The silent effect of menopause many women are unaware of
In the years around menopause women will experience the most rapid natural loss of bone mass in their lives. It makes good bone health essential, and there are things you can do.
When women have their final period and begin the transition towards menopause, a silent sideshow starts happening with little fanfare. There is a rapid loss of bone density that lasts about five years.
It’s caused by a drop in oestrogen and women can lose up to 20 per cent of their bone mass, leaving some susceptible to developing osteoporosis. The most at risk are women who enter menopause with low bone density in the first place and those who experience premature or early menopause or people who have certain medical conditions or lifestyle factors.
“Oestrogen is necessary for bone strength, for the bones to be strong, and without oestrogen the bones become weak and osteoporosis can occur and then fractures can result after that,” said Dr Shoshana Sztal-Mazer who is a member of the Healthy Bones Australia Medical and Scientific Advisory Committee and an endocrinologist at the department of endocrinology and diabetes at Alfred Health, Melbourne.
“The oestrogen drops a couple of years before menopause and years after, and that’s the steepest reduction in bone density that happens. After that it continues to reduce, but stabilises.”
Menopause is defined as 12 months after a woman’s final period; before that time she is still considered to be in perimenopause. Perimenopause itself can begin years before that and for some people they may experience symptoms similar to menopause, including night sweats and hot flushes, headaches, dry vagina or difficulty sleeping. But one of its main characteristics is disrupted periods where they no longer follow their regular cycle or there may be a noticeable change in flow.
Dr Elina Safro is a women’s health GP and chair of the education sub-committee of the Australasian Menopause Society.
“It’s can be a silent process,” she said of the bone density loss. “You don’t know until you actually get a minimal trauma fracture and this is when we start doing scans … but it’s very difficult to reverse the damage that’s already been done.
“One of the questions I always ask my menopausal patients is what age their mother went into menopause, or any sisters, and if there is any history in the family of osteoporosis or early fractures, because we know the loss of bone density can be genetically related.”
In Australia, it is estimated 1.2 million people have osteoporosis and a further 6.3 million have low bone density. Osteoporosis is a chronic disease where bones are brittle and at risk of fracture from minimal trauma (for example, tripping) or even no trauma. It tends to affect the hip, wrist, and spine the most. However, it can also affect other parts of the skeleton.
As well as the factors mentioned earlier, other risks for low bone density for women and men can include medical conditions such as thyroid issues, some eating disorders, auto-immune or digestive conditions such as coeliac disease, which may cause malabsorption, or people who do not or cannot consume dairy.
“We’re finding a lot of women in practice with low levels of vitamin D, so they may need some supplements with that or sun exposure in recommended doses,” Dr Safro said.
Calcium is essential for building and maintaining bones and strengthens bones by combining with other minerals to form hard crystals.
“Calcium is terribly important, and it’s important to pay attention to dietary calcium intake … resistance exercise is also very important, meaning that you stress those long bones, because by stressing them, you promote the generation of new bone,” Dr Safro said.
According to Healthy Bones Australia, almost 99 per cent of the body’s calcium is found in the bones while a small amount is absorbed into the blood and used for the healthy functioning of the heart, muscles, blood and nerves.
If you don’t get enough calcium through your diet, your body will take what is needed from your bones for use in other parts of the body. That can lead to a loss of bone density and increase your risk of developing osteoporosis.
Good bone health also comes from good lifestyle factors, including other dietary factors like getting enough protein and avoiding substances known to be bad for health.
“The general treatment that we can do is what everybody should be doing at all times in their life, which is avoiding toxins to the bones like smoking or (having) more than three alcoholic drinks a day, making sure that they’re doing adequate progressive resistance exercise training and having enough calcium, which is usually in the form of dairy as well as enough vitamin D balanced, of course, with being sun smart,” Dr Sztal-Mazer said.
For people with malabsorption or digestive concerns, doctors recommend seeking advice from a dietitian. For women who begin menopause early or have low bone density when they enter the transition, they may be offered Menopausal Hormone Therapy.
Not all countries approve MHT for the prevention of bone loss during menopause and most doctors here say it is not recommended to women who do not experience adverse symptoms or have low bone density or other risk factors.
In Australia, a revised version of the The Practitioner’s Toolkit for Managing the Menopause does recommend the therapy in post-menopausal women for the prevention of bone loss and fractures. Professor Susan Davis is one of the authors of the toolkit, which is designed for use by medical practitioners but is also available to the public.
National bone density screening doesn’t happen in Australia until the age of 70. However, Professor Davis said she always suggested it to younger patients with risk factors during their menopause consultation.
“If I’ve got a patient who I’m going to offer hormone therapy to who has got really bad symptoms, I’m probably not going to do a bone density (test), because I’m going to give hormones anyway,” Professor Davis said.
“But say there’s a 49 or 50 or 52-year-old lady who presents with no symptoms, I’ll then do a bone density test. And if her bone density is on the lower side of normal, I will review if there are other factors contributing to her low bone density I should be treating first, like vitamin D deficiency, like malabsorption, like a whole range of things, and if that’s not present … I would also discuss the use of hormone replacement therapy to prevent further bone loss. And I think that’s a very valid indication.”
One person dedicated to building bone strength through exercise is Professor Belinda Beck. She runs The Bone Clinic in Brisbane and is a member of the Menzies Health Institute Queensland at Griffith University and said the earlier people considered their bone health, the better.
“We all have a genetic predisposition to develop a certain amount of bone, and if you have a nice healthy diet and good exercise when you’re a kid, you’ll develop that amount of bone by the time you’re about 20 years old,” she said.
“As we get older, and really as we get more sedentary, we lose bone across our life. In my opinion, the No.1 most important thing is doing the right exercise.”
The right exercises include weight-bearing, resistance and balance techniques. Professor Beck also developed the Onero exercise program specifically for bone health, which has been backed by Healthy Bones Australia and expanded nationally and internationally. She said it was important people who did the program be supervised by well-trained professionals who are accredited, due to safety.
“If you’re doing it by yourself and don’t know what you’re doing, or someone else who doesn’t know what they’re doing, like if a personal trainer with very minimal qualifications is guiding you, they won’t know if you’ve got a pelvic floor prolapse or frozen shoulder or back problems, and they don’t have that clinical knowledge.
“Participants are discovering that not only can you grow bone when you are older, but you’re getting all these other amazing benefits by lifting heavy; your muscles are getting stronger.
“The sooner you start doing it, the better exercise is going to be the most powerful stimulus. But you do need to make sure that you’re eating the right food, so you’re getting the building blocks so your bones have got something to work with.”
Dr Safro agreed exercise was important for bone health and also recommended activities including dancing.
“If we do some regular dancing that might be useful. But you know, things like free weights, things like jogging, things like walking up the stairs, not taking a lift, that stresses out the bones. I’m not sure if walking qualifies, but certainly it’s good across all the other areas of maintaining cardiovascular fitness, and also, very importantly, when we go into an older age group. Walking can help promote healthy muscle mass and steady balance, in addition to a possible increase of bone mass.”
Good muscle mass plays an important role in bone health because it can help with balance and prevent falls, which can be fatal as we age. According to the World Health Organisation, falls are the second leading cause of unintentional injury deaths worldwide.
In Australia, 364 older Australians are hospitalised as a result of a fall each day and 14 people die.
More information about bone health and menopause can be found on Healthy Bones Australia and the Australasian Menopause Society websites.
