If you take one thing from this post, let it be this: you don't need to wait until there's a problem to start talking about your bones.
Most women I see haven't given their bone health a second thought. And why would they? Bone loss is silent. You can't feel it happening. For a lot of women, the first time it comes up is after a bone density scan in their 60s or 70s, or worse, after a fracture.
By then, we're playing catch up. The years where we have the most room to make a difference are the ones before menopause, when most of us aren't thinking about it at all.
1. Your bones change before you feel anything
Bone is living tissue. Your body is constantly breaking down old bone and building new bone, and estrogen plays an important role in keeping that process balanced.
As estrogen starts to fluctuate and then decline in perimenopause, that balance shifts. The SWAN study, which followed women through the menopause transition, found that bone loss picks up about a year before the final period, averaging roughly 2% a year at the spine. Over the transition, that adds up to about 10% on average, and up to 20% for some women. That's why I think of perimenopause as the window to get ahead of it, not the time to wait and see.
2. Why waiting for a DEXA scan isn't a plan
Bone density (DEXA) scans are ordered by your family doctor or nurse practitioner, and they generally follow Osteoporosis Canada's current guideline. It suggests screening at age 70 if you have no risk factors, between 65 and 69 if you have one risk factor, and between 50 and 64 if you've had a fracture or have two or more risk factors.
Those guidelines exist for good reasons. But if you're 45 and healthy, you're likely decades away from your first scan. That doesn't mean there's nothing to talk about in the meantime.
It also helps to know about FRAX. FRAX is a tool your healthcare provider can use to estimate your 10-year risk of a major fracture. It looks at things like your age, body size, previous fractures, family history, smoking, alcohol and certain medications, and it becomes more accurate when it's combined with a bone density result. Two of those, smoking and alcohol, are risk factors you can start working on today. If you have risk factors, asking about your FRAX score is a great way to start the conversation.
3. What you can measure now: body composition
Before you're eligible for a DEXA scan, one of the most useful things I look at with my patients is body composition.
In my practice, I use a SECA body composition scan to track lean muscle mass and percent body fat. Muscle and bone are closely connected. Muscle pulls on bone, and that pull is one of the signals that tells your body to keep bone strong. In midlife, many women lose muscle quietly, often before anything changes on the scale.
A baseline scan gives you a starting point. It shows whether you're holding onto lean muscle, and it gives you something real to track as you make changes. This matters even more if you're losing weight. Weight loss, especially rapid weight loss, is linked to more bone loss and a higher fracture risk, so protecting lean muscle while you lose fat is key. With so many women now using GLP-1 medications, this is a conversation I'm having more and more often.
4. Strength and movement are non-negotiable
If I could get every woman in her 40s to do one thing for her bones, it would be resistance training.
Osteoporosis Canada recommends progressive resistance training, along with balance and functional training, at least twice a week. "Progressive" is the key word. Your muscles and bones respond to a challenge, so the goal is to gradually lift a little heavier over time.
Movement in general matters too. Walking, taking the stairs, carrying your groceries and getting up from your desk all count. Bones respond to load, and a body that moves regularly sends a better signal than one that sits most of the day.
If you're new to strength training, or you're not sure where to start, working with a qualified trainer is worth it. They can help you build up safely, use good form and keep progressing. I'll be sharing more about how I approach strength training in a future post.
5. Calcium and protein: know where yours is coming from
Calcium is one of the most common things I review with patients, and the answer isn't always "take a supplement."
Osteoporosis Canada recommends getting calcium from food first. For women over 50, the recommended total is 1,200 mg per day. That total includes everything: food, drinks and any supplement you take.
Here's what I see in practice. Many women either aren't getting enough, or they're taking a calcium supplement on top of a diet that's already covering most of what they need. That's why I like to go through what you're actually eating before adding anything. Dairy, fortified plant milks, canned salmon or sardines with the bones, tofu made with calcium, almonds and leafy greens can all add up.
If you do need a supplement to fill the gap, smaller doses absorb better. Taking about 500 mg or less at a time is generally the way to go.
A fun one I sometimes mention: prunes. In a 12-month study of postmenopausal women, eating about 5 to 6 prunes a day helped preserve bone density at the hip compared with women who didn't eat them. It's a small study, prunes didn't build new bone, and more wasn't better, but it's an easy, tasty addition.
Don't forget protein. Bone isn't just calcium. Protein is a big part of your bone structure, and it's essential for keeping the muscle that protects your bones. The minimum recommended intake is 0.8 g per kg of body weight, and many bone health experts suggest aiming higher in midlife, around 1.0 to 1.2 g per kg. If you avoid dairy or eat mostly plant-based, this is one to pay extra attention to.
6. Vitamin D: especially here in Calgary
Vitamin D helps your body absorb calcium and supports bone health. In Calgary, our long winters and northern latitude make it hard to get enough from sunlight for much of the year.
Osteoporosis Canada suggests a minimum of 400 IU of vitamin D as a daily supplement, along with vitamin D rich foods. Some people need more than that, depending on their health history, so this is a good one to review with your healthcare provider.
7. Where hormone therapy fits
This is the question I get asked most often: does hormone therapy help protect your bones?
According to The Menopause Society's 2022 hormone therapy position statement, hormone therapy "has been shown to prevent bone loss and fracture." The same statement says that for most healthy women with symptoms who are under 60, or within 10 years of menopause, the benefits of hormone therapy outweigh the risks.
I'll be honest with you about where the research stands. I believe timing matters a lot, and that starting closer to the menopause transition can have a big impact on long-term bone health. But the research on timing is still evolving, and I'm not going to overstate it. What I can say is that if you're in perimenopause and dealing with symptoms, your bones are one more good reason to have the hormone conversation sooner rather than later.
Hormones aren't a replacement for strength training, nutrition or movement. They work best alongside them.
8. How to bring this up with your doctor
You don't need a symptom to ask about your bones. At your next appointment, you could say something like:
"I know I'm not due for a bone density scan yet, but I'd like to understand my risk. Can we go over my risk factors, and is a FRAX score something we could look at?"
It keeps the conversation open, and it puts your bone health on the table before it becomes a problem.
The bottom line
Bone health isn't something to start thinking about at 70. The habits you build in your 40s, and the conversations you have now, shape the bones you'll be living in for decades.
Measure what you can. Lift something heavy. Know where your calcium and vitamin D are coming from. And don't wait for a fracture to have the conversation.
Your next step
October 20 is World Osteoporosis Day, which makes this a great month to start.
If you're in perimenopause and wondering how much your symptoms are affecting your life, take the Perimenopause Impact Score. It's a short quiz that helps you see where you're at.
If you live in Alberta or BC and want to talk through your next step, you can book a free Hormone Clarity Call. It's 10 to 15 minutes to go over your symptoms and figure out what makes sense for you.
I see patients in person in Calgary at BioRevive Regenerative Medicine and the Mount Royal University Injury & Prevention Clinic, as well as in Fernie, BC. I also offer virtual hormone care for women anywhere in Alberta and BC.
Book an appointment
Dr. Tricia Breckon, ND Founder, BioRevive
This article is for general education and isn't a substitute for individual medical advice. If you have questions about your bone health, please speak with a qualified healthcare provider.
