The window we should not miss

Tomorrow, I turn a year older. After last year’s milestone birthday, the subsequent ones are still joyous occasions, but they also oblige us to think about how we are aging and what we hope to keep doing in the years ahead. For me, that includes staying strong and healthy to enjoy life with my family, to serve patients, to teach, and to travel. It also means paying attention to changes we cannot see, including those happening inside our bodies.

In my article earlier this month, “Before the Bones Grow Old,” I wrote about building strong bones in childhood and adolescence. Good nutrition and physical activity help establish the foundation we carry into adulthood. As women my age navigate through perimenopause, this brings another opportunity to act: preserving that strength as our hormones change.

We often associate perimenopause brings irregular periods, hot flashes, disrupted sleep, and mental or emotional changes. Some women experience irritability, anxiety, mood changes, difficulty concentrating, or “brain fog.” Bone loss receives less attention because it is silent. You can’t feel your bones getting weaker as estrogen levels decline.

This process can accelerate before menstruation stops completely. The Study of Women’s Health Across the Nation found that bone loss was greatest from about one year before the final menstrual period until two years afterward. Waiting until we feel “old enough” to worry about osteoporosis may mean missing an important opportunity for prevention.

This is why I encourage women to discuss hormone replacement therapy, also called menopausal hormone therapy, with their doctors. Treatment with estrogen prevents bone loss and reduces fracture risk, while also treating hot flashes and night sweats. For appropriately selected women, these benefits can make treatment a valuable part of care.

The benefit-to-risk balance is generally favorable for healthy women younger than 60 or within 10 years of menopause onset who have no contraindications to hormonal therapy. Treatment can begin during perimenopause when indicated and women need not wait until periods have stopped for a full year to seek help.

The decision requires an individual assessment. A history of breast cancer, blood clots, stroke, unexplained vawwginal bleeding, or significant liver disease may rule out hormonal therapy. Women with a uterus generally need a progestogen alongside estrogen to protect the uterine lining. Hormone therapy is not contraception, and its benefits and risks should be reviewed regularly. For women who cannot use hormones, other proven, effective treatments are available when fracture risk warrants medication.

Bone density testing (DXA) should not be postponed because a woman is younger than 65. DXA can detect low bone mass before the first fracture. While age 65 is the routine screening threshold, you don’t have to wait until then.

The International Society for Clinical Densitometry recommends testing women in the menopausal transition when clinical fracture risk factors are present: a family history of a parent with osteoporosis or fracture, having a low body weight, a previous fragility fracture, high-risk medication use (such as steroids), or having any condition associated with bone loss. Assess risk early rather than waiting for a fracture.

Daily habits remain essential. Aim for adequate calcium, preferably from food: about 1,000 milligrams daily through age 50 and 1,200 from age 51 onward. Milk, yogurt, calcium-fortified alternatives, and fish eaten with their bones can help. Supplements should fill dietary gaps. Adequate vitamin D supports calcium absorption; requirements and supplementation should be individualized.

Make room for brisk walking, stair climbing, or dancing, together with resistance exercises at least twice weekly. Strong muscles support mobility and balance, while loading the skeleton helps maintain bone strength. Eat enough protein and avoid crash diets that sacrifice muscle along with weight.

Avoid smoking, limit alcohol, and moderate intake of sodium and caffeine, especially when calcium intake is poor. Review medicines and conditions that affect bone health. Addressing sleep problems can also make regular exercise and healthier eating easier to sustain.

As I welcome another birthday, I am reminded that caring for our future selves involves decisions made today. The bones we built when we were young deserve continued attention through midlife. Perimenopause is a good time to ask questions, assess risk, and make a plan that helps us remain active and independent for years to come.