Menopause and bone health: what changes and what HRT does

Bone is living tissue that is continually broken down and rebuilt. Oestrogen restrains bone breakdown. After the menopause, breakdown outpaces rebuilding and bone density falls, most rapidly in the first years. Over time, this can lead to osteoporosis, in which bones are fragile and prone to fracture. Fractures of the wrist, hip and spine are the most common consequences.

• Premature or early menopause, including after surgery to remove the ovaries.

• Long-term use of oral corticosteroids.

• A previous fragility fracture or parental history of hip fracture.

• Low body weight, smoking and heavy alcohol use.

• Conditions affecting absorption or hormones, such as coeliac disease or hyperthyroidism.

• Prolonged immobility or low calcium and vitamin D intake.

HRT reduces bone turnover and loss, and trials show fewer fractures in women taking it. Guidance recognises bone protection as a benefit, especially for women with premature ovarian insufficiency, who are advised to continue HRT until at least the usual age of natural menopause. For women who start HRT for symptoms, bone protection is an added benefit. When HRT is stopped, bone loss resumes, so other measures may be needed.

Weight-bearing and resistance exercise, adequate calcium and vitamin D, stopping smoking and moderating alcohol all help. If fracture risk is high, a clinician may recommend bisphosphonates or other bone-protecting medicines. NICE and other guidelines describe how risk is assessed using tools that combine age, history and, where available, bone density.

A DEXA scan measures bone density in the hip and spine. It is considered for women with risk factors, such as early menopause, prolonged steroid use or previous fracture, and sometimes after fractures or loss of height. It is not routinely offered to all women at menopause. Results are expressed as a T-score, which a clinician interprets with other risk factors.

Include dairy or fortified alternatives, leafy greens, tinned fish with bones, beans and nuts as calcium sources. Consider vitamin D supplementation, particularly in autumn and winter, as advised by NHS guidance. Add strength and balance exercises. Keep an eye out for height loss or back pain that could suggest spinal fracture and mention them to your GP.

Ask whether you have risk factors that would justify a scan, how your fracture risk was estimated, whether HRT would help bone as well as symptoms and what the plan is if you later stop it. If you are already on a bone-protecting medicine, ask how long it will continue and how it will be reviewed. Mention any previous fractures, long-term steroid use, early menopause or a family history of hip fracture, because these change the assessment considerably.