Bone Loss Part I: Understanding Osteoporosis (Part 1 of 3 Part Series)

Osteoporosis isn’t a personal failure or an inevitable part of aging. It’s a measurable change in bone strength, one that women can address with knowledge, movement, and the right support. This first article explains what osteoporosis is, how it’s diagnosed, and why women in midlife deserve clear information, not fear.

What Is Osteoporosis?

Osteoporosis is a condition where bones become less dense and structurally weaker, making them more susceptible to fractures from stresses that wouldn’t normally cause injury. It’s diagnosed by both bone mineral density (BMD) and, in some cases, by the presence of a fragility fracture (a fracture from a low-energy incident such as a fall from standing height).

The World Health Organization defines bone density using T-scores (using DXA scans and explained below):

• Normal: T-score ≥ –1.0

• Osteopenia (low bone mass): –1.0 to –2.5

• Osteoporosis: ≤ –2.5

• Severe osteoporosis: ≤ –2.5 plus a fragility fracture

Osteoporosis becomes far more common in the midlife transition because bone remodeling changes dramatically with shifting hormone levels.

How Bone Changes Through Perimenopause and Menopause

Estrogen helps regulate the balance between bone breakdown (osteoclasts) and bone formation (osteoblasts). During the menopause transition, bone breakdown rises sharply, especially from late perimenopause into the first five to seven years after menopause. Women may lose up to 20 percent of their bone density during this period. [1,2].

This doesn’t mean bone loss is unstoppable. Bones continue responding to strength training and impact throughout life. Even women in their 60s and 70s can improve bone strength, balance, muscle power, and fracture resistance.

How Osteoporosis Is Diagnosed: The DXA Scan

You don’t need a DXA scan to understand this article, but DXA (dual-energy X-ray absorptiometry) is the gold-standard tool clinicians use to measure and monitor bone density.

What DXA Measures

A DXA scan gives two numbers:

T-score:
Compares your bone density to that of a healthy 30-year-old woman (peak bone mass).

Z-score:
Compares your bone density to that of women your same age and body size. Z-scores help clinicians identify whether something other than aging may be affecting bone.

Where DXA Looks

DXA evaluates specific skeletal sites that best reflect fracture risk and respond predictably to treatment [3,4]:

• Lumbar spine (L1–L4)

• Femoral neck

• Total hip

The forearm (one-third radius) is scanned in select situations, such as when hip or spine imaging isn’t interpretable or when certain medical conditions (e.g., hyperparathyroidism) make the wrist clinically relevant.

If you haven’t had a DXA, your clinician may recommend one based on age, risk factors, early menopause, or fracture history.

Who’s at Higher Risk?

Osteoporosis doesn’t have a single cause. Genetics, hormones, and lifestyle all play a role. Understanding risk factors helps women take informed action.

Non-modifiable risk factors

• Menopause (natural or surgical)

• Family history of hip or vertebral fractures

• Age 65+

• Low body weight or small frame

• Certain medical conditions (e.g., rheumatoid arthritis, endocrine disorders)

Modifiable risk factors

• Smoking

• High alcohol intake

• Low physical activity

• Chronically low energy intake

• Low dietary protein

• Certain medications (glucocorticoids, aromatase inhibitors, SSRIs, PPIs, certain anticonvulsants)

A clinician or PT can help determine which factors matter most in an individual case.

Why Osteoporosis Matters — and Why It’s Not a Life Sentence

The concern with osteoporosis is the increased likelihood of bone fractures, especially in the:

• Wrist

• Vertebrae

• Hip

Many vertebral fractures go unnoticed at first and can lead to progressive rounding of the upper back and loss of height over time. Hip fractures, especially in older adults, are associated with loss of independence and long recovery periods.

Here’s the encouraging part:
Research shows that fall prevention and strength improvements reduce fracture risk as effectively as changes in bone density [5–8]. Muscle strength, balance, power, and safe-movement strategies all play enormous roles in actual fracture risk, and every one of them is trainable at any age.

What This Means for You

Osteoporosis is measurable, manageable, and modifiable. A diagnosis can feel overwhelming, but knowledge and action change the trajectory:

• Strength training builds bone, supports posture, and protects joints

• Impact, introduced safely and gradually, stimulates bone remodeling

• Balance training dramatically reduces fall risk

• Nutrition fuels bone-building and muscle repair

• Medical treatments can slow bone loss or actively build bone

• Long-term, consistent training — like EWF programs — keeps you strong after PT or medical intervention

Our next resource, “Taking Action on Osteoporosis — Exercise, Nutrition, and Medical Support,” explores exactly what works and how you can build a stronger future.

References

1. Greendale GA, et al. Bone mineral density loss in the menopause transition: The Study of Women’s Health Across the Nation (SWAN). J Bone Miner Res. 2012.
https://doi.org/10.1002/jbmr.551

2. Cauley JA. Estrogen and bone health in men and women. JBMR. 2014.
https://doi.org/10.1002/jbmr.2154

3. International Society for Clinical Densitometry (ISCD). Adult Official Positions. 2023.
https://iscd.org/learn/official-positions/adult-positions/

4. National Osteoporosis Foundation. Bone Density Testing.
https://www.bonehealthandosteoporosis.org/patients/diagnosis-information/bone-density-examtesting/

5. Sherrington C, et al. Exercise for preventing falls in older people. BMJ. 2019.
https://doi.org/10.1136/bmj.l3513

6. Liu C-J & Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Review. 2021.
https://doi.org/10.1002/14651858.CD002759.pub2

7. Karinkanta S, et al. Effects of exercise on bone, fall prevention, and balance in postmenopausal women. Osteoporosis Int. 2009.
https://doi.org/10.1007/s00198-008-0815-z

8. Cadore EL & Izquierdo M. How to simultaneously optimize muscle strength, power, and balance in older adults. Age. 2013.
https://doi.org/10.1007/s11357-012-9381-5