I caught a lucky break
Last July, I fell down my neighbor’s stairs and broke my wrist. My neighbor and I were about to take our dogs on a walk and we were standing on her front stoop chatting when I absent-mindedly stepped backwards off two steps and fell back and down, catching myself with my right hand. My neighbor gasped in shock at my right leg, which was scraped up, bleeding with a hematoma already forming over my shin. In my embarrassment, I leapt up like a bouncy ball, brushed myself off, and assured her that I was fine. As I assess the superficial injury to my leg, all I kept thinking was, “I hope I didn’t break my wrist.” I shook it off and insisted I was fine, but by the end of the walk my wrist was aching and I could barely move it. So off to the ER I went and, indeed, I had a fractured my radius. I followed up with an orthopedic specialist and everything healed up nicely.
July 2023 Back from the ER with my splinted wrist
Nurse Fiona tending to my injury :)
That broken bone revealed a problem that was already present in my 52-year-old body. I requested a DXA scan and, to my surprise, learned that I had osteoporosis of my femur and lumbar spine and osteopenia of my hip. While my broken wrist was painful and inconvenient, the blessing in the break was that it woke me up to a silent condition within my bones. That important moment and subsequent diagnosis allowed me to take active steps to improve my bone health and motivated me to learn all I can about this very common condition. The fact that the condition is so common but so much about it is not common knowledge made me want to share this information, especially with women my age and those who are premenopausal. As you read further, you’ll see why the information is critical for women in that age range.
I’m a little embarrassed to say this, but I am going to share because I am hoping people will learn from my experience. I had this magical thinking that I’d skate through menopause. But the thing is, I don’t think this naïve notion was entirely of my own making. Now that I’ve had time to reflect, I think part of my delusion was related to the void of information around the topic of menopause in general. Is it just me, or do you think it’s odd that you don’t hear much about this topic? Most of what we hear or see about menopause is limited to women experiencing hot flashes or other negative tropes associated with woman aging. It doesn’t seem to come up much in movies or TV, even though every woman who is fortunate enough to live to be at least 55 years old will go through this important life transition.
Menopause is normal and natural, so why do we talk about it in hushed tones or not at all? Have we all internalized society’s projected shame about women getting older? I hate to admit it, but I think I did. It’s a topic that seems to be taboo on both sides, women (me included) and their health care providers are not initiating conversations about this important subject. At least mine didn’t. Are our health care providers too busy to engage in these discussions? Maybe they don’t have the training to feel confident answering our questions about menopause. My own gyn referred me to another provider when I asked her questions about menopause during my last visit.
As I look back, I think I was in denial and wanted to pretend as long as I could. I had not acknowledged my emotions about my own aging. For me, the loss of the cycle felt like a sad ending. Other life milestones are celebrated: birthdays, graduations, bat mitzvah’s and other coming of age celebrations. But the conclusion of a women’s childbearing years has a sad quality. The impact of negative feelings can influence whether or not to seek care, ask questions, and engage with our health care providers. Many of us go through this phase of life without the support and information needed to make informed decisions and take active steps to improve our health and wellbeing. My broken wrist was the wakeup call I needed. My intention in sharing my experience is to bring this topic into the light, empower others to navigate their menopause journey with confidence, and encourage women to be proactive in their health and wellness.
When it comes to health topics, bone health doesn’t get the attention it deserves. I want to give bone health it’s moment in the spotlight! We are told to take care of our hearts and our brains, staving off cardiovascular and neurodegenerative diseases. Yet, bone health is important at every age and stage of life, from childhood up until the very end. Bone health is not as sexy as the beating heart or as captivating as our incredible brains, but let’s give our bones some credit for literally holding us upright, giving our body stability and shape while protecting our internal organs, and providing an anchor for our muscles, as well as other important functions. The health of our bones is precious, being and important factor in our mobility and independence, which are at the core of our wellbeing. Taking care of the health our bones now will carry us into a healthy, active, and vibrant future.
Both men and women can develop osteoporosis. And there are other types of osteoporosis with risk factors besides menopause, but those are beyond the scope of this blog post. My emphasis here is on primary or menopausal osteoporosis. I will link to some resources, but if you have any questions about your bone health or risk factors, please be sure to discuss them with your health care provider. As I mentioned, it’s not just women, men also have risk factors for losing bone density. There are medical conditions as well as medications that can affect our bones.
Our bones are living tissue, constantly changing in a process called remodeling, where old bone is resorbed, and new bone is created. Children and teens form new bone faster than they lose it. Our bones get denser until peak bone mass is attained, and bones are at their strongest point by our mid 20’s. For those who want a deeper dive, perhaps those with kids in their life, here is the National Osteoporosis Foundation position statement on peak bone mass development and lifestyle factors. Here is another resource about building strong bones in children and adolescents.
Osteoporosis means “porous bone.” It is a reduction in the quality, quantity, and strength of the bone. It is a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As we age, we lose more bone than is replaced. This state of imbalance between the losses and gains leads to decreased bone density and strength. This changes the architecture of the bone, which increases risk of a fracture (called a fragility fracture). Osteoporosis has no symptoms; you can’t feel your bones getting weaker. Breaking a bone is often the first sign.
Primary osteoporosis is related to the aging process in conjunction with decreasing sex hormones. The average reduction in bone mineral density is about 10% during the menopause transition with approximately half of women losing bone more rapidly, perhaps as much as 10-20%. (1) Menopause transition, also known as perimenopause, is gradual and can last for years leading up to the final menstrual period. Most women experience menopause between the ages of 45 and 55 years as a natural part of aging. It’s caused by loss of ovarian function and decline in estrogen levels. Once you have gone 12 months without a menstrual period, you’ve officially reached menopause. Estrogen is a hormone that serves many functions in the body, including maintaining healthy bones. The role of estrogen as it pertains to bone health is that it regulates bone remodeling. During the menopause transition, estrogen levels drop significantly, which speeds up bone loss.
I wish I had known about my risk of decreasing bone density when I was in my 40’s. Because of my lack of information, I missed a crucial period during perimenopause when I could have taken important steps to protect my bones. I don’t recall any of my health care providers, who were all women, mentioning that I should be thinking about my bone health. I went for yearly well-checks with my primary care provider; I even had a checkup during the pandemic; I had a telehealth-visit the year I turned fifty. I do not recall any discussion around the topic of menopause or bone health. My risk factors were right there in plain sight; I am a small thin white woman with a family history of osteoporosis. Some guidance or information during this critical window of opportunity would have gone a long way. With the right information, I wonder if I could have slowed the onset of osteoporosis, or at least mitigated the bone loss. This is just one example of why I think our health care system needs health and wellness coaches, to bridge this gap. Well, so here I am, reading articles in medical journals and reliable sources that cite them so I can share this information about bone health.
Because bone mineral density as well as skeletal muscle decline over the menopause transition, midlife represents a critical period for intervention for women. This time period is very important because it represents a time to minimize the loss of bone strength as well as muscle strength and mass.(3) It is estimated that about half of the lifetime loss in bone mineral density occurs during this relatively short period. There is an accelerated period of loss in bone mineral density and bone strength that starts one to two years before menopause until two to five years post-menopause. (2)
Low bone mineral density has both fixed and modifiable risk factors. Being aware of them allows you to take steps to reduce bone loss as early as possible. My fixed risk factors for developing osteoporosis are that I am female, white, thin, small-boned, and have a family history of osteoporosis. Some modifiable risk factors include lifestyle behaviors such as a sedentary lifestyle/physical inactivity, smoking, excessive alcohol (more than 2 drinks/day), vitamin D deficiency, eating disorders, low body mass index, and poor nutrition. Your doctor can advise you about your personal risk factors.
If you already have osteoporosis or osteopenia, focus on fracture prevention. The idea is to lower your chances of breaking a bone in the first place. Pharmacologic treatments that target bone mineral density are the first line of therapy for patients at high risk for fracture, according to American College of Obstetrics and Gynecology. However, we do not have to rely solely on medications to manage this condition; the medications do not have any effect on improving other key fracture risk factors, such as muscle strength, balance, coordination, and overall functional performance, all of which are associated with an increased risk for falls and fracture, independent of bone mineral density.
The good news is there are steps everyone can take for bone health. Your bones get stronger when you use them. Staying active is very important to preserve mobility and strengthen bones. In addition to decreasing bone mineral density, there is also a significant decline in muscle mass during the menopause transition. This study demonstrated that physical activity is associated with greater muscle mass and suggests a physically active lifestyle during midlife may reduce the risk of sarcopenia (loss of muscle mass and strength) later in life. (3)
There are two types of exercises that are important for maintaining and building strong bones, weight-bearing and muscle strengthening exercises. Weight bearing are activities that make you move your body against gravity and can be high or low impact. High impact is more effective than low but be mindful to work at your own fitness level. If you’ve broken a bone due to osteoporosis or if you’re not sure, please check with your health care provider first. Examples of high impact exercises include jumping rope, jogging, hiking up a hill or mountain, stair climbing, tennis, jumping jacks, and dancing. If you’re unable to do high impact activities, examples of safe alternatives are brisk walking, elliptical machines, and low impact aerobics. Muscle strengthening exercises, also known as “resistance training,” use weights, weight machines, or resistance bands. Here is an excellent blog post that reviews and summarizes the exercise recommendations for people with osteoporosis.
There is no one size fits all when it comes to exercise. It should be tailored to the individual based on medical history, experience with exercise, and other factors. Preventing falls is important to avoiding fractures, which is why improving posture and balance training are also important. Yoga is good for muscle strengthening, coordination, posture and balance. There is evidence that yoga can also help improve bone mineral density. Leisurely walking and other low impact exercise such as cycling and swimming have little or no effect on preventing bone loss. But do continue to walk and engage in the other health-promoting activities you enjoy and can do safely.
A well-balanced diet with sufficient calcium, vitamin D, protein, and other nutrients are essential to building strong bones. Calcium is a building-block for our bones, and our bones store 99% of our body’s calcium. Our body does not produce its own calcium, which is why it’s vital to get enough calcium from our diets. Our individual needs will change depending on stage of life, with teens needing more because their bones are rapidly growing. As we age, our body’s ability to absorb calcium declines. Vitamin D helps our body absorb calcium. We get vitamin D from sunlight, food, and supplements. Here's a safety fact sheet about calcium and vitamin D supplements.
A traditional X-ray can identify a fracture, but it cannot measure bone density. Osteoporosis is usually diagnosed with an X-ray called a DXA scan, or dual-energy X-ray absorptiometry. Routine screening generally starts once you turn 65, but you may benefit from getting one sooner if you have risk factors. Advocate for yourself. If you’re in your midlife or beyond and your health care provider hasn’t talked to you about bone health, it’s time to bring it up. Here are a few questions you can ask your doctor: Do I have any risk factors for osteoporosis? Do I need a bone density test? How can I get enough calcium and vitamin D? What kind of exercises should I do to strengthen my bones and muscles?
There is no one specialty dedicated to treating osteoporosis. Start with your primary care provider first to discuss your concerns. If your primary care doctor does not have expertise in treating osteoporosis, specialists in gynecology, endocrinology, rheumatology, orthopedics, and geriatrics can help. But not all doctors within a given specialty will have expertise in treating osteoporosis.
There are many things beyond our control. I know and understand how hard-working and busy our health care providers are. They’re stretched to the max, working in a system that does not allow enough time to address every issue. I worked as a nurse practitioner in one of those busy practices. I don’t have the answers, but I think there is room for improvement. Recently the WHO issued a call to action for primary care provider to lead the effort in managing osteoporosis, due to the fact it continues to be underdiagnosed and undertreated. (Watch this video abstract of the call to action.) I wish I had had a better understanding of my risk factors for developing this common condition and that I had known that the bone loss begins during perimenopause. Neither my primary care physician nor my gynecologist discussed lifestyle recommendations such as taking supplements or talked to me about the types of exercise that strengthen and protect my bones. This is an opportunity and a call to action. Share this with the women in your life. My intention here is not to disparage our health care system or providers but to raise awareness. We can do better.
We have these amazing bodies, and we need to take care of the whole body: heart, brain, bones, and all. There is no quick fix, but taking care of ourselves is worth the time and the effort. This is a lifelong journey; it is very important to me to do everything I can to prevent another fracture and to stay active and independent. I’m working on the things I can control. I don’t want to look back when I’m 65 or 75 and wish I had done more when I had the opportunity. It’s important for all of us to recognize that midlife represents a time of shifting needs. What was working for us before menopause is likely not going to have the same effect. We need to evolve with the changes in our bodies through each stage of life. Each of us has our own unique challenges, situations, and sometimes it can be overwhelming to figure out how to incorporate lifestyle changes into our complex and busy lives. But you don’t have to do it alone. We have each other. We can talk about the changes in our bodies, learn together, and help each other.
(1) Primary Osteoporosis in postmenopausal women
(3) Muscle and bone mass in middle-aged women: role of menopause status and physical activity
Please remember this content is not a substitute for medical advice. Please seek advice from your doctor or other qualified health care provider.
