bone loss). Though it is not FDA approved for women with normal bone density, you can use it to treat other menopause symptoms, like hot flashes, and it is widely accepted that bones will benefit as well.
Another reason that I prefer hormones for bone support is that they can be used long term, which is not the case for many osteoporosis medicines. Plus, hormones have so many other benefits such as improved mortality, improved cardiovascular disease and lower risk of diabetes (if started within 10 years of menopause,) reduction in hot flashes, better genital health, and quality of life. Experts at the Menopause Society advise that extended use of hormone therapy is recommended and there is no specific age when hormones need to be stopped. Personalized risk assessment should always guide these decisions. Treating hot flashes alone is an important goal since research shows that worse hot flashes are associated with both increased bone loss and higher cardiovascular disease risk.
Many of my patients wonder if it matters which kind of hormones they take. Oral and topical estrogen both work as do both conjugated equine estrogens (CEE) and bioidentical human estradiol. I prefer topical estrogen to diminish blood clotting risk. In terms of estrogen dose, any of the FDA approved estradiol patch doses will help maintain bone density. Likewise, synthetic progestins and bioidentical progesterone all support bone health. More recently, providers are using bioidentical progesterone more often than synthetic progestins because evidence suggests progesterone is better for breast health than synthetic progestins.
As far as when to start…the earlier the better! Clearly the best way to prevent bone loss is by providing hormone support throughout the rocky peri-menopause and early menopause years when rate of bone loss is greatest. But, starting later will still show benefit. In the Women’s Health Initiative study, the average age of starting hormones was 63 and women still saw significant fracture reduction if taking hormones.
I encourage women to speak with their Ob Gyn about hormone therapy in peri-menopause and menopause to support their long-term health, including bone health. Menopause.org is a reliable website to find menopause literate providers who can prescribe hormones. If you would like to work with me, click on the “Get started” tab to set up a free 15-minute discovery call.