Perimenopause Bone Density Guide: What You Lose, When, and What Actually Helps

The Bone Loss You Cannot Feel

Bone loss is one of the most medically significant things that happens during the menopausal transition, and it is almost entirely invisible until something goes wrong. You do not feel your bones becoming thinner. There is no pain signal, no warning. The first sign for many women is a fracture from a fall that would not have broken a bone ten years earlier. Understanding what is happening and when gives you a real opportunity to change the outcome. This is one of the clearest areas in perimenopause medicine where early action makes a measurable long-term difference.

How Much Bone You Lose and When

Estrogen plays a critical role in regulating bone remodeling. It slows the activity of osteoclasts, the cells that break down bone, and supports the osteoblasts that build it up. As estrogen declines during perimenopause, the balance tips toward more breakdown and less rebuilding.

The most rapid period of bone loss occurs in the two years before and the two years after the final menstrual period. During this window, some women lose 2 to 3 percent of their bone density per year. For context, the bone loss typical of general aging is closer to 0.5 to 1 percent per year. The perimenopause and early postmenopause window represents an outsized, concentrated risk.

Over the first five to seven years after the final period, it is possible to lose 10 to 20 percent of peak bone density. This is why taking bone health seriously before your final period, not after, is the highest-impact timing.

DEXA Scans and T-Scores Explained

A DEXA scan (dual-energy X-ray absorptiometry) is the standard test for measuring bone density. It takes about 15 minutes, is painless, and uses very low levels of radiation. It measures bone density at the hip and lumbar spine, the two sites most predictive of fracture risk.

The result is reported as a T-score. The T-score compares your bone density to the expected density of a healthy young adult at peak bone mass.

A T-score of 0 to -1 is normal. A T-score of -1 to -2.5 indicates osteopenia, meaning below-normal bone density that is not yet in the osteoporosis range. A T-score of -2.5 or lower indicates osteoporosis.

Osteopenia is not a disease. It is a finding that indicates elevated risk and warrants active management. Many people are told they have osteopenia and given no further guidance, which is a missed opportunity. If you receive an osteopenia result, ask specifically: what should I be doing now, and when should I be rescanned?

Current guidelines generally recommend a baseline DEXA scan at menopause for women with risk factors, and by age 65 for all women. If you have additional risk factors, such as celiac disease, a history of corticosteroid use, or a family history of osteoporosis, earlier screening makes sense.

Calcium: From Food and Supplements

Calcium is the primary mineral in bone. Getting enough of it does not guarantee strong bones, but getting too little over years guarantees worse ones.

For perimenopausal women, a total calcium intake of 1,200 mg per day is widely recommended. The key word is total: this includes what you get from food plus any supplement. Most healthcare providers now suggest prioritizing food sources first, with supplements filling gaps rather than replacing dietary calcium entirely.

The best food sources of calcium include dairy products (one cup of milk or yogurt provides approximately 300 mg), sardines and canned salmon with bones (around 200 to 350 mg per serving), firm tofu made with calcium sulfate, fortified plant milks, and dark leafy greens like kale, bok choy, and broccoli.

If you use calcium supplements, calcium citrate is better absorbed than calcium carbonate, particularly if your stomach acid is lower or if you take acid-reducing medication. Split doses of 500 mg or less absorb more efficiently than a single large dose.

Studies have examined whether calcium supplements increase cardiovascular risk, and the results are mixed enough that total dietary plus supplement calcium in the recommended range, rather than very high supplement doses alone, is currently considered the safer approach.

Vitamin D: The Absorption Partner

Vitamin D is essential for calcium absorption in the gut. Without adequate vitamin D, you can consume plenty of calcium and still absorb too little of it. Vitamin D also has direct effects on bone cell activity independent of calcium.

Vitamin D is made in the skin in response to sun exposure, but many people in northern latitudes, those who spend limited time outdoors, or those with darker skin tones have consistently low vitamin D levels. Blood testing is the only reliable way to know your level. A 25-hydroxyvitamin D test is the relevant measurement, and most practitioners target a blood level of 40 to 60 ng/mL (100 to 150 nmol/L).

For most adults, a supplement of 1,000 to 2,000 IU of vitamin D3 per day is a reasonable starting point, but people who are deficient often need higher doses to restore levels. Food sources of vitamin D include fatty fish, egg yolks, and fortified foods, but it is genuinely difficult to achieve adequate intake from food alone, especially in winter months.

Retesting your vitamin D level after three to six months of supplementation is reasonable to check that your dose is sufficient.

Exercise That Actually Builds Bone

Not all exercise builds bone with equal effectiveness. The stimulus that drives bone remodeling is mechanical loading, the physical forces that pass through bone during movement. The higher the impact and the more varied the direction of force, the stronger the bone-building signal.

Weight-bearing exercise that involves ground impact is most effective for bone. Running, jumping, dancing, tennis, hiking, and aerobics all qualify. Walking is beneficial but provides a lower-magnitude stimulus than higher-impact activities.

Resistance training is also highly effective for bone, particularly when it involves progressively heavier loads. Lifting weights places force on the bones of the spine, hips, and arms, signaling them to adapt. Research consistently shows that combined impact and resistance exercise produces the strongest bone outcomes.

Swimming and cycling, despite being excellent for cardiovascular and joint health, do not provide meaningful bone-building stimulus because they are non-weight-bearing. If these are your primary movement forms, adding even two resistance training sessions per week significantly changes your bone health trajectory.

Consistency over years matters more than intensity in any single session. The bone-building response to exercise is real, but it works slowly. Expecting results in weeks is unrealistic. Expecting results over one to two years of consistent effort is well supported by research.

HRT and Bone: What the Evidence Shows

Hormone replacement therapy is one of the most effective tools available for preventing perimenopause bone loss. Estrogen directly preserves bone density by maintaining the balance between bone breakdown and bone formation. Studies have examined this extensively and consistently show that women who use HRT during perimenopause and early postmenopause have significantly higher bone density and lower fracture rates than those who do not.

The protective effect of HRT on bone continues for as long as it is used. When HRT is discontinued, bone loss resumes at an accelerated rate. This is one reason that some providers recommend continuing HRT for bone protection beyond the shortest duration possible, particularly for women at elevated fracture risk.

If bone density is a significant concern for you, it is worth specifically asking your healthcare provider how HRT factors into your bone health management, not just as a hot flash treatment but as a bone-protective therapy.

For women who cannot or choose not to use HRT, prescription medications specifically for bone density exist, including bisphosphonates like alendronate. These are typically reserved for osteopenia that is progressing or for osteoporosis, and they work differently than HRT.

Putting It Together: Your Bone Health Action Plan

The most impactful steps you can take for perimenopause bone health are not complicated. They do require consistency and some attention, but they are genuinely actionable.

First, know your baseline. If you have not had a DEXA scan, ask your provider whether one is indicated now. Having a number changes the conversation from abstract concern to specific management.

Second, hit your calcium and vitamin D targets most days. Get your vitamin D level tested if you have not recently.

Third, include weight-bearing movement and resistance training in your regular routine. Two to three strength training sessions per week, combined with walking and any higher-impact activity you enjoy, covers the exercise side of the equation.

Fourth, talk to your provider explicitly about bone health as part of your perimenopause management. Whether or not HRT is right for you overall, bone protection is a specific consideration worth discussing.

PeriPlan helps you track your workouts and daily habits so you can build the consistency that bone health requires over the long term.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.