Don’t wait until menopause to strengthen your bones 

I confess: If I think about skeletons, it’s around Halloween. I especially enjoy the yard displays of larger-than-life skeletons engaging in mundane activities, like walking skeleton dogs.

But our own skeletons are something we should be thinking about year-round, especially as we age. Heading into midlife and beyond, bones can lose their heft. A drop below a certain bone density leads to a diagnosis of osteoporosis and bones that are weak and fragile.

Osteoporosis can happen to all adults, but it’s more common in women — about 27 percent of U.S. women age 65 and older have the disorder compared with close to 6 percent of men the same age, according to the U.S. Centers for Disease Control and Prevention.

Bones weakened by osteoporosis are more likely to fracture, which can be debilitating and even deadly. Hip fractures are especially devastating. Around 20 percent of people die within one year of having a hip fracture. Only 40 to 60 percent of survivors are likely to regain their pre-fracture mobility. Lingering physical limitations degrade quality of life.

In January, the U.S. Preventive Services Task Force reaffirmed its recommendation that women 65 and older should be screened for osteoporosis. That’s done with a bone density test.

“A lot of emphasis on the postmenopausal, 65-plus population is warranted because we know that fractures happen at a higher incidence,” says Nicole Wright, an osteoporosis epidemiologist at Tulane University in New Orleans. “But it doesn’t necessarily mean that younger women should not be concerned about their bone health.”

Bone loss really gets going right around menopause. Starting the year before the last menstrual period and for about two years after, bone density drops about 2 percent each year on average due to the decline in estrogen. Bone loss continues more slowly after that.

However, there isn’t a blanket recommendation for screening for postmenopausal women ages 50 to 64. Instead, those at higher risk for osteoporosis in this age range might be screened. Smoking, a history of fracture or having a close relative with a fracture history are among the risk factors that could warrant screening. Women with conditions that can cause osteoporosis, such as rheumatoid arthritis, diabetes and celiac disease, or who are taking certain medications that increase the risk, like glucocorticoids, should already be under a close eye.

For younger postmenopausal women, it’s challenging to predict future fracture risk. Osteoporosis risk prediction tools don’t work very well, researchers reported in JAMA Network Open in March. Nor does the tool for fracture risk prediction, past work has found.

Bone density testing helps determine whether a person needs osteoporosis medications, says Kristine Ensrud, a general internist and epidemiologist at the University of Minnesota in Minneapolis. Yet “we really don’t have good evidence on the benefits versus the harms of beginning treatment in younger postmenopausal women,” she says.

So many younger postmenopausal women are in a kind of limbo, with bone loss under way but perhaps no cause to screen early and scant evidence on how to proceed. But there are ways to minimize the rate of decline in bone density. It’s not “here comes menopause and now we all have osteoporosis,” Wright says.

To preserve bone health, it’s back to the classics: exercise and nutrition. That means weight-bearing exercises, such as walking and running, Ensrud says, and muscle-strengthening exercises. “And remember, a lot of fractures, especially fragility fractures, are related to falls,” she says, “so work on your balance.” It’s also important to get enough calcium and vitamin D, preferably from your diet, and to avoid smoking and excessive amounts of alcohol, she says.

If a woman is taking hormone therapy to treat hot flashes or other menopause symptoms, there’s the added benefit that the estrogen boost prevents bone loss.

Wright would like to see more appreciation for our skeletons. While there’s been a greater awareness about other health issues that affect women, such as breast cancer and cardiovascular disease, it’s not there yet for osteoporosis and fractures, she says. “We need to be thinking about it because there are things we can do.”