Protecting Bone After Menopause: HRT, Non-Hormonal Options and a Naturopathic Perspective
Menopause-related bone loss is common, but osteoporosis and fractures are not inevitable. HRT can reduce bone loss while it is being used, while non-hormonal medicines, nutrition, exercise and fall prevention provide important add-on strategies. The safest plan is always an individual one.
Why does menopause affect bones?
Bone is living tissue that is continually remodelled. Cells called osteoclasts break down and resorb bone tissue, while osteoblasts help form new bone. Note that slight drops in blood pH directly activate osteoclasts because bone acts as an essential chemical buffer: when extracellular fluids become acidic, osteoclasts increase bone resorption to release alkaline minerals (such as calcium and carbonate) into the bloodstream, thereby restoring normal pH.
Oestrogen normally helps restrain excessive bone breakdown; when oestrogen levels fall during the menopausal transition, bone turnover can increase, and bone density may decline more quickly.
The amount of bone loss varies considerably. Previous fractures, family history, low body weight, smoking, excess alcohol, long-term corticosteroid use, certain medical conditions and increasing age can all influence fracture risk. A clinician may use a fracture-risk tool such as FRAX and, where appropriate, arrange a DXA scan to assess bone mineral density.
How HRT protects bone
HRT replaces oestrogen, with a progestogen added when needed to protect the uterine lining. By restoring oestrogen activity, HRT reduces excessive bone resorption and helps maintain bone mineral density.
Evidence found that women currently taking HRT had lower risks of fragility, vertebral, non-vertebral and hip fractures than comparable non-users. The protective effect is strongest while HRT is being taken; after stopping, fracture risk should be reassessed rather than assuming that protection will continue indefinitely.
HRT may be especially relevant when a younger postmenopausal woman has troublesome menopausal symptoms and a raised fracture risk, provided her individual risk of adverse effects is low.
HRT is not suitable for everyone. A prescribing discussion should consider factors such as unexplained vaginal bleeding, previous hormone-sensitive cancer, blood clots, stroke, liver disease, migraine history and cardiovascular risk. The route, dose and formulation also matter, so treatment should be personalised and reviewed.
Non-hormonal medicines
Non-hormonal osteoporosis medicines do not replace oestrogen, but they can reduce bone loss and fracture risk through other mechanisms.
— Bisphosphonates
Alendronate and risedronate are commonly used oral options, while zoledronic acid is given intravenously. They attach to bone and reduce osteoclast-mediated bone breakdown.
Oral bisphosphonates must be taken according to specific instructions, usually with plain water while sitting or standing, because they can irritate the oesophagus. They may not be suitable for everyone, particularly people with certain swallowing, oesophageal or kidney problems.
— Denosumab
Denosumab is an injection administered every six months that reduces osteoclast activity. It can be useful when bisphosphonates are unsuitable, but it requires careful treatment planning.
It should not be stopped or significantly delayed without a healthcare professional’s plan for follow-on anti-resorptive treatment. Unplanned cessation can cause rapid bone loss and increase the risk of multiple vertebral fractures.
— Raloxifene
Raloxifene is a selective oestrogen-receptor modulator. It can reduce the risk of vertebral fracture, but it is not usually the preferred option when hip fracture risk is the main concern. It can increase the risk of venous thromboembolism, so a clinician must assess whether it is appropriate.
— Bone-building treatments
Teriparatide, abaloparatide and romosozumab are specialist treatments for selected people with severe osteoporosis or very high fracture risk. They stimulate bone formation or influence bone-forming pathways and are generally followed by an anti-resorptive medicine to preserve the gain in bone density.
These treatments are not routine supplements or general menopause therapies. Their use depends on fracture history, DXA findings, clinical risk factors, cardiovascular history and local prescribing criteria.
A naturopathic foundation
A naturopathic approach can support bone health by addressing modifiable foundations while respecting the need for evidence-based medical treatment.
— Prioritise dietary calcium
Aim to obtain calcium mainly from food. Useful sources include dairy products, canned fish with edible bones, beans, leafy greens and some nuts and seeds.
The exact requirement depends on age, diet and clinical circumstances. UK guidance commonly recommends an overall daily calcium intake of approximately 700–1,200 mg, preferably from food, rather than relying on high-dose supplements to compensate for low intake. Plus, supplemental calcium is often taken in concentrated doses that can contribute to plaque formation.
A practical step is to record two or three typical days of food intake and discuss the estimate with a dietitian, nutrition professional or clinician. Calcium supplements may be useful when dietary intake is inadequate, but excessive supplementation is not automatically better and may cause gastrointestinal symptoms or be inappropriate in some medical situations. Calcium should always be supplemented alongside vitamins D and K.
— Check vitamin D status and exposure
Vitamin D supports calcium absorption and normal muscle function. Sensible outdoor activity can contribute to vitamin D production, but this depends on season, latitude, skin type, clothing, age and sun exposure.
In the UK, supplementation is often considered during periods of limited sunlight or for people at increased risk of deficiency (around 50% of the UK population). Testing or supplementation should be individualised, particularly where kidney disease, malabsorption or other medical conditions are present. Do not use high-dose vitamin D without professional supervision.
— Use progressive resistance exercise
Muscle-strengthening exercise provides a direct stimulus for bone and also supports balance and function. Examples include:
Squats or sit-to-stand exercises
Step-ups
Resistance-band exercises
Free weights or gym-based resistance training
Calf raises and upper-body strengthening.
Start at an appropriate level and progress gradually. If there has been a vertebral, hip or other fragility fracture, or if you have severe osteoporosis, obtain advice from a physiotherapist or appropriately trained exercise professional before beginning high-impact exercise.
Weight-bearing activity such as brisk walking can support general health, but walking alone may not provide the same stimulus as progressive resistance training. Exercise should be consistent, enjoyable and realistic enough to maintain.
— Reduce fall risk
Preventing a fall is as important as improving bone strength. Practical measures include improving lighting, removing loose rugs and trip hazards, using suitable footwear, checking vision and reviewing medicines that cause dizziness or sedation.
Balance training, lower-limb strengthening and safe movement practice can be particularly useful for people who feel unsteady. A physiotherapist can help tailor these measures.
— Support adequate protein and overall nutrition
Adequate protein helps maintain muscle mass, which supports strength and reduces the risk of falls. Include a protein source at regular meals, such as fish, eggs, dairy foods, tofu, beans, lentils, poultry or meat, according to dietary preference.
Avoid restrictive diets that lead to low energy intake, unintended weight loss or nutrient deficiencies. If appetite, digestion, coeliac disease, inflammatory bowel disease, vegan nutrition or weight loss is a concern, seek individual dietary guidance rather than relying on a generic supplement programme.
Supplements: a cautious approach
Supplements can be useful when a deficiency or inadequate intake has been identified, but they are not interchangeable with osteoporosis medicines. Calcium and vitamin D are particularly important when intake or status is low.
Check supplements for interactions with prescribed medicines. Calcium, for example, can interfere with the absorption of some medicines if taken at the same time. A pharmacist can advise on spacing and suitability.
Avoid unverified high-dose combinations and products from major e-commerce sites, including Amazon. There is currently a complete lack of consumer protection to prove that the product is authentic, contains what the label shows, and is free of adverse effects on human health. Studies on Amazon found that a significant portion failed basic label verification, containing either a fraction of the advertised active ingredient or unlisted compounds. Worse, counterfeit versions of major brands have periodically tested positive for hidden pharmaceutical ingredients and contain hazardous ingredients that replace those listed on the label.
“Natural” does not automatically mean risk-free, and a supplement should have a clear rationale, an appropriate dose, and a review date.
When medical treatment matters
Lifestyle measures are valuable for everyone, but they may not be enough when fracture risk is high. Medical treatment should be discussed promptly after:
A fracture from a fall from standing height or less
A vertebral fracture or significant height loss
A DXA result in the osteoporotic range
Long-term corticosteroid treatment
A strong family history of hip fracture
Recurrent falls, marked frailty or conditions that impair nutrient absorption.
Treatment decisions should include benefits, adverse effects, duration, monitoring and what happens if treatment is stopped. Routine “drug holidays” are not appropriate for everyone, and the 2024 NOGG guidance recommends reassessing fracture risk when treatment is paused.
Questions for your healthcare provider
Take the following questions to an appointment:
What is my current fracture risk, and do I need a FRAX assessment or DXA scan?
Are my menopausal symptoms and bone risk factors compatible with HRT?
If I do not want HRT, which non-hormonal medicine best fits my health history?
Do I need blood tests for vitamin D, calcium, thyroid function, kidney function or causes of secondary osteoporosis?
How much calcium do I currently obtain from food?
Which exercise programme is safe for my spine, hips and current bone density?
If considering denosumab or a bone-building medicine, what is the long-term treatment and stopping plan?
When should my fracture risk, symptoms, blood tests or DXA be reviewed?
A balanced naturopathic plan can then be added to the medical assessment and will improve nutrition, strength, balance, sleep and fall prevention, while using HRT or non-hormonal osteoporosis medication when the person’s risk–benefit assessment supports it. The aim is to preserve mobility, independence and quality of life while preventing fractures.
Sources
National Osteoporosis Guidelines Group UK (https://www.nogg.org.uk)
NICE. (2024). NG23 Menopause: Full guideline. Available: https://www.nice.org.uk/guidance/ng23/evidence/full-guideline-pdf-559549261
NOGG Clinical guideline for the prevention and treatment of osteoporosis. Available: https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2024.pdf
NICE. (2026). Menopause: identification and management. Available: https://www.nice.org.uk/guidance/ng23/chapter/recommendations
NICE. (2026). Bisphosphonates for treating osteoporosis. Available: https://www.nice.org.uk/guidance/ta464
NOGG. (2026). Section 6: Pharmacological treatment options. Available: https://www.nogg.org.uk/full-guideline/section-6-pharmacological-treatment-options
NICE. (2026). Abaloparatide for treating osteoporosis after menopause. https://www.nice.org.uk/guidance/ta991/documents/674
NICE. (2026). Romosozumab for treating severe osteoporosis | Guidance https://www.nice.org.uk/guidance/ta791/chapter/3-Committee-discussion
Gregson, CL., Armstrong, DJ., Avgerinou, C. et al. (2024). National Osteoporosis Guideline Group (NOGG). The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis. 20(1), 119. doi:10.1007/s11657-025-01588-3