Bones and heart: the midlife risks that do not announce themselves

The symptoms that get discussed at menopause appointments are the ones you can feel. Meanwhile two processes are underway that produce no sensation at all until something breaks or blocks. Neither is inevitable in its severe form, and both respond to attention in your forties and fifties more than to attention in your seventies.

This is the least dramatic article on this site and probably the most useful.

Bone: a silent disease with a loud ending

Osteoporosis develops when bone mineral density and bone mass decrease, or when the structure and strength of bone changes, leaving bones more likely to break ¹.

It is described as a silent disease because you typically have no symptoms and may not know you have it until you break a bone. It is the major cause of fractures in postmenopausal women, most often in the hip, the vertebrae of the spine, and the wrist ¹.

What menopause has to do with it

Losing bone is a normal part of ageing, but some people lose it much faster. Women lose bone rapidly in the first few years after menopause, and are more at risk of osteoporosis than men, particularly if menopause begins early, before the age of 45, or if the ovaries have been removed ². NIAMS puts the start earlier still: for many women, the disease begins to develop a year or two before menopause ¹.

The WHO includes loss of bone density at menopause among the changes associated with it, and describes it as a significant contributor to higher rates of osteoporosis and fractures ⁵.

Risk factors worth knowing about yours

Some you cannot change: being female, age, small frame and low body weight, and family history, particularly a hip fracture in a parent ¹².

Some you can influence or at least know about. Taking high-dose steroid tablets for more than three months. Inflammatory, hormonal or malabsorption conditions. Long-term use of medicines that affect bone strength or hormone levels, including the anti-oestrogen tablets many women take after breast cancer. A history of an eating disorder. Low BMI. Not exercising regularly. Heavy drinking and smoking ².

NIAMS adds a longer medicines list including antiepileptics, cancer treatments that use hormones, proton pump inhibitors, selective serotonin reuptake inhibitors and thiazolidinediones ¹.

If several of those apply to you, that is a specific thing to raise, not a general worry.

How it gets assessed

If a doctor suspects osteoporosis, they can estimate your future fracture risk using an online tool such as FRAX or Q-Fracture, and may refer you for a bone density scan, a DEXA scan, which is short and painless and takes ten to twenty minutes ².

The result comes as a T score comparing your density to that of a healthy young adult. Above -1 standard deviation is normal. Between -1 and -2.5 indicates bone loss and is defined as osteopenia. Below -2.5 is defined as osteoporosis ².

Osteopenia does not always progress to osteoporosis, and there are steps that reduce the risk. Depending on how weak the bones are and your fracture risk, a doctor may also prescribe one of the bone-strengthening treatments ².

Prevention, concretely

NIAMS lists staying physically active with weight-bearing exercise, drinking alcohol in moderation, not smoking, taking prescribed medications, and eating a diet rich in calcium and vitamin D ¹. The NHS adds a specific supplement figure: a daily supplement containing 10 micrograms of vitamin D ².

On exercise, the guidance is more specific than "keep active", and the specificity matters because not all activity loads bone.

A combination of three types is described as best. Weight-bearing exercise, which produces a force on bones, including brisk walking at three to four miles per hour, jogging, racket sports, climbing stairs and dancing. Resistance training using weight machines, free weights, resistance bands or your own body weight. And balance training, especially for older adults, including walking on an unstable surface, tai chi, walking backwards, step-ups, lunges and weight-shifting drills ³.

The volume target for adults is at least 150 minutes a week of moderate-intensity exercise or 75 minutes of vigorous-intensity, plus muscle-strengthening activities of at least moderate intensity at least twice a week ³.

Swimming and cycling have other benefits but are not weight-bearing.

NICE puts the same emphasis into the menopause consultation itself, recommending that clinicians give advice on bone health to people experiencing menopause and discuss it at review appointments, and explain the importance of maintaining muscle mass and strength through physical activity ⁶.

Where HRT fits

NICE's outcome tables state that fragility fracture risk is decreased while taking HRT, that the benefit is maintained during treatment but decreases once treatment stops, and that it may continue for longer in people who take HRT for longer. It also notes that baseline fracture risk around the age of menopause is low in the UK and varies from person to person ⁶.

The Menopause Society states that hormone therapy has been shown to prevent bone loss and fracture, and includes prevention of bone loss among the indications for which the benefit-risk balance is favourable in women under 60 or within ten years of menopause onset ⁸.

Talk to your clinician about whether that applies to you. Nobody reading a website can tell you.

Heart: a risk profile that shifts, not a switch that flips

Cardiovascular disease is the leading cause of death in women, and women have a notable increase in risk after menopause, typically developing coronary heart disease several years later than men ⁴.

The interesting question is whether the transition itself contributes, or whether this is simply ageing. Twenty years of longitudinal studies following women through menopause have been able to partly separate the two, and the 2020 American Heart Association scientific statement gathers that evidence ⁴.

What the statement found

The overall conclusion is that the menopause transition is a time of accelerating cardiovascular risk, which makes midlife a critical window for early prevention ⁴.

The specifics are more persuasive than the summary.

On lipids: SWAN data demonstrated that total cholesterol, LDL cholesterol and apolipoprotein B increase substantially within a short window, from the year before to the year after the final menstrual period, and that these associations were independent of ageing alone ⁴. A longitudinal analysis found lipid measures peaked during late perimenopause and early postmenopause, with the relative odds of an LDL cholesterol of 130 mg/dL or above being 2.1 in early postmenopause compared with premenopause ⁴.

HDL cholesterol behaves strangely, and this is worth knowing because it undercuts a familiar reassurance. The transition is associated with an apparent reversal in the direction of the association between HDL cholesterol and cardiovascular risk, with higher HDL associated with less carotid atherosclerosis before menopause but with greater carotid atherosclerosis after it ⁴.

On blood vessels: marked increases in carotid intima-media thickness and carotid adventitial diameter were found during late perimenopause relative to premenopause, independent of ageing, and arterial stiffness measured by carotid-femoral pulse wave velocity increased by 7.5% within one year of the final menstrual period, not explained by traditional risk factors ⁴.

On body composition: midlife weight gain is largely explained by chronological ageing, and in SWAN there was no difference in weight or BMI between premenopausal and postmenopausal women after adjusting for age. Women gained an average of about 2.0 to 2.3 kg over three years, and this was not related to menopausal status. But the transition was independently associated with adverse changes in body composition and increases in visceral fat, and using DEXA over 18 years across the final menstrual period, the rate of fat gain doubled around two years before it ⁴.

That distinction is easy to miss and worth restating. The weight is mostly ageing. The redistribution towards visceral and ectopic fat looks related to the transition, and visceral fat is the part that matters for cardiometabolic risk.

There is also a symptom link. Women with hot flushes had reduced flow-mediated dilation and greater aortic calcification independently of cardiovascular risk factors and oestradiol, and women reporting hot flushes at two visits two years apart had higher carotid intima-media thickness than those reporting none, particularly among women who were overweight or obese ⁴. Vasomotor symptoms at midlife have also been linked to an adverse lipid profile, insulin resistance and greater risk of incident hypertension ⁴.

These are associations. They do not establish that hot flushes cause vascular change, and the statement does not claim they do.

The WHO makes the population-level version of the same point: women's advantage over men in cardiovascular disease gradually disappears with the significant decline in oestrogen levels after menopause ⁵.

What that means for prevention

The AHA statement's own framing is that its findings emphasise the importance of monitoring women's health during midlife and targeting this stage for early intervention ⁴.

The honest limitation is that the intervention evidence specific to this window is thin. The statement notes that the Pittsburgh Women's Healthy Lifestyle Project was probably the first and, to date, the only randomised trial designed specifically to assess a diet and exercise intervention during the transition. It randomised 535 healthy premenopausal women aged 44 to 50 to assessment only or a five-year programme combining a lower-calorie, lower-saturated-fat diet with moderately increased leisure-time physical activity, and the LDL cholesterol increase seen in the control group from perimenopause to postmenopause was blunted in the intervention group ⁴.

One trial is not a body of evidence, and the statement calls for randomised trials of therapeutic interventions in women transitioning menopause, noting this population has not been the focus of previous trials ⁴.

What HRT is not for

NICE is unambiguous: do not offer combined or oestrogen-only HRT for primary or secondary prevention of cardiovascular disease, and refer instead to its guideline on cardiovascular risk assessment and reduction ⁶.

Its outcome tables also state that coronary heart disease risk does not increase with either combined or oestrogen-only HRT, and that cardiovascular mortality does not increase ⁶. Not increasing risk and preventing disease are different claims.

Guidance in the US and Europe

The US Preventive Services Task Force recommends screening for osteoporosis in women aged 65 or over, and in postmenopausal women under 65 who are at increased risk of fracture based on a clinical risk assessment ⁹. It recommends against using hormone therapy to prevent chronic conditions, including fractures and heart disease, in postmenopausal people without symptoms, finding no net benefit ¹⁰.

In Europe, the European Menopause and Andropause Society (EMAS) care pathway includes screening for diseases of later life and covers both hormone therapy and non-oestrogen treatments for protecting bone ¹¹.

What is still uncertain

Whether the cardiometabolic changes observed across the transition are modifiable by intervening at that point, and by how much, has not been established by adequate trials ⁴.

The mechanism connecting vasomotor symptoms to vascular measures is unresolved ⁴.

And whether smoking's effect on bone is from tobacco alone or from other risk factors clustering in people who smoke is still being studied ¹.

When to see a clinician

NICE says bone health should be discussed at menopause reviews ⁶. It is particularly relevant if you had an early menopause, have taken steroids long term, have a parent who fractured a hip, have a low BMI, or take any of the medicines listed above ¹².

The AHA statement's central point is about timing: it frames midlife, rather than later life, as the window for attention to blood pressure, cholesterol and glucose ⁴.

NIAMS advises talking to a health care provider before starting an exercise programme if you already have low bone density, osteoporosis, or other physical limitations ³.

Call emergency services for a possible heart attack

Symptoms may include chest pain that feels like crushing or squeezing, which may spread to the arm, neck or jaw; shortness of breath; nausea or vomiting; a feeling like indigestion; sweating; and pale, blue or grey skin, which on black or brown skin may be easier to see on the palms ⁷.

The NHS says to call emergency services for chest pain that feels tight or like squeezing, chest pain spreading to the arms, neck or jaw, severe difficulty breathing, or lips or skin that look pale, blue or grey, and not to drive yourself to hospital ⁷. Not sure of the number: find help numbers where you live.

The record that helps here

Bone and cardiovascular risk are managed with numbers taken years apart, which makes them easy to lose track of.

Keep your own copies: blood pressure readings, cholesterol results with dates, any DEXA T score, vitamin D, and the date of your last review. When a clinician can see the trend rather than a single reading, the conversation changes.