You’ve probably heard that women are prone to
losing bone during menopause. For the
most part, nature has provided healthy women with ample bone mass to accommodate
this perimenopausal and menopausal bone loss, but some women can end up with dramatically
less bone mass than when they began the transition — up to 20% for a few women
I see at the Center for Better Bones.
Our bones naturally break down and rebuild themselves on a daily basis, and until
women reach the age of 30, the building of bone outweighs breakdown. Shortly after
peak bone mass is reached — somewhere around our 29th birthday — we
lose bone density. This loss seems to accelerate in many women during the
menopause transition. And for many years, the medical and research community blamed
estrogen. But as it turns out, estrogen is not the only factor responsible for bone
health during the menopause transition. Neither is
calcium for that matter. The truth is, finding one definitive cause for
thinning bone during menopause is unrealistic. Bone mineral density loss during
menopause depends on a combination of factors.
The good news is that in most cases, accelerated bone loss slows down within five
to seven years after your last period. So the window of time we are most concerned
about is the few years before and the few years after your last period. There is
also a lot you can do to preserve your bone density — or even increase it
— during this time.
Let’s take a look at how you can keep your bones strong and healthy through
menopause so you can give yourself the best possible foundation for the second half
of your life!
#1: Make nutrition your first priority
There are at least 20 key
nutrients that are required for optimal bone health. A balanced diet containing
a range of vegetables and fruit, whole grains, seeds and nuts, and lean protein
will help supply these nutrients, while
supporting the body’s acid-alkaline balance.
Many of us in the US are suffering from chronic low-grade metabolic acidosis
because of our diets. Foods like excess animal protein, refined grains, excess sugar,
sodas, and preservatives can cause the pH in our blood and tissues to become slightly
more acidic than is optimal. And when this happens the bones release their alkalizing
mineral compounds into the blood to “rescue” our all-critical pH balance.
This happens at the expense of bone mineral density and maintaining the living bone
protein matrix. Eating more alkalizing fruits and vegetables and less acidifying
animal proteins, grains, and processed foods can prevent your body from drawing
on mineral reserves stored in your bones to offset a highly acidifying diet.
Since no diet is perfect, I also recommend women take a high-quality supplement
specifically formulated for bone health to fill any nutritional gaps. It’s
important to understand that micronutrients interact with each other and that simply
taking one, such as calcium, is never as helpful as getting a well-rounded nutrient
base. That being said, menopausal women should pay special attention to increasing
vitamin D and vitamin K intake. Here are some of the reasons why:
Tips on getting vitamin D from the sun
- Limit sun exposure to before 10:00 a.m. and after 2:00 p.m. during summer months
to prevent skin damage.
- Expose the skin to full sun for 30 minutes per day — longer if you’re
dark-skinned. But don’t allow yourself to burn.
- If you’re light-skinned and concerned about sunburn, sun exposure in increments
— three 10-minute exposures at different times in the day, rather than one
- If you live above 40° latitude (a horizontal line running below New York City west
to northern California), the sun is only strong enough to trigger vitamin D synthesis
between May and September. From October through April, you will need to supplement
your diet with other vitamin D sources.
Vitamin D. Adequate vitamin D levels are critical for
us to absorb calcium in our intestines and to metabolize calcium throughout life.
Without enough vitamin D, less than 10% of ingested calcium may be absorbed. The
role vitamin D plays in menopause is very clear. As estrogen levels drop, the bone
breakdown hormone known as parathyroid hormone tends to increase. Vitamin
D has been shown to limit the rise in parathyroid hormone and, in turn, limit bone
Unfortunately the majority of Americans are deficient in vitamin D. Aside from compromising
bone, low vitamin D levels are linked to life-threatening diseases like cancer,
diabetes, and heart disease, as well as other conditions like depression and circulatory
disorders. Simply exposing the skin to full sun triggers vitamin D production in
But there is no guarantee you will achieve adequate vitamin D levels without appropriate
supplementation. In my office I have seen remarkable variation in my patients’
levels of vitamin D, so I always suggest that everyone
has her vitamin D level tested. Optimal levels are between 50–60 ng/mL.
Testing is the only way to really know if you have enough of this life-saving nutrient.
Recent research suggests an ideal intake of 2000 IU vitamin D3 daily for the average
Vitamin K. Along with D, vitamin K has very recently been
recognized as essential to bone health, and many, if not most, menopausal women
in America are deficient in it. Vitamin K is a key player in the formation of the
bone protein osteocalcin and the binding of calcium to the bone matrix.
It also limits how much calcium we excrete in our urine. Vitamin K has been associated
with higher bone mineral density, reduced bone breakdown, and lower risk of fracture.
During the early stages of menopause, vitamin K metabolism is altered in many women,
and intake may need to be increased during this transition.
Ovary removal may be associated with an even greater reduction in vitamin K status
than natural menopause. A 2006 study found that after ovary removal, the concentration
of undercarboxylated osteocalcin (an inactive form of osteocalcin) increased
quickly, suggesting that there wasn’t enough vitamin K on board to carboxylate
and activate the protein. Thus scientists now suggest that the need for vitamin
K is higher in both natural and surgical menopause.
Foods rich in vitamin K
- Aged cheese
I encourage you to increase your intake of both vitamins K1 and K2 (also known as
MK-7) during the menopausal transition because I’ve seen what a difference
it makes. For added vitamin K in food, see the list at left. If you are wisely thinking
of supplementing with vitamin K, your bones will benefit most from the form of vitamin
K2 known as MK-7 (menaquinone), so look for this to be included in your
bone health supplement. At the Center for Better Bones, we are conducting a clinical
trial using MK-7 to halt menopausal bone loss. Our preliminary results look promising,
and I’ll keep you informed about our vitamin K / MK-7 research as we complete
this exciting study.
#2: Preserve and build muscle mass
Like our bone mass, our muscle mass generally reaches its peak in youth, then progressively
decreases as we age. By the time women are transitioning through menopause, they
have been steadily losing muscle since around the age of 30 — unless they’ve
made an ongoing effort to maintain muscle strength. This makes it more important
than ever to exercise during the years leading up to and right after menopause.
Save muscle with an alkaline diet
According to a 2008 study, scientists have now documented that an alkaline diet
helps to preserve muscle mass as we age.
We’ve known for a long time that
exercise helps to build bone. After all, our bones adapt to the stress we
put on them, so the more we use them the stronger they become. This is somewhat
more difficult for women in perimenopause and menopause because of the other stressors
their bodies are dealing with and the tendency to lose bone rather than build it.
But intensive strength training allows many women to regain bone as they build muscle.
Exercise studies show that women in early post-menopause can not only maintain,
but gain an average of 1.5% in bone mineral density in as little as nine
months with rigorous strength-training regimes — a far cry from the 2% of
lost bone that might otherwise occur.
Even simply doing aerobic exercise three times per week for half an hour, or a regular
practice as gentle yet powerful as Pilates, can do wonders for preventing bone loss.
If you’re interested in learning more about strength training for your bones,
you can take a look at Miriam Nelson’s book, Strong Women, Strong Bones, or Wayne
Westcott’s Strength Training Past Fifty.
#3: Balance your hormones
Researchers always assumed the main reason for bone loss after menopause was a lack
of estrogen — and estrogen does play a large role in bone health. For starters
it can preserve calcium in the body by increasing our ability to absorb it in the
intestine. It also prevents bone breakdown (resorption) by limiting parathyroid
hormone, the hormone primarily responsible for releasing calcium from bone
into the bloodstream, and by stimulating osteoprotegerin (OPG), a potent
inhibitor of bone resorption. These are some of the reasons why millions of women
were put on hormone replacement therapy after menopause.
But when scientists took the trouble to study the stage immediately before menopause
— known as perimenopause — they found that a great deal of
bone loss occurs in women before their last period. This complicates things, because
women are known to have a rollercoaster ride of spikes and dips in estrogen levels
combined with low progesterone levels during perimenopause. So the cause and effect
relationship between estrogen and bone loss becomes less definitive.
Over the years, noted Canadian endocrinologist Dr. Jerilynn Prior and others have
conducted research on the effects of progesterone on bone. Progesterone, in many
cases, is the hormone to decrease first in the perimenopause transition. Dr. Prior’s
work shows that progesterone and our bone-building cells, called osteoblasts,
have a complex relationship and progesterone may help build bone, although others
have had different results. There is also recent evidence showing that a natural
increase in follicular stimulating hormone (FSH) during perimenopause may be linked
to perimenopausal bone loss.
It’s clear that our sex hormones have an impact on the way our bones remodel
themselves. During menopause these hormone levels are likely to change, with a consequent
effect on bone building. But this does not mean you should turn to hormone replacement
therapy, especially given the health risks of HRT. Mother Nature didn’t plan
for our bodies to maintain reproductive levels of estrogen and progesterone throughout
life, and your bones don’t require them to stay healthy. All things in life
are cyclical, including our hormones, and the body can adapt. We just have to take
care to support it in the transition.
You can do this in many ways, one of which is by eating a well balanced diet full
of fresh whole fruits and vegetables, high-quality protein and fats. Herbal therapies
(phytotherapy) can also gently help your body restore its hormonal balance.
#4: Take care with weight loss
Many women are surprised to hear that losing weight can be a significant risk factor
for bone loss in perimenopausal and recently menopausal women. It’s not that
weight loss is itself necessarily unhealthy — if you’re overweight or
obese, it’s still a good idea to address the health issues that have led to
your excess weight. But the methods you use to lose weight are very important, and
I would caution all women who plan to lose weight during the years leading up to
and right after the menopausal transition to take rigorous steps to protect their
Researchers all around the world have noticed that the combination of low weight
and advancing age are the most important risk factors for determining low bone density.
In fact, if a practitioner does no other tests or screening at all, she can predict
who is likely to have low bone density simply by looking at age and weight. And
when postmenopausal women lose weight, they tend to lose bone. The numbers indicate
that a 10% loss in body weight will give you about 1% loss in bone mass.
We’re not entirely sure why women lose bone when they lose weight. More research
is needed in this area, but here are some possibilities. First, simple physics tells
us that women who are thin have less weight to carry around, and therefore the everyday
force of impact placed on their bones is lower than what an average or overweight
woman sustains — so their bones receive fewer signals to regenerate in the
course of daily life. Second, weight loss causes the release of bone-detrimental
toxins that have accumulated in fat cells over the years. Third, fat cells are secondary
producers of estrogen, which helps protect against bone loss.
Personally, my favorite theory is that our prevalent chronic low-grade metabolic
acidosis is worsened by calorie restriction, high animal protein and/or high fat
diets leading to a loss in the urine of calcium and other bone nutrients. Ultimately,
how you lose weight is a key factor in whether your weight loss improves
your health (see our articles on healthy weight for more
Data from a large, six-year study done in Scotland showed that Caucasian women (already
at higher risk for low bone density than other ethnicities) who lost weight in the
stage leading up to menopause and shortly thereafter lost greater bone density than
participants who did not lose weight during this time. Although it was the change
in weight rather than low weight per se that was associated with loss of
hip bone mineral density, lower weight at follow-up was associated with
greater loss of spinal bone, suggesting that both low weight and losing
weight result in lower bone density overall.
What all this means in sum is that women approaching menopause who want or need
to lose weight should do so in a thoughtful, planned way that is targeted toward
improving their whole health so they don’t lose bone along with the weight.
Nutritional support during your weight loss is key: a healthy diet and appropriate
nutritional supplements are important. If you plan to lose weight during the menopause
transition, be sure to do the following to protect your bones:
- Engage in healthy exercise that builds muscle. Some examples include
weight-training, yoga, qi gong, t’ai chi, and Pilates.
- Decrease your body’s acidity by following an alkaline diet.
- Supplement with the 20 key bone-building nutrients.
- Get your vitamin D levels tested and supplement with vitamin D and K as
#5: Decrease inflammation and improve digestion
Chronic inflammation has very recently been discovered as another factor in bone
loss. Our bodies become “inflamed” when they are reacting to a situation
that calls for the activation of the immune system, such as an injury or disease.
Persistent exposure to food allergies or a generalized deficiency in healthy gut
bacteria can also lead to chronic inflammation in the body. And when inflammation
starts in (or is centered around) the gut, it can affect our ability to absorb bone-building
Inflammatory disorders that impact your bones
- Heart disease
- High blood pressure
- High cholesterol
- Irritable bowel syndrome
Interestingly, our bone breakdown osteoclast cells share a common precursor
with immune cells. Consequently, when the immune system is recurrently activated,
the body overproduces bone breakdown cells, and bone is broken down more readily
than it would be otherwise.
Inflammation’s harmful effects on bone tend to accelerate during menopause
for two reasons. First, estrogen has a natural anti-inflammatory effect, and during
menopause estrogen levels decline. Second, as we age inflammatory free radicals
and oxidative stress accumulate, which increases bone breakdown and lowers bone
There are useful ways to lower your inflammation that can definitely serve your
bones. Solving gastrointestinal problems is a good place to start, since soothing
an irritated GI tract could help reverse inflammation throughout the body. Pay close
attention to how you feel after each of your meals and see if any particular foods
evoke a negative response. Sugar, caffeine, and refined carbohydrates tend to increase
inflammation (and blood acidity), and foods like wheat, dairy, soy, nuts, and eggs
also are common irritants. Daily omega-3 fatty acids have been shown to decrease
inflammation, as has an alkaline diet. Turmeric and ginger have also historically
been used to calm the immune system.
#6: Reduce physical and emotional stress
There is an old saying that osteoporosis is common in thin, worried women. I’ve
seen how worry and stress can compound bone loss in many women. Our bodies are under
enormous physical stress during any hormonal transition — whether it’s
puberty, pregnancy, or menopause. And the emotional stress that comes along with
these transitions can add to the burden. Stress causes us to release higher levels
of the fight-or-flight hormone cortisol, which in turn may lead to increased programmed
cell death, or apoptosis, in our bone-building osteoblast cells.
Cortisol can weaken the bones and cause all kinds of other problems in our bodies
when sustained at high levels over the years. Because our bodies are particularly
stressed during the menopausal transition, it’s really important to incorporate
stress reduction into our lives. At the clinic, we commonly find a connection between
poor bone health and level of emotional support — when a patient has osteoporosis
or osteopenia, it’s often the case that her low bone density mirrors a similar
lack of solid support in her home life. So techniques to improve your emotional
well-being are crucial in countering bone loss. My patients find meditation, yoga,
t’ai chi, qi gong and other mind-body practices helpful
in countering stress. T’ai chi, yoga, and qi gong are especially
helpful because they facilitate stress reduction, build bone, strengthen muscles,
and improve balance to prevent falls.
Stress can also stem from unresolved emotional issues that require more than the
common forms of stress relief. You might also explore the possibility that stress
may stem from a poor diet, food allergies, or prescription medication. The point
is, stress reduction is an important factor that women often forego in the midst
of their busy lives, and for the sake of their bones (as well as overall health)
it shouldn’t be ignored.
An entry way for the healthy years to come
Menopause is a time for many women to rethink their roles and their lives in general.
If bone health is a concern for you during this time you can transform this concern
into a “window of opportunity” to improve your bones and improve your
health overall. Poor bone health is a marker of systemic problems that affect the
whole body, so the natural, life-supporting changes you make to strengthen
your bones will help provide a sound foundation for a long and active life.
You don’t have to lose excessive bone during the menopausal transition or
suffer from dangerous fractures in old age. Once you understand how to support your
bones during this period of life, you have the power to work with nature to build
and maintain strong bones. Hormone replacement and prescription drugs like Fosamax
and Actonel should be thought of as a last resort, because our bodies have the innate
wisdom and the power to maintain lifelong healthy bones when we give them the right
1 Reginster, J., et al. 2005. Fractures in osteoporosis: The challenge
for the new millennium. Osteo. Int., 16 (Suppl. 1), S1–S3. URL (preview):
http://www.springerlink.com/content/glrvdbu9cch2yuj1/ (accessed 08.21.2008).
2 Tenenhouse, A., et al. 2000. Estimation of the prevalence of low bone
density in Canadian women and men using a population-specific DXA reference standard:
The Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos. Int., 11
(10), 897–904. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/11199195 (accessed
Prior, J. 1998. Perimenopause: The complex endocrinology of the menopausal
transition. Endocr. Rev., 19 (4), 397–428. URL: http://edrv.endojournals.org/cgi/content/full/19/4/397
3 National Institutes of Health. 1994. Consensus Development Conference
Statement. National Institute on Aging, Washington, DC. URL: http://consensus.nih.gov/1994/1994OptimalCalcium097html.htm
4 Lips, P., et al. 2001. A global study of vitamin D status and parathyroid
function in postmenopausal women with osteoporosis: Baseline data from the multiple
outcomes of raloxifene evaluation clinical trial. J. Clin. Endocrinol. Metab., 86
(3), 1212–1221. URL: http://jcem.endojournals.org/cgi/content/full/86/3/1212 (accessed
Lukert, B., et al. 1992. Menopausal bone loss is partially regulated
by dietary intake of vitamin D. Calcif. Tissue Int., 51 (3), 173–179. URL
(abstract): http://www.ncbi.nlm.nih.gov/pubmed/1422960 (accessed 07.22.2008).
5 Brown, Susan. 2000. Better Bones, Better Body, 101. Los Angeles:
6 Cannell, J., et al. Vitamin D Scientists’ Call to Action Statement.
Documentation from the Diagnosis and Treatment of Vitamin D Deficiency Seminar.
April 9, 2008, San Diego, CA. URL: www.grassrootshealth.org/documentation/scientistscall.php
7 Macdonald, H., et al. 2008. Vitamin K1 intake is associated with higher
bone mineral density and reduced bone resorption in early postmenopausal Scottish
women: No evidence of gene–nutrient interaction with apolipoprotein E polymorphisms.
Am. J. Clin. Nutr., 87 (5), 1513–1520. URL: http://www.ncbi.nlm.nih.gov/pubmed/18469278
Booth, S., et al. 2003. Vitamin K intake and bone mineral density in
women and men. Am. J. Clin. Nutr., 77 (2), 512–516. URL: http://www.ajcn.org/cgi/content/full/77/2/512
8 Lukacs, J., et al. 2006. Differential associations for menopause and
age in measures of vitamin K, osteocalcin, and bone density: A cross-sectional exploratory
study in healthy volunteers. Menopause, 13 (5), 799–808. URL (abstract):
http://www.ncbi.nlm.nih.gov/pubmed/16912661 (accessed 08.21.2008).
9 Yasui, T., et al. 2006. Change in serum undercarboxylated osteocalcin
concentration in bilaterally oophorectomized women. Maturitas, 56 (3),
288–296. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/17030103 (accessed 07.22.2008).
10 Engelke, K., et al. 2006. Exercise maintains bone density at spine
and hip EFOPS: A 3-year longitudinal study in early postmenopausal women. Osteoporos.
Int., 17 (1), 133–142. URL: http://www.ncbi.nlm.nih.gov/pubmed/16096715
11 Pruitt, L. et al. 1992. Weight-training effects on bone mineral density
in early postmenopausal women. J. Bone Miner. Res, 7 (2), 179–185. URL
(abstract): http://www.ncbi.nlm.nih.gov/pubmed/1570762 (accessed 07.22.2008).
12 Civitelli, R., et al. 1988. Effects of one-year treatment with estrogens
on bone mass, intestinal calcium absorption, and 25–hydroxyvitamin D-1 alpha-hydroxylase
reserve in postmenopausal osteoporosis. Calcif. Tissue Int., 42 (2), 77–86.
URL: http://www.ncbi.nlm.nih.gov/pubmed/3127028 (accessed 07.22.2008).
Gallagher, J., et al. 1980. Effect of estrogen on calcium absorption
and serum vitamin D metabolites in postmenopausal osteoporosis. J. Endocrinol. Metab.
51 (6), 1359–1364. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/6255005
13 Brown, S. 2000. Better Bones, Better Body, 188. Los Angeles:
14 Gallagher, J. 2008. Advances in bone biology and new treatments for
bone loss. Maturitas, 60 (1), 65–69. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/18555623
15 Prior, J. 1998.
16 Macdonald, H., et al. 2004. Nutritional associations with bone loss
during the menopausal transition: Evidence of a beneficial effect of calcium, alcohol,
and fruit and vegetable nutrients and of a detrimental effect of fatty acids. Am.
J. Clin. Nutr., 79 (1), 155–165. URL: http://www.ajcn.org/cgi/content/full/79/1/155
17 Quinkler, M., et al. 2008. Progesterone is extensively metabolized
in osteoblasts: Implications for progesterone action on bone. Horm. Metab. Res.,
40 (10), 679–684. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/18537080
Lydeking–Olsen, E., et al. 2004. Soymilk or progesterone for prevention
of bone loss — a 2-year randomized, placebo–controlled trial. Eur. J. Nutr., 43
(4), 246–257. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/15309425 (accessed
Liang, M., et al. 2003. Effects of progesterone and 18-methyl levonorgestrel
on osteoblastic cells. Endocr. Res., 29 (4), 483–501. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/14682477
Prior, J. 1990. Progesterone as a bone-trophic hormone. Endocr. Rev.,
11 (2), 386–398. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/2194787
18 Azizi, G., et al. 2003. Effect of micronized progesterone on bone
turnover in postmenopausal women on estrogen replacement therapy. Endocr. Res.,
29 (2), 133–140. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/12856800
Leonetti, H., et al. 1999. Transdermal progesterone cream for vasomotor
symptoms and postmenopausal bone loss. Obstet. Gynecol., 94 (2), 225–228.
URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/10432132 (accessed 08.21.2008).
19 Sun, L., et al. 2006. FSH directly regulates bone mass. Cell, 125
(2), 247–260. URL (abstract): http://www.ncbi.nlm.nih.gov/pubmed/16630814 (accessed
20 Ravn, P., et al. 1999. Low body mass index is an important risk factor
for low bone mass and increased bone loss in early postmenopausal women. Early Postmenopausal
Intervention Cohort (EPIC) study group. J. Bone Miner. Res., 14 (9), 1622–1627.
URL: http://www.ncbi.nlm.nih.gov/pubmed/10469292 (accessed 07.22.2008).
21 Shapess, S. 2001. Chapter 30. Weight loss and the skeleton. In Nutritional
Aspects of Osteoporosis, eds. P. Burckhardt, B. Dawson–Hughes, & R.
Heaney. San Diego, CA: Academic Press.
22 Macdonald, H., et al. 2005. Influence of weight and weight change
on bone loss in perimenopausal and early postmenopausal Scottish women. Osteoporosis
Int., 16 (2), 163–171. URL: http://www.ncbi.nlm.nih.gov/pubmed/15185065
23 McCormick, K. 2007. Osteoporosis: Integrating biomarkers and other
diagnostic correlates into the management of bone fragility. Review article. Alt.
Med. Rev., 12 (2), 113–145. URL (PDF): www.thorne.com/media/Osteoporosis_2.pdf
24 McCormick, K. 2007.
25 Pereira, R., et al. 2002. Effects of cortisol and bone morphogenetic
protein-2 on stromal cell differentation: Correlation with CCAAT–enhancer binding
protein expression. Bone, 30 (5), 685–691. URL: http://www.ncbi.nlm.nih.gov/pubmed/11996905
Reference regarding alkaline diet and muscle mass
Dawson–Hughes, B., et al. 2008. Alkaline diets favor lean tissue mass in older adults.
Am. J. Clin. Nutr., 87 (3), 662–665. URL: http://www.ajcn.org/cgi/content/full/87/3/662
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