Curriculum
Module 07 · 60 min

Bone Loss, Fracture Risk and the Sarcopenia Overlap

The fastest bone loss of a woman's life happens in a four-year window most clinicians never screen.

Bone & musculoskeletalPrimary care track
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Learning objectives

By the end of this module you will be able to

  • L01State the rate and timing of bone loss across the transition.
  • L02Use FRAX appropriately and list situations where it underestimates risk.
  • L03Explain that MHT reduces fractures at the hip and spine in unselected postmenopausal women.
  • L04Describe the mandatory follow-on therapy after stopping denosumab.
  • L05Prescribe progressive resistance and impact exercise with specifics, not a vague 'stay active'.
Scope

Topics covered

01Transmenopausal bone loss: rate, timing and the trabecular predilection
02RANKL, oestrogen withdrawal and osteoclast lifespan
03DXA, FRAX and when the tool underestimates risk
04MHT as fracture prevention and how it compares with bisphosphonates
05Denosumab discontinuation and rebound vertebral fracture
06Sarcopenia, falls and the resistance training evidence
07Vitamin D and calcium — where the real evidence sits
Module narrative

How this plays out in practice

Primary care view· your track

Assess fracture risk at menopause, not at 70. Use FRAX with BMD where available, and treat the whole picture: vitamin D repletion if deficient, adequate dietary calcium (food first, roughly 1000–1200 mg daily), and specific exercise — resistance training twice weekly plus impact activity. For a woman under 60 with menopausal symptoms and low bone density, MHT is often the single treatment addressing both problems.

Specialist view

Sequence antiresorptives and anabolics deliberately. Anabolic-first (teriparatide, abaloparatide, romosozumab) followed by an antiresorptive produces greater BMD gains than the reverse sequence in high-risk patients. Denosumab is never a drug to stop casually: transition to a bisphosphonate. In POI and early menopause, hormone therapy until the average age of menopause is the bone-protective standard, and bisphosphonates are generally inappropriate in women who may conceive.

Advanced note

Oestrogen restrains osteoclastogenesis by suppressing RANKL and promoting osteoclast apoptosis, so withdrawal increases both the number and lifespan of osteoclasts, uncoupling resorption from formation. Trabecular bone, with its high surface-to-volume ratio, is affected first, which is why vertebral BMD declines before hip BMD and why early loss is invisible on hip-only screening.

Expected takeaways

What you should walk away believing

  • →Women lose roughly 2% of spinal BMD per year across the late transition and first postmenopausal years — around 10% in total.
  • →WHI showed MHT reduced hip and vertebral fractures in an unselected population — the only therapy to do so in women not selected for osteoporosis.
  • →FRAX does not capture falls risk, recent fracture recency, glucocorticoid dose or lumbar spine BMD — clinical judgement must override it.
  • →Stopping denosumab without follow-on antiresorptive therapy causes rapid rebound bone loss and multiple vertebral fractures.
  • →Progressive resistance plus impact training improves BMD modestly but improves falls risk and muscle function substantially.
Myth-buster

What patients — and colleagues — get wrong

The claim

“Calcium and vitamin D supplements prevent fractures in the general population.”

Reality

In community-dwelling adults without deficiency, supplementation shows little to no fracture reduction, and high-dose intermittent vitamin D has increased falls in some trials. Correcting documented deficiency is worthwhile; population-wide supplementation as a fracture strategy is not supported.

Graded claims

Evidence grading for this module

A

MHT reduces hip and vertebral fracture risk in unselected postmenopausal women

Established — RCT / guideline-grade — WHI both arms — a rare positive primary-prevention fracture finding.

A

Bone loss accelerates in the late transition, before the final menstrual period

Established — RCT / guideline-grade — SWAN Bone substudy.

A

Stopping denosumab without follow-on therapy causes rebound vertebral fractures

Established — RCT / guideline-grade — FREEDOM extension analyses and multiple case series.

A

Progressive resistance training reduces falls and improves function in postmenopausal women

Established — RCT / guideline-grade — Consistent meta-analytic evidence.

E

Routine calcium plus vitamin D prevents fractures in replete community-dwelling adults

Popular, weak or conflicting support — USPSTF and large meta-analyses show little to no benefit.

D

Whole body vibration platforms prevent fractures

Biologically plausible, unproven — Small BMD signals, no fracture endpoint evidence.

Evidence summary

Graded claims, key takeaways and sources for this module.

Open printable summary
Clinical vignettes

Apply it in clinic

Osteopenia at 52 with vasomotor symptoms

A 52-year-old, 18 months post-FMP, with frequent hot flushes and a T-score of -1.8 at the spine. FRAX 10-year major osteoporotic fracture risk is 7%. She is nervous about 'HRT'.

Best first-line strategy?

Self-assessment

Check your recall

Q1

Bone loss across the menopause transition is fastest:

Q2

A 68-year-old wishes to stop denosumab after 5 years. Correct advice?

Q3

FRAX is most likely to underestimate risk in which situation?

Flashcards

Retrieval practice

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Glossary

Terms used in this module

FRAX
Ten-year fracture probability calculator; does not incorporate falls, fracture recency or dose-dependent glucocorticoid exposure.
RANKL
Receptor activator of nuclear factor kappa-B ligand — the key osteoclastogenic cytokine restrained by oestrogen.
Sarcopenia
Age-related loss of muscle mass and strength; interacts with bone loss to drive fracture through falls.
Primary sources

Read the evidence yourself