Osteoporosis around menopause: questions and evidence answers
Dr Aditya Aggarwal, MS (Ortho), PMC 45581, Aggarwal Clinic, Patiala
Last reviewed · next review 18 October 2027
Evidence summary for clinicians. For discussion, not a prescription. Grades are a GRADE-style reading of the cited sources unless a guideline grade is quoted.
How to read the grades: High or Moderate means randomised trials or a guideline built on them. Low or Very low means observational data, indirect trials or small studies; treat as a guide, not a rule. Expert consensus means a guideline says it, but no trial tests it directly. Grades are a GRADE-style reading of the cited sources, unless a guideline grade is quoted.
Screening: who to scan and when
Q1. Does every woman with irregular periods need a DXA scan?
No. US and Indian guidance both use targeted case-finding, not a scan for every woman in the transition. USPSTF advises screening at 65 and in younger postmenopausal women with raised risk1. The Indian Menopause Society (IMS India 2026) says population DXA screening is not cost-effective in India and advises risk-based case-finding, with DXA where available2.
Evidence grade: Moderate. USPSTF grade B; IMS India Grade B.
Q2. Which women in the menopause transition should have a DXA?
IMS India 2026 lists women in the transition with a secondary cause of bone loss (endocrine, metabolic or drug-related), any fragility fracture, X-ray osteopenia or a vertebral compression fracture, and a baseline before starting a bone drug. After menopause it adds every woman more than 5 years past her last period, and earlier if she has risk factors2.
Common risk factors in practice: glucocorticoids, early menopause or premature ovarian insufficiency, low body weight, a parent with hip fracture, smoking, heavy alcohol, rheumatoid arthritis and enzyme-inducing anti-epileptic drugs2, 3.
Evidence grade: Moderate. IMS India Grade B.
Q3. Should FRAX be used for Indian women?
Yes, as a starting point, with care. The Indian FRAX model comes from a small North Indian cohort and likely underestimates risk2. ISBMR makes the same point and notes that Indian women fracture earlier than Western women4. Where DXA is not available, IMS India suggests OSTA (age and weight only) for first triage, then FRAX2.
OUTSIDE INDIA FRAX was built from 9 population cohorts and checked in 11 more. Clinical risk factors plus hip BMD gave a hip-fracture gradient of risk of 4.2 per SD at age 505. Not Indian data; use as a guide.
Evidence grade: Low. FRAX calibration for India is unvalidated.
Q4. At what age should bone health come up in Indian women?
Average age at natural menopause in India is about 46.6 years, earlier than in many Western countries6. IMS India proposes “Start at 35”: awareness from 35 and screening for non-communicable diseases, including low bone mass, from 402.
OUTSIDE INDIA Mean age at natural menopause was 48.8 years across 46 studies in 24 countries, lower in Asia, Africa and Latin America7. Not Indian data; use as a guide.
Evidence grade: Low. IMS India grades the “Start at 35” advice Grade C.
Lifestyle: calcium, vitamin D, exercise
Q5. How much calcium, and from food or tablets?
Food first. Average Indian intake is about 400 mg a day. IMS India sets a practical target of at least 800 mg a day from food, with supplements only for the gap2. The UK guideline also puts diet first and supplements only if intake is low3.
Calcium for fracture prevention is weak evidence. In a systematic review, dietary calcium was not linked to fracture risk, and in the trials at lowest risk of bias, supplements made no difference8.
Evidence grade: Low. Intake targets are consensus; fracture benefit is unproven in women with adequate diets.
Q6. Should all perimenopausal women take vitamin D?
Correct deficiency; do not expect routine vitamin D to prevent fractures in women with normal levels. In VITAL, daily vitamin D3 did not lower fractures in healthy midlife and older adults not selected for deficiency (HR 0.98)9. Deficiency is common in South Asia, with a pooled prevalence of 68%10. IMS India recommends 1000 to 2000 IU a day for Indian adults and tests only women at risk2.
OUTSIDE INDIA In a worldwide review of 195 studies from 44 countries, 37.3% of studies reported a mean 25(OH)D below 50 nmol/L11. Not Indian data; use as a guide.
Evidence grade: Moderate for no benefit in replete adults; low for the Indian dose advice.
Q7. What exercise helps bone?
Resistance and impact training, plus balance work. In the LIFTMOR trial (101 women with low bone mass, mean age 65), supervised high-intensity resistance and impact training raised spine BMD by 2.9% against a 1.2% fall in controls12. A Cochrane review found small BMD gains from exercise but could not show fewer fractures13. IMS India notes that brisk walking alone is not enough for bone2.
Evidence grade: Low. BMD gains are shown; fracture reduction from exercise is not proven.
Hormone therapy (MHT/HRT)
Q8. Does menopausal hormone therapy protect bone?
Yes. In WHI, oestrogen plus progestin cut hip fractures (HR 0.66) and all fractures (8.6% vs 11.1%, HR 0.76) in women not selected for low bone density14, 15. Oestrogen alone cut hip fractures too (HR 0.61)16. The 2025 Cochrane review rates the fall in clinical fractures with combined therapy as moderate certainty (RR 0.78)17.
Evidence grade: Moderate. Benefit lasts while on treatment; it fades after stopping18.
Q9. Should MHT be started only for bone in a woman without symptoms?
Guidelines differ. USPSTF recommends against hormone therapy to prevent chronic disease, including fractures (grade D)19. The Menopause Society (NAMS 2022) says that under 60 or within 10 years of menopause the balance is favourable for symptoms and for preventing bone loss20. IMS India puts MHT as a first-line option for women at intermediate or high fracture risk within 10 years of menopause2. ESE 2025 treats MHT for chronic disease prevention as a contested question21.
Evidence grade: Low. No trial has fracture as the reason for treatment in perimenopausal women.
Q10. What about early menopause or premature ovarian insufficiency?
Women with menopause at or before 45 have higher risk of osteoporosis and fracture2. Hormone replacement is advised at least until the average age of natural menopause unless there is a contraindication2.
Evidence grade: Moderate. Observational fracture data; consistent guideline advice.
When to start a bone drug
Q11. Who needs an anti-osteoporosis drug?
IMS India lists three clear triggers: a fragility fracture, osteoporosis on DXA (T-score -2.5 or lower), or low bone mass with a FRAX 10-year risk above 3% for hip or above 20% for major osteoporotic fracture2. The UK guideline uses age-dependent FRAX thresholds3.
A new fracture after 50 is a warning. A vertebral fracture raises the risk of another vertebral fracture about 5-fold22.
Evidence grade: High. Drugs cut fractures in women with osteoporosis or prior fracture (placebo-controlled RCTs).
Q12. Which drug first?
For most women, an oral bisphosphonate such as alendronate. In women with an existing vertebral fracture, alendronate roughly halved new vertebral fractures (8.0% vs 15.0%)23. Yearly zoledronate and six-monthly denosumab also cut vertebral and hip fractures24, 25. IMS India allows MHT, a bisphosphonate or denosumab as first line in high-risk women within 10 years of menopause2. For very high risk, see sequential and combination therapy.
Evidence grade: High.
Q13. Should a woman with osteopenia alone get a drug?
Usually no, unless FRAX risk is high. In FIT, alendronate did not significantly cut clinical fractures in women whose hip BMD was above the osteoporosis range26. Zoledronate every 18 months did cut fragility fractures in older women with osteopenia (HR 0.63, 15 treated to prevent one)27. In women aged 50 to 60, zoledronate at baseline and 5 years cut new vertebral fractures over 10 years (RR 0.56)28.
Evidence grade: Moderate. The 50-60 trial is a single New Zealand RCT; X-ray (morphometric) vertebral fractures were the main outcome.
Monitoring, breaks and stopping
Q14. How often should DXA be repeated?
IMS India advises a repeat scan between 1 and 5 years, set by risk, on the same machine and at the same site2.
Evidence grade: Expert consensus. IMS India Grade B.
Q15. Can a bisphosphonate be stopped after some years?
Review; do not stop by default. The UK guideline says routine “drug holidays” are not supported by the evidence. In the extension trials, women who stayed on alendronate after 5 years, or on zoledronate after 3 years, had fewer vertebral fractures than those switched to placebo. Those who gain most from continuing have low hip BMD, a vertebral fracture, or a new fracture on treatment. Reassess with FRAX and BMD before any pause3.
Evidence grade: Moderate.
Q16. What is special about denosumab?
It must not be stopped without a plan. After stopping, vertebral fracture rates rose from 1.2 to 7.1 per 100 patient-years, and more women had multiple vertebral fractures29. Plan a switch to a bisphosphonate3. Details are in sequential and combination therapy.
Evidence grade: Moderate. Post hoc analysis of RCT data, but consistent across guidelines.
How guidelines differ by region
| Region and group | Screening | MHT for bone | Drug threshold |
|---|---|---|---|
| UK: NOGG 20243 | Case-finding with FRAX; DXA when FRAX is near the threshold | An option; reduces fractures in unselected women; transdermal for clot risk | Age-dependent FRAX intervention thresholds |
| US: USPSTF 2025, 20221, 19 | DXA at 65; younger if risk is raised (B) | Against for prevention alone (D) | Not covered |
| US: BHOF 2022, Endocrine Society 201922, 30 | Risk-based | Not assessed for this article | Country-specific risk tool guides treatment |
| US: Menopause Society 202220 | Not its focus | Favourable under 60 or within 10 years for symptoms and bone-loss prevention | Not covered |
| Europe: ESE 202521 | Not its focus | Covers symptom care, POI and early menopause; treats MHT for chronic disease prevention as contested | Not covered |
| India: IMS India 2026, ISBMR 20212, 4 | “Start at 35”; OSTA, then FRAX, then DXA | First-line option within 10 years of menopause at intermediate or high risk | Fracture, T-score -2.5, or FRAX hip >3% / MOF >20% |
ACOG and EMAS/IOF guidance was not re-checked; no verified source was added for them.
How the advice changed over time
| When | What happened | Effect on practice (interpretation) |
|---|---|---|
| Before 2002 | HRT widely given for symptoms and to prevent heart disease and osteoporosis, largely on observational data14 | Broad, long-term use |
| 2002 | WHI oestrogen plus progestin arm stopped early: more breast cancer, heart events, strokes and clots; fewer hip and colorectal events14 | Sharp fall in HRT use; bisphosphonates became the main bone drug |
| 2004 | WHI oestrogen-alone arm stopped: more strokes, fewer hip fractures, no rise in breast cancer16 | Oestrogen alone seen differently from combined therapy |
| 2013 and 2017 | Long-term WHI follow-up: most risks and benefits faded after stopping; no change in deaths over 18 years; better balance at 50-5918, 31 | “Timing” idea: start near menopause, under 60 |
| 2019 | Worldwide meta-analysis: breast cancer risk rises with duration and persists after stopping32 | More detail in consent about type and duration |
| 2022 to 2026 | USPSTF D for prevention19; NAMS favourable under 6020; NOGG 20243; ESE 202521; IMS India 20262 | MHT is an individual choice; bone benefit counts, but prevention alone stays contested |
Where the evidence is weak
- No randomised trial has fracture as the main outcome in perimenopausal women. Most data come from women over 60 (WHI mean age 63)17, 31.
- Indian fracture-risk data are thin. FRAX India is uncalibrated, and the “one in five perimenopausal women with vertebral fracture” figure comes from one hospital study, quoted by IMS India2.
- OUTSIDE INDIA In 15,570 Europeans aged 50 to 79, about 12% of women had a vertebral deformity on X-ray, range 6% to 21% by centre (EVOS)33. Not Indian data; use as a guide.
- Calcium and vitamin D: weak or no fracture benefit in women who are not deficient8, 9.
- ESE 2025 statements are based on its published summary only; the full guideline was not reviewed21.
- NICE NG23 and NICE CG146 carry no PMID or DOI, so they are not in the numbered list.
Related evidence pages
Questions
Common questions
- Does every woman with irregular periods need a DXA scan?
- No. US and Indian guidance both use targeted case-finding. USPSTF advises screening at 65 and in younger postmenopausal women with raised risk; IMS India 2026 advises risk-based case-finding.
- Should FRAX be used for Indian women?
- Yes, as a starting point, with care. The Indian FRAX model comes from a small North Indian cohort and likely underestimates risk. Where DXA is not available, IMS India suggests OSTA first, then FRAX.
- Who needs an anti-osteoporosis drug?
- IMS India lists a fragility fracture, a DXA T-score of -2.5 or lower, or low bone mass with a FRAX 10-year risk above 3% for hip or above 20% for major osteoporotic fracture.
- How often should DXA be repeated?
- IMS India advises a repeat scan between 1 and 5 years, set by risk, on the same machine and at the same site.
- Can a bisphosphonate be stopped after some years?
- Review rather than stop by default. The UK guideline says routine drug holidays are not supported; extension trials showed fewer vertebral fractures in women who continued.
- Can denosumab be stopped?
- Not without a plan. After stopping, vertebral fracture rates rose from 1.2 to 7.1 per 100 patient-years. A switch to a bisphosphonate should be planned.
References33 sources, linked to PubMed or DOI
Verified by PMID and DOI. Vancouver style.
- US Preventive Services Task Force, Nicholson WK, Silverstein M, et al. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2025. PubMed 39808425 · doi:10.1001/jama.2024.27154
- Meeta M, Anuradha M, Ashraf AB, et al. Clinical Practice Guidelines for Menopause: An Executive Summary and Recommendations: Indian Menopause Society 2026. J Midlife Health. 2026. PubMed 41767293 · doi:10.4103/jmh.jmh_302_25
- Gregson CL, Armstrong DJ, Avgerinou C, et al. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2025. PubMed 40921943 · doi:10.1007/s11657-025-01588-3
- Bhadada SK, Chadha M, Sriram U, et al. The Indian Society for Bone and Mineral Research (ISBMR) position statement for the diagnosis and treatment of osteoporosis in adults. Arch Osteoporos. 2021. PubMed 34176015 · doi:10.1007/s11657-021-00954-1
- Kanis JA, Oden A, Johnell O, et al. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int. 2007. PubMed 17323110 · doi:10.1007/s00198-007-0343-y
- Prasad JB, Tyagi NK, Verma P. Age at menopause in India: A systematic review. Diabetes Metab Syndr. 2021. PubMed 33524647 · doi:10.1016/j.dsx.2021.01.013
- Schoenaker DA, Jackson CA, Rowlands JV, et al. Socioeconomic position, lifestyle factors and age at natural menopause: a systematic review and meta-analyses of studies across six continents. Int J Epidemiol. 2014. PubMed 24771324 · doi:10.1093/ije/dyu094
- Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: systematic review. BMJ. 2015. PubMed 26420387 · doi:10.1136/bmj.h4580
- LeBoff MS, Chou SH, Ratliff KA, et al. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med. 2022. PubMed 35939577 · doi:10.1056/NEJMoa2202106
- Siddiqee MH, Bhattacharjee B, Siddiqi UR, et al. High prevalence of vitamin D deficiency among the South Asian adults: a systematic review and meta-analysis. BMC Public Health. 2021. PubMed 34627207 · doi:10.1186/s12889-021-11888-1
- Hilger J, Friedel A, Herr R, et al. A systematic review of vitamin D status in populations worldwide. Br J Nutr. 2014. PubMed 23930771 · doi:10.1017/S0007114513001840
- Watson SL, Weeks BK, Weis LJ, et al. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res. 2018. PubMed 28975661 · doi:10.1002/jbmr.3284
- Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011. PubMed 21735380 · doi:10.1002/14651858.CD000333.pub2
- Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002. PubMed 12117397 · doi:10.1001/jama.288.3.321
- Cauley JA, Robbins J, Chen Z, et al. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women's Health Initiative randomized trial. JAMA. 2003. PubMed 14519707 · doi:10.1001/jama.290.13.1729
- Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004. PubMed 15082697 · doi:10.1001/jama.291.14.1701
- Bofill Rodriguez M, Yong LN, Mirkov S, et al. Long-term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2025. PubMed 41307293 · doi:10.1002/14651858.CD004143.pub6
- Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013. PubMed 24084921 · doi:10.1001/jama.2013.278040
- US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2022. PubMed 36318127 · doi:10.1001/jama.2022.18625
- “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022. PubMed 35797481 · doi:10.1097/GME.0000000000002028
- Lumsden MA, Dekkers OM, Faubion SS, et al. European society of endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause. Eur J Endocrinol. 2025. PubMed 41082911 · doi:10.1093/ejendo/lvaf206
- LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022. PubMed 35478046 · doi:10.1007/s00198-021-05900-y
- Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996. PubMed 8950879 · doi:10.1016/s0140-6736(96)07088-2
- Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007. PubMed 17476007 · doi:10.1056/NEJMoa067312
- Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009. PubMed 19671655 · doi:10.1056/NEJMoa0809493
- Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998. PubMed 9875874 · doi:10.1001/jama.280.24.2077
- Reid IR, Horne AM, Mihov B, et al. Fracture Prevention with Zoledronate in Older Women with Osteopenia. N Engl J Med. 2018. PubMed 30575489 · doi:10.1056/NEJMoa1808082
- Bolland MJ, Nisa Z, Mellar A, et al. Fracture Prevention with Infrequent Zoledronate in Women 50 to 60 Years of Age. N Engl J Med. 2025. PubMed 39813642 · doi:10.1056/NEJMoa2407031
- Cummings SR, Ferrari S, Eastell R, et al. Vertebral Fractures After Discontinuation of Denosumab: A Post Hoc Analysis of the Randomized Placebo-Controlled FREEDOM Trial and Its Extension. J Bone Miner Res. 2018. PubMed 29105841 · doi:10.1002/jbmr.3337
- Eastell R, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. 2019. PubMed 30907953 · doi:10.1210/jc.2019-00221
- Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA. 2017. PubMed 28898378 · doi:10.1001/jama.2017.11217
- Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019. PubMed 31474332 · doi:10.1016/S0140-6736(19)31709-X
- O'Neill TW, Felsenberg D, Varlow J, et al. The prevalence of vertebral deformity in european men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res. 1996. PubMed 8797123 · doi:10.1002/jbmr.5650110719
This article is for healthcare professionals. It is not medical advice for individual patients and doesn’t replace clinical judgement or a consultation.