Bone health in perimenopause: what the evidence shows

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.

Why perimenopause matters for bone

The US SWAN cohort followed women through the menopause transition with repeated DXA scans. Bone loss began about 1 year before the final menstrual period and slowed, but did not stop, about 2 years after it. Over 10 years, women lost 10.6% of spine BMD and 9.1% of femoral neck BMD. About two-thirds of that loss happened in the 3-year window around the last period¹.

Loss was slower in women with a higher BMI and faster in Chinese and Japanese women¹. No similar long-term DXA cohort exists for Indian women.

NO INDIAN DATA No Indian cohort of bone loss through the transition was found.

OUTSIDE INDIA See the SWAN spine and hip BMD loss figures above¹. Use as a guide.

Evidence grade: Moderate. Prospective cohort; US women of four ethnic groups.

The Indian picture: earlier menopause, earlier fractures

• Average age at natural menopause in India is about 46.6 years, from a systematic review of household surveys².
• IMS India 2026 reports that hip fractures in India occur about a decade earlier than in the West (mean age 65 to 71 years, against over 75 to 80)³. ISBMR makes the same observation⁴.
• IMS India estimates that about 3 in 4 women eat less calcium than recommended and about 2 in 3 are vitamin D deficient³. A South Asian meta-analysis found a pooled deficiency rate of 68%⁵.

OUTSIDE INDIA Mean age at natural menopause was 48.8 years across 46 studies in 24 countries, lower in Asia, Africa and Latin America⁶. Not Indian data; use as a guide.

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/L⁷. Not Indian data; use as a guide.

Evidence grade: Low. Indian estimates come from varied, mostly hospital or regional studies.

Who needs assessment: case-finding, not mass screening

Irregular periods alone are not a reason for DXA. Assess women with a fragility fracture, glucocorticoid use, early menopause or premature ovarian insufficiency, low body weight, a parent with hip fracture, or another secondary cause^{3, 8}. USPSTF advises screening at 65, and earlier after menopause when risk is raised⁹.

A stepwise approach for India

IMS India suggests OSTA (age and weight) in primary care, FRAX without BMD in secondary care, and FRAX with DXA where a treatment decision is needed. FRAX India probably underestimates risk³.

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 50¹⁰. Not Indian data; use as a guide.

Evidence grade: Moderate. USPSTF grade B; IMS India Grade B.

What every woman should do

• Calcium from food. Aim for at least 800 mg a day, the IMS India target, from milk, curd, paneer, ragi, sesame, greens and dal. Average Indian intake is about 400 mg³. Supplement only the gap.
• Vitamin D. Correct deficiency. IMS India suggests 1000 to 2000 IU a day for Indian adults³. Routine vitamin D did not prevent fractures in a large trial of adults who were not deficient¹¹.
• Exercise. Progressive resistance and impact training raise BMD. In LIFTMOR, supervised training raised spine BMD by 2.9% while controls lost 1.2%¹². Walking alone is not enough for bone³.
• Falls, smoking and alcohol. Balance work prevents falls; stopping smoking and keeping alcohol low reduce fracture risk^{3, 8}.

Evidence grade: Low. BMD benefits are shown; fracture benefit from lifestyle alone is not proven in trials^{13, 14}.

Hormone therapy and bone

Oestrogen stops the bone loss of the transition. In WHI, combined therapy lowered hip fracture (HR 0.66) and all fractures (HR 0.76) in women not chosen for low bone density^{15, 16}. The benefit faded after treatment stopped¹⁷.

Guidelines agree that MHT suits women under 60 or within 10 years of menopause who have symptoms, and that bone protection is an added benefit^{8, 18}. They disagree on MHT for bone alone. USPSTF recommends against it for prevention (grade D)¹⁹, while IMS India lists it as a first-line option for women at raised risk within 10 years of menopause³. The HRT article covers the risks.

Evidence grade: Moderate. RCT fracture data, but mostly in women over 60.

When to start a bone drug

A fragility fracture, a T-score of -2.5 or lower, or a high FRAX score (IMS India: hip above 3% or major osteoporotic fracture above 20% in 10 years) calls for treatment³. IMS India lists bisphosphonates or denosumab as first line, with MHT as an option within 10 years of menopause³. Alendronate cut new vertebral fractures from 15.0% to 8.0% in women with a prior vertebral fracture²⁰.

Denosumab needs a planned exit. Stopping it without follow-on treatment raised vertebral fracture rates from 1.2 to 7.1 per 100 patient-years²¹. See sequential and combination therapy.

Evidence grade: High. Placebo-controlled RCTs.

Follow-up

Repeat DXA between 1 and 5 years depending on risk, on the same machine³. Review bisphosphonates after some years rather than stopping by default⁸.

Evidence grade: Expert consensus.

Key messages

• Bone loss is fastest from 1 year before to 2 years after the last period¹.
• Indian women reach menopause and fracture earlier^{2, 3}.
• Screen by risk, not by the pattern of periods; FRAX India may underestimate risk³.
• Food calcium, vitamin D repletion, resistance training and fall prevention for all.
• MHT protects bone; bone alone as the reason is contested^{18, 19}.
• Fracture or T-score -2.5: start a drug; plan the end of denosumab²¹.

Where the evidence is weak

• No Indian long-term cohort of bone loss through the transition.
• Fracture trials of MHT are in women around 63 years on average, not in perimenopause²².
• Calcium and vitamin D advice rests on consensus and deficiency correction, not fracture trials^{11, 14}.

Related evidence pages

• Fracture risk around menopause and how to reduce it
• Menopausal hormone therapy (HRT): who, when and why
• Osteoporosis around menopause: questions and evidence answers