Why do bones become more brittle after menopause, and what can help?

After menopause, oestrogen levels drop sharply, and that is the primary reason bones become more brittle. Oestrogen normally inhibits the breakdown of bone tissue. Once that brake is removed, breakdown outpaces formation. Bone loss is greatest in a period of roughly 3 years around the final menstrual period, and during this time the internal bone structure also deteriorates, not just the density. Additional risk factors include smoking, low body weight, excessive alcohol use, older age, and certain diseases or medications. These factors compound the oestrogen deficiency.

The foundation for every woman after menopause is diet and exercise. Sufficient calcium, vitamin D and protein in your diet, regular weight-bearing activity (walking, strength training), not smoking, and moderate alcohol use. This is not a substitute for medication when it is needed, but the foundation on which everything else rests.

Hormone therapy (oestrogen, possibly combined with a progestogen) is the only bone-protective treatment shown to work regardless of your baseline risk. It reduces the risk of fractures at all sites by 20 to 40%. The benefit-risk balance depends strongly on the type of hormone, the dose, the form of administration, and your personal situation. Some of the earlier safety concerns later turned out to be more nuanced than originally thought. Always discuss this with your doctor, as it is not a one-size-fits-all decision.

If you already have osteoporosis or a clearly elevated fracture risk, several approved medications are available. Bisphosphonates and denosumab inhibit bone breakdown. Teriparatide, abaloparatide and romosozumab instead stimulate bone formation and are intended for more severe cases. Your doctor determines which treatment is most suitable based on your risk profile.

Research has also been conducted into supplements. Resveratrol (75 mg twice daily, 12 months) led in one randomised trial to a small improvement in bone density in the spine and hip, and less bone breakdown, particularly in women who also took calcium and vitamin D. Shilajit extract inhibited bone loss in a dose-dependent manner in a small study (60 women) involving women with mild bone loss. Both findings are preliminary and each based on a single small study. They are interesting but do not yet justify a recommendation alongside the proven approach.