Saturday, August 01, 2026

by Adam Irvine, Physicians Office Resource 

For many women, menopause represents one of the most consequential transitions in skeletal health. Hot flashes, sleep disruption, mood changes, weight concerns, and genitourinary symptoms may dominate the clinical conversation, but declining estrogen is also producing changes that patients cannot see or feel: accelerated bone remodeling and loss of bone mineral density (BMD).

That makes the menopausal transition an important opportunity for primary care physicians to assess bone health before osteoporosis announces itself with a fracture.

The challenge is not simply determining whether to order a dual-energy x-ray absorptiometry (DXA) scan. Clinicians must decide which patients warrant earlier screening, how fracture risk should influence interpretation of BMD, when vitamin D testing is appropriate, and when low bone density should trigger an evaluation for secondary causes.

At the same time, emerging evidence has challenged the assumption that more testing is always better. In particular, routine measurement of serum 25-hydroxyvitamin D [25(OH)D] in otherwise healthy adults is no longer supported by several major guidelines.¹˒²

For primary care physicians, the goal should therefore be a more targeted strategy: identify women at increased skeletal risk, use DXA and laboratory testing when the results are likely to change management, and intervene before the first fragility fracture occurs.

Menopause Is a Critical Inflection Point for Bone

Bone is constantly being remodeled through the coordinated activity of osteoclasts and osteoblasts. Estrogen is an important regulator of this process, helping restrain bone resorption.

During the menopausal transition, declining estrogen shifts remodeling toward increased resorption. Bone loss accelerates around menopause and can remain particularly pronounced during the first several postmenopausal years. The National Institutes of Health notes that declining estrogen during menopause and for approximately five years afterward results in bone resorption occurring faster than bone formation.³

This biological transition does not mean every woman entering menopause requires immediate DXA screening. It does mean that menopause should trigger a deliberate assessment of skeletal risk.

A 52-year-old woman entering menopause with a normal body mass index, no fracture history, no relevant medications, and no major risk factors is very different from a 52-year-old woman with low body weight, a previous low-trauma fracture, chronic glucocorticoid exposure, or a parental history of hip fracture.

The menopausal visit provides an opportunity to distinguish between them.

Start With Clinical Risk, Not a Test

A bone-health assessment can begin with information already available during routine primary care.

Age, menopausal status, body weight, previous fractures, family history, smoking, alcohol consumption, physical activity, falls, medications, and conditions associated with secondary osteoporosis should all contribute to the assessment.

Particular attention should be given to women who experience premature ovarian insufficiency or early menopause, because they experience estrogen loss earlier and may have a longer lifetime exposure to accelerated skeletal loss.

Medication history is equally important. Chronic systemic glucocorticoid use is perhaps the most familiar example, but anticonvulsants, aromatase inhibitors and other therapies can also affect bone health.

The International Society for Clinical Densitometry (ISCD) recommends BMD testing in women age 65 and older and in younger postmenopausal women when risk factors for low bone mass are present, including low body weight, previous fracture, high-risk medication use, or a disease or condition associated with bone loss. The ISCD also identifies women in the menopausal transition with clinical fracture risk factors as candidates for BMD testing.⁴

The key is recognizing that menopause is not a binary indication for testing. It is a clinical signal to assess risk.

Who Should Receive a DXA Scan?

The U.S. Preventive Services Task Force (USPSTF) updated its osteoporosis screening recommendation in January 2025.

The USPSTF recommends screening all women age 65 years and older for osteoporosis to prevent osteoporotic fractures. For postmenopausal women younger than 65, it recommends screening those who are at increased fracture risk as determined through clinical risk assessment.⁵

For women younger than 65, the USPSTF describes a two-step approach.

First, clinicians identify the presence of one or more risk factors in addition to postmenopausal status. These include low body weight, parental history of hip fracture, cigarette smoking, and excessive alcohol consumption. Women with one or more risk factors can then be evaluated with a validated clinical risk-assessment tool to determine whether DXA is warranted.⁵

Importantly, these screening recommendations apply to adults without known osteoporosis or a previous fragility fracture. Patients with diseases or medications known to cause secondary osteoporosis require individualized evaluation outside the routine screening framework.⁵

Central DXA of the hip and lumbar spine remains the established standard for osteoporosis diagnosis.⁵

In postmenopausal women, a T-score of −2.5 or below at an appropriate skeletal site is consistent with densitometric osteoporosis. A T-score between −1.0 and −2.5 is generally classified as low bone mass, historically referred to as osteopenia.

But the T-score is only part of the story.

Why Fracture Risk Matters as Much as BMD

A common misconception is that fracture risk becomes clinically meaningful only when a patient’s T-score reaches −2.5.

In reality, many fragility fractures occur in people whose BMD does not meet the densitometric definition of osteoporosis. The USPSTF specifically notes that most fragility fractures occur in individuals with T-scores above −2.5.⁵

Age is particularly important. Two women can have identical femoral-neck BMD measurements but substantially different fracture risks because of differences in age, fall risk, previous fractures, medication exposure, and other clinical factors.

This is where fracture-risk assessment becomes valuable.

The Fracture Risk Assessment Tool (FRAX) estimates a patient’s 10-year probability of hip fracture and major osteoporotic fracture using demographic and clinical factors, with the option to incorporate femoral-neck BMD. FRAX considers factors including age, sex, weight, height, previous fracture, parental hip fracture, smoking, glucocorticoid exposure, rheumatoid arthritis, secondary osteoporosis, and alcohol consumption.⁵

FRAX is useful, but it should not replace clinical judgment. It does not fully capture every contributor to fracture risk, including some aspects of fall risk, frailty, glucocorticoid dose, and certain medical conditions.⁵

The practical lesson is straightforward: treat the patient, not the T-score.

Vitamin D: An Important Nutrient, but Not an Automatic Test

Few laboratory tests have become as closely associated with bone health as 25(OH)D.

Vitamin D is essential for calcium absorption and normal skeletal mineralization, and severe deficiency can contribute to osteomalacia and abnormalities of calcium metabolism. Yet the widespread use of vitamin D testing has outpaced evidence supporting universal screening.

The Endocrine Society’s 2024 guideline on vitamin D for disease prevention recommends against routine 25(OH)D testing in generally healthy adults.¹ The guideline emphasizes that clinical trials have not established specific 25(OH)D concentrations that provide outcome-specific benefits in otherwise healthy populations.

This has an important implication for menopause-focused care.

Menopause alone is not an indication for routine vitamin D screening.

A healthy 52-year-old woman should not necessarily receive a vitamin D test simply because she has entered menopause. Testing becomes more useful when there is a specific clinical question—for example, suspected osteomalacia, hypocalcemia, malabsorption, metabolic bone disease, or another established indication.

The USPSTF has similarly concluded that evidence is insufficient to determine the balance of benefits and harms of screening asymptomatic, community-dwelling adults for vitamin D deficiency.²

This distinction between population screening and diagnostic evaluation is essential. A recommendation against routine screening should not be interpreted as a recommendation against testing patients in whom vitamin D status is clinically relevant.

Vitamin D Supplementation: More Is Not Necessarily Better

The enthusiasm surrounding vitamin D has also contributed to widespread supplementation, sometimes at doses far exceeding nutritional requirements.

For generally healthy adults ages 51 through 70, the Recommended Dietary Allowance (RDA) for vitamin D is 600 IU (15 μg) daily. For adults older than 70, the RDA increases to 800 IU (20 μg) daily.⁶

The Endocrine Society’s 2024 guideline suggests against routine empiric vitamin D supplementation above established dietary reference intakes in generally healthy adults ages 50 through 74.¹

Large randomized trials have also tempered expectations that vitamin D supplementation alone will prevent fractures in generally healthy, vitamin D–replete adults. In the VITAL ancillary fracture study, supplementation with 2,000 IU of vitamin D₃ daily did not significantly reduce total, nonvertebral, or hip fractures compared with placebo.⁷

This does not mean vitamin D is unimportant.

Rather, it reinforces the distinction between ensuring adequate nutrition and treating a documented or clinically suspected deficiency. Patients with osteoporosis, malabsorption, metabolic bone disorders, or other relevant conditions may require individualized assessment and supplementation.

Medication reconciliation should therefore include over-the-counter vitamins and supplements. Patients may be taking substantially more vitamin D than their physicians realize.

Calcium: Think Dietary Intake Before Automatic Supplementation

Calcium remains fundamental to skeletal mineralization, but supplementation should not automatically substitute for dietary assessment.

The recommended calcium intake for women ages 51 through 70 is approximately 1,200 mg per day, and adults age 71 and older also require approximately 1,200 mg daily.⁸

A brief dietary history can help determine whether supplementation is necessary. Milk, yogurt, cheese, fortified beverages, calcium-set tofu, certain leafy vegetables, and canned fish containing edible bones can contribute meaningfully to intake.

The evidence that calcium and vitamin D supplements prevent fractures in otherwise healthy, community-dwelling adults is mixed.³˒⁶ For this reason, the objective should be nutritional adequacy rather than reflexively prescribing high-dose supplementation to every postmenopausal patient.

Patients who cannot meet calcium requirements through diet may benefit from supplementation to close the gap between dietary intake and recommended intake.

When Low Bone Density Should Trigger Laboratory Evaluation

An abnormal DXA should sometimes be considered the beginning of the diagnostic process rather than its conclusion.

Menopause and aging account for a large proportion of osteoporosis, but secondary causes of bone loss are common enough that physicians should remain alert for them—particularly when osteoporosis occurs earlier than expected, appears severe relative to age, progresses rapidly, or is accompanied by other clinical abnormalities.

Laboratory evaluation should be individualized, but depending on the clinical context may include serum calcium, renal function, phosphorus, alkaline phosphatase, complete blood count, thyroid-stimulating hormone, and 25(OH)D.

Additional testing may include parathyroid hormone, evaluation for celiac disease or malabsorption, serum or urine protein electrophoresis, urinary calcium, or other studies when history and examination suggest a secondary process.

The most useful question is not, “Which osteoporosis panel should I order?”

It is, “Could there be a reversible or treatable contributor to this patient’s bone loss?”

Hyperparathyroidism, hyperthyroidism, chronic kidney disease, malabsorption, glucocorticoid exposure, nutritional deficiency, and other disorders can alter skeletal metabolism. Identifying one may significantly change management.

The Fragility Fracture Is a Diagnostic Clue That Should Not Be Missed

One of the most valuable pieces of bone-health information does not come from the laboratory or DXA scanner.

It comes from the patient’s history.

A fragility fracture is generally understood as a fracture resulting from a fall from standing height or less—an injury that would not ordinarily fracture healthy bone.⁵

A wrist fracture at age 58, for example, should not automatically be dismissed as an isolated orthopedic event. It may be an early manifestation of skeletal fragility.

Vertebral fractures can be even easier to miss. Some occur without a dramatic traumatic event and may present as height loss, kyphosis, or persistent back discomfort rather than an acute fracture complaint.

Asking about adult fractures, height loss, and previous imaging findings should therefore be part of menopause-focused bone assessment.

The importance of identifying these patients cannot be overstated. The Endocrine Society recommends pharmacologic treatment for postmenopausal women at high fracture risk, particularly those who have experienced a recent fracture.⁹

Exercise, Muscle and Fall Prevention Belong in the Bone Conversation

Bone strength is only one component of fracture prevention.

Muscle strength, balance, coordination, vision, medications, neuropathy, orthostatic symptoms, and the home environment influence whether a patient falls in the first place.

Weight-bearing physical activity and resistance exercise are therefore important not only because of their effects on the skeleton but also because they help preserve muscle and physical function.

This becomes increasingly important with age, when sarcopenia and osteoporosis can coexist.

Smoking cessation and avoidance of excessive alcohol intake should also be incorporated into counseling. Adequate protein and overall nutrition support muscle and skeletal health.

For older women at increased fall risk, fracture prevention should therefore be approached from both sides of the equation: preserve bone strength while reducing the likelihood and consequences of falls.

Where Menopausal Hormone Therapy Fits

Menopausal hormone therapy (HT) adds another layer to the bone-health discussion.

Systemic estrogen reduces the accelerated bone resorption associated with menopause and prevents bone loss. The Menopause Society recognizes prevention of bone loss and reduction of fracture risk among the indications for hormone therapy.¹⁰

However, the decision to initiate systemic HT should be individualized and should not be based solely on a DXA result.

Age, time since menopause, vasomotor symptoms, thromboembolic and cardiovascular risk, breast cancer risk, hysterectomy status, and patient preferences all contribute to the benefit-risk discussion.

The Endocrine Society suggests menopausal HT as an option for fracture prevention in appropriately selected postmenopausal women at high fracture risk who are generally younger than 60 years or fewer than 10 years beyond menopause, have bothersome menopausal symptoms, and do not have relevant contraindications.⁹

For a symptomatic woman early in the menopausal transition, preservation of bone mass may therefore be an additional benefit of treatment.

For an older woman with established osteoporosis and high fracture risk, osteoporosis-specific pharmacologic therapy is generally the more relevant conversation.

A Practical Menopause-Focused Testing Strategy

For primary care, bone-health assessment does not need to become complicated.

Begin with the history.

Determine menopausal status and age at menopause. Ask about adult fractures, height loss, parental hip fracture, smoking, alcohol use, weight changes, falls, exercise, calcium intake, medications, and conditions associated with secondary osteoporosis.

Then decide whether the patient meets criteria for DXA.

Women age 65 and older should be screened. In younger postmenopausal women, identify clinical risk factors and use risk assessment when appropriate to determine whether earlier DXA is warranted.⁵

If DXA demonstrates osteoporosis or unexpectedly low BMD, ask whether secondary causes should be investigated.

Order laboratory tests because they answer a clinical question—not because they are automatically associated with menopause.

The same principle applies to vitamin D. Routine screening of otherwise healthy women is not supported by current evidence, but targeted testing remains appropriate when vitamin D status could affect diagnosis or treatment.

Finally, address the modifiable factors that no laboratory test can replace: nutrition, resistance and weight-bearing exercise, smoking, alcohol, muscle strength, and fall prevention.

From Fracture Treatment to Fracture Prevention

Osteoporosis is often called a silent disease because patients may experience progressive skeletal deterioration without symptoms until a fracture occurs.

Primary care has an opportunity to change that trajectory.

Menopause creates a natural clinical checkpoint—a time to assess risk, identify patients who warrant DXA, reconsider medications and lifestyle factors, and recognize when additional laboratory evaluation is appropriate.

Importantly, better bone-health care does not necessarily mean ordering more tests.

It means ordering the right tests for the right patients.

DXA should be guided by age and clinical risk. Fracture-risk tools can add context but should not replace clinical judgment. Vitamin D testing should answer a meaningful clinical question rather than become a routine component of every menopause laboratory panel. Abnormal bone density should prompt consideration of secondary causes when appropriate.

And throughout the process, physicians should remember the outcome that matters most.

The goal is not simply to improve a T-score or normalize a laboratory value.

The goal is to prevent the fracture that changes a patient’s mobility, independence, and quality of life.

References

1. Demay MB, Pittas AG, Bikle DD, et al. Vitamin D for the prevention of disease: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2024;109(8):1907-1947. doi:10.1210/clinem/dgae290.
2. US Preventive Services Task Force. Screening for vitamin D deficiency in adults: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(14):1436-1442. doi:10.1001/jama.2021.3069.
3. National Institutes of Health Office of Dietary Supplements. Calcium: fact sheet for health professionals. Updated 2025. Accessed August 7, 2026.
4. International Society for Clinical Densitometry. 2023 ISCD Official Positions: Adult. Updated August 24, 2023. Accessed August 7, 2026.
5. US Preventive Services Task Force. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. JAMA. Published January 14, 2025.
6. National Institutes of Health Office of Dietary Supplements. Vitamin D: fact sheet for health professionals. Updated 2025. Accessed August 7, 2026.
7. LeBoff MS, Chou SH, Ratliff KA, et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-309. doi:10.1056/NEJMoa2202106.
8. National Institutes of Health Office of Dietary Supplements. Calcium: fact sheet for consumers. National Institutes of Health. Accessed August 7, 2026.
9. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. doi:10.1210/jc.2019-00221. Updated recommendations published 2020.
10. The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028.

Clinical Sidebar: Bone Health Testing at a Glance

DXA (Dual-Energy X-Ray Absorptiometry)
Consider when: Women are age 65 or older; younger postmenopausal women have increased fracture risk; patients have fragility fractures, high-risk medication exposure, or conditions associated with bone loss.
Clinical role: Primary diagnostic measurement of BMD and cornerstone of osteoporosis screening.

FRAX or Other Clinical Risk Assessment
Consider when: Evaluating fracture risk, particularly in postmenopausal women younger than 65 with clinical risk factors or when BMD alone does not adequately describe risk.
Clinical role: Estimates 10-year fracture probability and adds clinical context to BMD.

25-Hydroxyvitamin D [25(OH)D]
Consider when: There is an established clinical indication such as suspected deficiency in the context of metabolic bone disease, hypocalcemia, malabsorption, or another condition in which vitamin D status may change management.
Not routinely indicated: Universal screening of otherwise healthy adults solely because they have entered menopause.

Calcium and Metabolic Evaluation
Consider when: Osteoporosis, unexpectedly low BMD, abnormal calcium metabolism, renal disease, or another secondary cause is suspected.
Clinical role: Helps identify metabolic abnormalities and potentially reversible contributors to bone loss.

Targeted Secondary Osteoporosis Testing
Consider when: Bone loss is premature, severe, rapidly progressive, or inconsistent with the patient’s expected clinical risk.
Potential tests: Renal function, phosphorus, alkaline phosphatase, CBC, TSH, PTH, celiac testing, protein electrophoresis, urinary calcium, or other studies selected according to the clinical presentation.