A healthy woman who followed recommended bone health measures during the menopause transition later had vertebral and hip fractures.
Dr. Michael R. McClung is the founding and emeritus director of the Oregon Osteoporosis Center in Portland. He presented 'The toll of estrogen avoidance—bone health' at The Menopause Society 2026 Annual Meeting, held October 20 to 24, 2026, in San Diego, California. His talk was part of the 'Presidential Symposium: The toll of estrogen avoidance.' He reviewed what preventing menopause-related bone loss could achieve.
He called the symposium's subject 'a really important topic that is long, long overdue.' In his opening case, a 50-year-old woman began having hot flashes in 2000. She maintained good nutrition, resistance training, walking, and calcium and vitamin D intake. When her last menstrual period occurred 2 years later, she began hormone therapy, but it was discontinued after a few months when the Women's Health Initiative (WHI) results became known. At age 64, she had new vertebral fractures. Despite osteoporosis treatment, another vertebral fracture followed, and then a hip fracture at age 70. He asked whether attention to bone health at menopause could have changed that outcome.
What the WHI and later studies showed about estrogen and fracture risk
The WHI confirmed that estrogen reduces clinical fracture risk, even in a low-risk population, and that protection disappeared within 1 to 2 years of stopping. After 2002, many women discontinued therapy. In a Kaiser Permanente study, hip fracture risk increased with time off hormone therapy. In a British study, 5 to 10 years of estrogen use was associated with 25% lower fracture risk, but 'within one year that fracture protection is gone,' he said.
Why perimenopause might be the best time to prevent osteoporosis
Data from the Study of Women's Health Across the Nation show that rapid bone loss begins about 2 years before the final menstrual period. This interval accounts for 40% to 50% of the decline in bone mineral density and trabecular bone score between premenopause and age 80. 'It provides the optimal time to make a difference in preserving not only bone mass but especially bone architecture,' Dr. McClung said.
No therapy can restore bone mass or structure, he noted, so his strategy is to preserve them. In his strategy, estrogen therapy is followed by short and then intermittent bisphosphonate courses. By his estimates, a woman entering perimenopause with a T-score of 0 has a 42% lifetime fracture risk, which would decrease to 24% if her bone density were maintained.
Dr. McClung recommended skeletal assessment at perimenopause for all women, especially those with low body weight or a family history of osteoporosis. He proposed that estrogen be considered for at-risk women even without vasomotor symptoms, and that preventing menopause-related bone loss be a prominent part of the Society's position statements. 'By not providing therapy to prevent menopause-related bone loss, we are missing a unique opportunity to protect women from the consequences of osteoporosis,' he concluded.
Abbreviations: WHI, Women's Health Initiative.