The Link Between Osteoporosis and Menopause

About 1 in 2 women in the US will have a broken bone at some point after the age of 50. This means one of us is likely to suffer an osteoporotic fracture at some point in the years ahead. 

That’s a wake-up call. Our risk of a hip or vertebral fracture in the low back (lumbar spine) later in life is on par with the chances of having breast, uterine, and ovarian cancer combined. 

The trouble is, you may not know you have osteoporosis until you break a bone. A study this year (2021) showed that three in ten postmenopausal women over 50 had osteoporosis. Of those three women with osteoporosis, only two had been diagnosed. 

Statistics aside: A bone fracture or hip fracture is a traumatic experience. 

Our bones are made of living, growing tissue. An outer shell of dense bone encases trabecular bone, a sponge-like bone. When a bone is weakened by osteoporosis, the “holes” in the “sponge” grow larger, weakening the bone structure.

Recovering from a broken bone is harder as the decades go by. What’s most troublesome is that bone breaks increase mortality later in life. This is especially true for fractures of the hip and spine because you lose mobility. 

The best way to limit the risk of osteoporosis fractures later in life is to keep bones healthy and strong through the menopause transition and beyond. Research over the past ten years or shows that taking probiotics and prebiotics can support bone health. Let’s look at why and how much to take. 

Menopause And Osteoporosis: What’s the Connection? 

After menopause, bones tend to become weaker. This trend continues as we age. Women often hear it’s because of estrogen deficiency, which then leads to osteoporosis. The “estrogen deficiency” story is partially true. But why? Men get osteoporosis, too, after all. Even so, about 8 million of the estimated 10 million people in the US diagnosed with osteoporosis are women.

Osteoporosis affects women more than men in part because we are more likely to have low bone density and tend to have smaller, thinner bones from the get-go. 

Estrogen decline does play a role but maybe not in ways you imagine. We’ll get to that shortly. First, permit us to emphasize that menopause is not a disease that puts you on track for a steady state of decline. You have a lot to say in how you – and your bones – age.

menopause and osteoporosis

If you’re like most people, you imagine your bones as the architectural frame that keeps you upright from heel to head. Most of us think bones grow long and strong in childhood. Then, when we reach a certain height and stature, they stop growing. Later in life, such as during menopause, they get weaker, and this is osteoporosis. We tend to see bones as relatively inert and fixed.

But bones are living tissue. They change constantly. Bone cells – bone cells – form and die just like other cells in the body. This constant bone turnover is called bone remodeling

During formation, bone cells deposit calcium and other minerals into bone tissue. In fact, bones are the body’s storehouse of minerals, being about 90% mineral.

Some people compare bone tissue to reinforced concrete with two primary components: mineral and protein. Minerals resist compression. Protein provides tensile strength, which protects against pulling and sheering forces. Together, minerals and protein give bone strength. 

When bone is healthy, bone formation and bone loss balance out. When that balance tilts, bone can start to build up or break down too quickly. On the breakdown side, bones lose minerals, namely calcium. We call this mineral loss bone resorption. The body reabsorbs the calcium deposited into the living bone tissue. 

When bones lose calcium, they lose bone density. Using the concrete analogy, you could say the “concrete” starts to erode. Loss of bone density is loss of bone mass. The less bone mass you have, the greater your risk of osteoporosis and osteoporotic fractures. 

Have you ever stood on a sandy shore as the tide goes out and felt the sand drift from beneath your feet? You might imagine bone resorption like that, only at a much, much slower rate. That sand beneath your feet is the bone mineral density “washing away.”

sand beneath your feet

Many factors combine to tip the balance between bone formation and bone resorption. Estrogen loss is one of those risk factors. 

Estrogen helps keep the scales balanced between bone formation and bone resorption – in women and men. When estrogen declines in mid and later life for both sexes, bone formation can’t keep up with bone resorption, and you have bone loss. 

But there’s more to the estrogen story. (There’s always more to the story. When it comes to the body, don’t let the simple version of any story fool you!)

Estrogen provides natural anti-inflammatory protection. With less estrogen in mid and later life, you lose that protection. This is important for healthy bones because unchecked inflammation is the primary culprit for bone loss. And this is where things get interesting. . . . 

Osteoporosis is a Disease of Modern Life

In 2020, a group of researchers at the University of Pennsylvania proposed that osteoporosis is new for humans. Their work echoes a growing body of research that says our bodies are not matched for our modern lives. Mainly, their osteoporosis research points to the effects of the modern diet and lack of physical activity on bone health. 

Our bodies haven’t caught up to the overwhelming changes that human technology has brought about over the last 10,000+ years. It’s astounding if you think about it: Humans went from gathering and hunting to farming, then to manufacturing, and more recently, sedentary work. All this in a matter of 500 generations. 

Most of us would not survive if we found ourselves needing to gather food from the wild. Even so, our bodies haven’t yet gotten the memo that we no longer know how to do that. Human health sometimes suffers at the hands of human ingenuity.

You might think of it this way: Our ancient human ancestors wandered miles day after day gathering and grazing on fruits, nuts, seeds, berries, leaves, stems, tubers, and roots. Many relied on insects as a primary source of protein – and calcium. They benefitted from four to five times as much fiber each day than the average American eats. And to reemphasize, they moved – a lot. From what we can tell, our ancient ancestors did not have osteoporosis.

As unappealing as that diet and lifestyle may seem, there are pieces of it that are vital for our wellbeing – and healthy bones. Exercise, sunshine, and diet are all needed for healthy bone growth and maintenance. Not only do fresh plant foods provide fiber, but they also offer a bounty of micronutrients not found in processed food. Processed food is a significant source of inflammation in the gut. Inflammation in the gut triggers inflammation in surrounding tissues, including bone tissue. Fresh plant micronutrients quell inflammation.

Today, we’re prone to have more inflammation and fewer nutrients to quiet it: more unchecked inflammation from modern life and less of Nature’s protection. With estrogen’s anti-inflammatory protection waning in midlife, bone tissue is more at risk of succumbing to inflammatory bone loss. 

Activity also plays an important part. Activity, when we’re young, determines peak bone mass. Peak bone mass is that stage in bone development when bone density is greatest. 

But all is not lost. There are ways to overcome the modern-life conundrum, lead a healthy life, and limit the risk of osteoporosis. The goal of nurturing healthy bones is to slow the pace of bone loss from that early stage of peak mass.

What You Can Do to Support Healthy Bones 

You’d be hard-pressed to find advice against eating a fresh plant-rich diet and moving regularly. These two practices are vital for health and wellbeing. There’s another pillar to add to these two for healthy bones and osteoporosis prevention: feeding your microbiome. Let’s start there. 

Feed Your Microbiome. 

Healthy bones need a healthy gut. A healthy gut begins with a healthy microbiome.

feed your microbiome

Taking a calcium supplement is essential for healthy bones before and after menopause if there is not enough calcium intake in your diet, such as from leafy greens and sardines. Even so, you can take all the calcium in the world, and if it isn’t doesn’t make it into cells and tissues, it’s of no use to the body. 

Together, probiotics and prebiotics make calcium available to cells and tissues, including bone tissue. 

Probiotics are friendly bacteria that provide a health benefit to your body. They add diversity and abundance to the friendly bacteria already in the gut. In midlife, the diversity and abundance of those communities decline. You can offset these changes by feeding your microbiome with probiotics. 

Friendly gut bacteria make up your microbiota, which is important for healthy bones in several ways. 

  • Microbiota supports gut health, where a lot of systemic inflammation begins. 
  • Friendly bacteria produce short chain fatty acids (SCFAs). SCFAs lower the pH in the gut, meaning they make it more acidic. A more acid gut makes calcium and other minerals available for absorption and ready for transport to bones. 

Prebiotics are food for beneficial bacteria. They come from the soluble fibers of plants that the human body can’t digest, but friendly gut bacteria can. Prebiotics also support calcium absorption, although research hasn’t yet clarified why. Inulin is an especially beneficial prebiotic found in various plant foods, including chicory root, raw onions, garlic, sunchokes, asparagus, sunflower seeds, flax seeds, and cocoa. 

During its journey through the intestinal tract, inulin interacts with calcium in many ways and boosts calcium absorption. One study showed a 30% increase in calcium transport into intestinal cells with inulin supplementation. 

Another group of researchers showed that postmenopausal women taking 8 grams of chicory fiber daily for three months had a 42% increase in calcium absorption. The control group, on the other hand, saw a 29% decrease in calcium absorption. 

Supplementing with 8-10 grams of inulin a day will suffice. It’s best to do so long-term because calcium balance constantly changes. This dose is equal to about a teaspoon of powdered chicory – perhaps the most concentrated food source of inulin. You’d have to eat a third of a cup of raw onion to consume that much inulin. 

If you’re not a fan of the bitter taste of chicory root, you can mask it in a (low-sugar) smoothie. Chicory coffee is good for liver and bile health but doesn’t add measurable amounts of inulin to your daily diet. 

Although most people tolerate inulin just fine, if you are switching from a low- to a high-fiber diet, you may have bloating and gas in the beginning. If so, you might try halving the amount and slowly increasing it to a teaspoon. 

Probiotics that contain prebiotics are called synbiotics. You will not find a full 8-10 gram dose of inulin in a synbiotic capsule. All the same, taking probiotics and prebiotics together in a synbiotic boost their joint action on calcium absorption and gives you a little more inulin each day.

Eat Your Greens.

Unchecked inflammation is the greatest threat to bone health. Nutrient-rich plant foods quiet inflammation. 

  • A plant-rich diet forms the nutrient building blocks for healthy bones through all stages of life. 
  • Canned sardines are an excellent source of calcium. 
  • Vitamin D is essential for calcium absorption. Consider adding a vitamin D supplement at the recommendation of your healthcare provider so that you get enough but not too much. 

leafy greens

Although most of us learned that dairy products are the primary dietary source of calcium, we do not include them here. The proteins in dairy, casein, and whey can be difficult to digest, especially as we get older. These proteins can give way to gut inflammation. If so, dairy intake can become a source of calcium loss in bones. 

Take a Walk. 

If you don’t use bone, you lose bone.

Bones need to be regularly stressed to be healthy. Movement provides that stress, namely weight-bearing and strengthening forms of movement. Movement tugs at and compresses bones to fortify them. What’s more, movement improves balance and makes falls less likely. 

A systematic review and analysis of 43 randomized controlled trials of over 4000 postmenopausal women showed that strength training had the most significant benefit on bone health. Women who engaged in a combination of exercises (weight-bearing and strengthening) had an average of 3.2% less bone loss than those who were inactive. 

take a walk

Variety seems to matter when it comes to movement for reducing bone loss and fracture risk. Of course, you want to keep in mind a few safety considerations if you’re starting a movement program. 

These include: 

  • How able your body is
  • Pain
  • Balance
  • Access to safe places to move
  • Climate and seasons

You may have been told already that you have bone loss or osteoporosis, or you or your healthcare provider suspect that you may be at risk. In this case, it’s a good idea to have a bone density test before you start a movement program so that you don’t risk causing a bone break. You might want to consult with a physical therapist to begin safely. 

Most importantly, pay attention to what you enjoy. We’re all more likely to continue what we enjoy.

Explore More

how to restore healthy gut flora

Why (and How!) to Befriend Your Gut Microbiome for Menopause & Healthy Aging.


  1. Bakirhan, H, Karabudak, E. Effects of inulin on calcium metabolism and bone health. Int J Vitam Nutr Res. 2021:1-12.
  2. Blair, HC, Robinson, LJ, Huang, CL-H, et al. Calcium and bone disease. Biofactors. 2011;37(3):159-167.
  3. Choi, MH, Yang, JH, Seo, JS, et al. Prevalence and diagnosis experience of osteoporosis in postmenopausal women over 50: Focusing on socioeconomic factors. PLoS ONE. 2021;16(3):e0248020.
  4. Cordain, L, Eaton, SB, Sebastian, A, et al. Origins and evolution of the Western diet: Health implications for the 21st century. Am J Clin Nutr. 2005;81(2):341-354.
  5. Coxam, V. Current data with inulin-type fructans and calcium, targeting bone health in adults. J Nutr. 2007;137(11):2527S-2533S.
  6. Daly, RM, Via, JD, Duckham, RL, et al. Exercise for the prevention of osteoporosis in postmenopausal women: An evidence-based guide to the optimal prescription. Braz J Phys Ther. 2019;23(2):170-180.
  7. Eaton, SB, Nelson, DA, Calcium in evolutionary perspective. Am J Clin Nutr. 1991;54(1 Suppl):281S-287S.
  8. Florowska, A, Krygier, K, Florowski, T, et al. Prebiotics as functional food ingredients preventing diet-related diseases. Food Funct. 2016;7:2147-2155.
  9. Howe, TE, Shea, B, Dawson, LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women (Review). Cochrane Database Syst Review. 2011.
  10. Khosla, S, Oursler, MJ, Monroe, DG. Estrogen and the skeleton. Trends Endocrinol Metab. 2012;23(11):576-581.
  11. Kralick, AE, Zemei, BS, Evolutionary perspectives on the developing skeleton and implications for lifelong health. Front Endocrinol. 2020;11:99.
  12. Kim, Y-Y, Jang, K-H, Lee, E-Y, et al. The effect of chicory fructan fiber on calcium absorption and bone metabolism in Korean Postmenopausal women. Nutr Sci. 2004;7(3):151-157.
  13. Krupa-Kozak, U, Świątecka, Bączek, N, et al. Inulin and fructoligoosaccharide affect in vitro calcium uptake and absorption from calcium-enriched gluten-free bread. Food Funct. 20167(4):1950-1958.
  14. Lerner, UH. Inflammation-induced bone remodeling in periodontal disease and the influence of post-menopausal osteoporosis. J Dent Res. 2006;85:596.
  15. Li, J, Ho, WTP, Liu, C, et al. The role of gut microbiota in bone homeostasis: A systematic review of preclinical animal studies. Bone Joint Res. 2021;10(1):51-59.
  16. McCabe, L, Britton, RA, Parameswaran, N. Prebiotic and probiotic regulation of bone health: Role of the intestine and its microbiome. Curr Osteoporos Rep. 2015;13(6):363-371.
  17. Mundy, GR. Osteoporosis and inflammation. Nutr Rev. 2007;65(12):S147-S151.
  18. Nath, A, Molnár, A, Csighy, A, et al. Prebiotics and symbiosis with probiotics on controlling osteoporosis, blood-lipid and glucose levels. Medicina. 2018;54(6):medicina54060098.
  19. National Osteoporosis Foundation. What women need to know. 2021.
  20. Okamoto, K, Nakashima, T, Shinohara, M, et al. Osteoimmunology: The conceptual framework unifying the immune and skeletal systems. Physiol Rev. 2017;97:1295-1349. https://doi.10.1152/pysrev.00036.2016
  21. Sapir-Koren, R, Livshits, G. Postmenopausal osteoporosis in rheumatoid arthritis: The estrogen deficiency-immune mechanisms link. Bone. 2017;103:102-115.
  22. Straub, R. The complex role of estrogens in inflammation. Endocrine Rev. 2007;28(5):521-574.
  23. Teng, GG, Curtis, JR, Saag, KG. Mortality and osteoporotic fractures: Is the link causal, and is it modifiable? Clin Exp Rheumatol. 2008;26(5 Suppl 51):S125-S137. PMID:19026155; PMCID:PMC4124750
  24. Tilg, H, Moschen, AR, Kaser, A, et al. Gut, inflammation and osteoporosis: Basic and clinical concepts. Gut. 2008;57:684-694.
  25. Yatsonsky II, D, Pan, K, Shendge, VB, et al. Linkage of microbiota and osteoporosis: A mini literature review. World J Orthop. 2019;10(3):123-127.

Written By: