Osteoporosis after the menopause: prevention and screening
In brief
Osteoporosis after the menopause (postmenopausal osteoporosis) affects almost one woman in three: the fall in oestrogen leads to rapid bone loss, which is greatest in the first years after the menopause. Bone densitometry (DXA) is the main test for assessing risk; it is reimbursed in postmenopausal women who have certain risk factors. According to the 2021 guidelines of the CNGOF (French College of Gynaecologists and Obstetricians) and the GEMVi (French Group for the Study of Menopause and Hormonal Ageing), menopausal hormone therapy prevents this bone loss and reduces the risk of fracture by 20 to 40%, while physical activity combining impact and muscle strengthening helps to preserve bone density.
Why does the menopause weaken bones?
Bone is a living tissue, constantly renewed. Oestrogens slow down its breakdown. At the menopause, their collapse upsets this renewal: bone is broken down faster than it is rebuilt.
According to the CNGOF and GEMVi guidelines, this bone loss is greatest in the first years after the menopause. It reduces bone mineral density and alters the microarchitecture of the bone, which becomes more fragile.
Osteoporosis is not painful until a fracture occurs. It is often discovered following a fracture after minimal trauma, such as a fall from standing height: wrist, vertebra, neck of the femur. Vertebral fractures may go unnoticed and show only as a loss of height or a rounding of the back.
What are the risk factors for osteoporosis?
The risk depends on bone density, but also on clinical factors:
- age;
- personal history of fracture after minimal trauma;
- hip fracture in a first-degree relative;
- early menopause, particularly before the age of 40;
- low body weight (body mass index below 19 kg/m²);
- long-term corticosteroid treatment;
- smoking, excessive alcohol consumption;
- certain diseases (hyperthyroidism, hyperparathyroidism, inflammatory rheumatic diseases, digestive diseases with malabsorption) and certain treatments (hormone therapy for breast cancer with aromatase inhibitors);
- risk of falling (balance problems, poor eyesight, sedentary lifestyle).
What is bone densitometry and who should have it?
Bone densitometry (or bone density scan, DXA) measures bone mineral density in the lumbar spine and the hip. It is a quick, painless test with low radiation exposure, performed lying down, without injection.
The result is expressed as a T-score, which compares bone density with that of a young adult woman:
| T-score | Interpretation |
|---|---|
| Above –1 | Normal bone density |
| Between –1 and –2.5 | Osteopenia (reduced density) |
| Less than or equal to –2.5 | Osteoporosis |
When is it reimbursed?
According to the Assurance maladie (French national health insurance, ameli.fr), a first bone densitometry is covered, on prescription:
- in the general population: in the event of a fracture occurring without major trauma, or of a disease or treatment that promotes osteoporosis (long-term corticosteroid treatment, hyperparathyroidism, etc.);
- in postmenopausal women, in the presence of at least one risk factor: fracture of the neck of the femur in a first-degree relative, body mass index below 19 kg/m², menopause before the age of 40, corticosteroid treatment for at least three months.
A second test is covered in certain situations, in particular when stopping an osteoporosis treatment, or 3 to 5 years after a first normal test if new risk factors have appeared.
And at the start of the menopause, without risk factors?
According to the CNGOF and the GEMVi, bone densitometry may be offered on a case-by-case basis at the start of the menopause, when its result is likely to change management, in particular the decision to start hormone therapy.
Whether you need bone densitometry is discussed at the consultation at the practice; the scan is carried out at an imaging centre.
Is the FRAX score useful?
FRAX is an online tool that estimates the ten-year probability of fracture based on age, weight, medical history and, if known, bone density. It is used to help decide on treatment in certain older women.
However, the CNGOF and GEMVi guidelines emphasise that at the start of the menopause, clinical risk factors, alone or combined in FRAX, do not reliably predict fractures or osteoporosis. In a recently postmenopausal woman, measuring bone density remains the preferred test.
How can osteoporosis be prevented after the menopause?
Physical activity
The 2021 French guidelines state that exercises combining weight-bearing activities with impact (brisk walking, climbing stairs, adapted jumping, dancing) and muscle strengthening are the most effective for maintaining or improving bone density and preventing fractures. The effect appears after at least 12 weeks of practice and is only maintained if the activity is continued. Reducing time spent sitting is beneficial, whatever the level of activity.
Physical activity also improves balance and muscle strength, which reduces the risk of falling.
Calcium and vitamin D
According to the HAS (French National Authority for Health), any calcium or vitamin D deficiency should first be corrected, through diet and, if necessary, supplementation. Dairy products, certain calcium-rich mineral waters, green vegetables and nuts contribute to calcium intake. Vitamin D is produced by skin exposed to sunlight; supplementation is often offered, particularly in winter or in case of insufficient exposure.
Other measures
- Stopping smoking, moderating alcohol.
- Maintaining sufficient body weight.
- Preventing falls: lighting, removing slippery rugs, correcting eyesight, caution with sleeping tablets.
What is the role of menopausal hormone therapy?
According to the CNGOF and the GEMVi, menopausal hormone therapy (MHT) prevents bone loss and deterioration of the microarchitecture at the start of the menopause. It reduces the risk of fracture by 20 to 40% at all sites, whatever the initial level of risk, with an effect that depends on the oestrogen dose.
When it is prescribed to prevent osteoporosis in a woman at risk, a new bone densitometry is advised after two years of treatment, on the same machine, to check that there has been no significant bone loss.
When MHT is stopped, bone loss resumes temporarily; within 2 to 5 years the risk of fracture returns to that of an untreated woman of the same age. This is why bone densitometry is recommended when treatment is stopped, in order to discuss, if necessary, switching to another treatment.
The decision to start MHT is based on the overall benefit/risk balance (symptoms, cardiovascular risk, breast cancer risk), discussed individually.
What are the other treatments for osteoporosis?
According to the HAS, drug treatment for osteoporosis is only indicated when the risk of fracture is high. Slightly low bone density, on its own, is not enough to justify treatment.
| Treatment | Role according to the HAS |
|---|---|
| Bisphosphonates (alendronate, risedronate, zoledronate) | First line in postmenopausal osteoporosis; dental check-up before starting, then at least once a year |
| Raloxifene | First line, reserved for women at low risk of peripheral fracture (spinal osteoporosis, under 70, no risk of venous thrombosis) |
| Romosozumab | First line only in postmenopausal women under 75 with severe osteoporosis and a previous severe fracture, and no history of coronary heart disease; prescribed only by rheumatologists and geriatricians |
| Teriparatide | Only if there are at least two vertebral fractures |
| Denosumab (injection every 6 months) | Second line, following bisphosphonates; when it is stopped, a bisphosphonate must be given to follow it |
These treatments are most often prescribed or coordinated with a rheumatologist.
Frequently asked questions
From what age should a bone density scan be done?
There is no fixed age. The test is indicated according to risk factors; it may also be offered at the start of the menopause when its result may change management.
Is osteopenia a disease?
Osteopenia means that bone density is below normal without reaching the threshold for osteoporosis. On its own it does not justify drug treatment, but it is a reason to strengthen preventive measures and to assess other risk factors.
Should calcium be taken systematically after the menopause?
No. The priority is sufficient dietary intake. Calcium or vitamin D supplementation is offered in case of deficiency or insufficient intake.
Is hormone therapy enough to protect the bones?
It effectively prevents bone loss for as long as it is taken. After stopping, bone loss resumes: a check of bone density is then recommended in women at risk.
Is walking enough?
Walking is beneficial, but French guidelines show that combining impact activities with muscle strengthening is more effective for bone.
References
- Pouillès JM, et al. [Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. Gynecol Obstet Fertil Senol, 2021. doi:10.1016/j.gofs.2021.03.015 — PMID 33753297
- Duclos M, et al. [Effects of physical activity and decreased sedentary behaviours in menopausal women. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. Gynecol Obstet Fertil Senol, 2021. doi:10.1016/j.gofs.2021.03.013 — PMID 33753298
- Haute Autorité de santé. Les médicaments de l'ostéoporose [Osteoporosis medicines]. Appropriate-use guidance sheet, updated January 2023. https://www.has-sante.fr/jcms/c_1751307/fr/les-medicaments-de-l-osteoporose
Dr Olivier KadochObstetrician-gynaecologist and gynaecological surgeon in Paris (16th and 5th arrondissements). Former chef de clinique-assistant (senior registrar) at the Paris public hospitals (AP-HP); individually accredited by the French National Authority for Health (HAS). RPPS 10003957809. Background and practice locations
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