A complete, empowering guide for women

If you’ve ever been told you have osteopenia, osteoporosis, or that your “bone density is low,” it can feel quietly frightening. Bones are something most of us never think about — until suddenly we’re asked to.

What I want you to know from the very beginning is this:
bone health is not all-or-nothing. It is something you can influence at every stage of life.

This article brings everything together — what osteoporosis really is, why it matters, how it’s diagnosed, and what truly helps to protect and strengthen your bones for the future.

A gentle note before we go further: this article is designed to educate and empower, not to replace personalised medical care. Every woman’s health history, risk profile, and preferences are different. Use this guide to build understanding and confidence — and then take that knowledge into a conversation with your health professional so you can make decisions that are right for you.

What osteoporosis actually is

Osteoporosis means that bones have become weaker and more fragile, making them more likely to fracture with very little force — sometimes from something as simple as a minor fall or even bending forward (1).

But bone strength is not just about how much bone you have.
It is also about bone quality — the internal structure of the bone.

A helpful way to picture this is to think of a house.
Bone density is like how thick the walls are.
Bone quality is like how strong the beams and framework are.

You can have reasonably thick walls, but if the beams are weak, the house still collapses under stress. The same is true for bones (2).

How common is osteoporosis?

Osteoporosis is far more common than most women realise.

In New Zealand:

• Over 50% of women over 60 have osteoporosis (3)

• By age 65, 1 in 2 women are affected (3)

• By age 75, around 70% of men and women will have it (3)

The lifetime impact is significant:

• 1 in 3 women over 50 will have a fragility fracture of the hip, spine, or wrist (3)

• Around 4000 osteoporotic hip fractures occur in NZ each year (3)

• After a hip fracture, 5–20% of people die within a year, and 60% need long-term help with daily activities (3)

This is why osteoporosis isn’t just about bones — it’s about independence, mobility, and quality of life.

How osteoporosis develops — the story inside your bones

Your bones are living tissue, constantly being renewed.

Two key types of cells work together:

• Osteoclasts break down old bone

• Osteoblasts build new bone

When these are in balance, your skeleton stays strong. When breakdown happens faster than rebuilding, bones gradually weaken (4).

The role of age and menopause

Bone density peaks around age 30. After that, we all slowly lose bone with time (4).

For women, the most dramatic change happens at menopause.

Oestrogen normally protects bone. When oestrogen levels fall:

• Osteoclasts speed up

• Osteoblasts can’t keep pace

• Bone loss accelerates (4)

This is why the first years after menopause are such a critical window for bone health.

What increases the risk of osteoporosis?

Some risks we can’t change. Others we can influence.

Non-modifiable factors

• Increasing age

• Being female

• Early or premature menopause

• Smaller body size

• Family history

• Certain ethnic backgrounds (5)

Modifiable and medical factors

• Low calcium and vitamin D intake

• Little weight-bearing exercise

• Smoking

• Alcohol

• Long-term steroid use

• Conditions such as thyroid disease, diabetes, coeliac disease, rheumatoid arthritis

• Low body weight or rapid weight loss

• Previous fragility fractures (5)

A fascinating long-term twin study followed people for 25 years and found that genes alone did not explain who fractured. Lifestyle and health factors mattered just as much — often more. Genetics sets the stage, but environment writes much of the script (6).

Testing and diagnosis

How osteoporosis is diagnosed

Osteoporosis is often silent at first. Many women feel completely well until a fracture happens.

Possible warning signs later on include:

• Loss of height

• Persistent back or neck pain

• Stooping posture

• A curved upper back due to spinal compression fractures (2)

But the main way osteoporosis is detected is with a DEXA scan.

What is a DEXA scan?

DEXA stands for Dual-Energy X-ray Absorptiometry.

It is:

• Quick

• Painless

• Uses very low radiation

• Measures bone density at the hip and spine (7)

Understanding your DEXA results

DEXA results are given as T-scores and Z-scores.

T-score — the key number

This compares your bone density to that of a healthy 30-year-old woman.

• 0 = average peak bone density

• −1 to −2.5 = osteopenia

• Below −2.5 = osteoporosis (7)

If your T-score is below −2.5 and you’ve already had a fracture, this is called severe established osteoporosis (7).

Z-score — useful context

This compares you to others of the same age and body size.
It doesn’t diagnose osteoporosis but helps clinicians decide whether something unusual might be going on (7).

What is the FRAX score?

The FRAX score estimates your 10-year risk of fracture.

It combines:
age, sex, weight, height, personal fracture history, family history of hip fracture, smoking, alcohol use, steroid use, certain medical conditions — and sometimes your bone density.

Rather than looking only at your scan, FRAX looks at you as a whole person.

Two women can have the same T-score but very different fracture risks.
FRAX helps guide decisions about whether medication is likely to be helpful — especially for women with osteopenia who sit in a grey zone between “normal” and “osteoporosis.”

You can use an online tools like these ones to assess your risk.

Why prevention and treatment belong together

Osteoporosis develops slowly over years.
That means prevention and treatment sit on the same continuum.

Whether you are protecting your bones or already managing osteoporosis, the principles are the same:
nourish your bones, challenge them safely, reduce risk — and use medical tools when appropriate (1).

Lifestyle medicine for strong bones

1. Nutrition: feeding your skeleton

Bones need more than calcium alone. They require a whole network of nutrients.

Key nutrients include:

• Vitamin D – helps absorb calcium

• Vitamin K – activates bone-building proteins

• Magnesium – keeps bone flexible

• Protein – forms the structural framework

• Trace minerals – zinc, copper, selenium and more (8)

Calcium — food before supplements

Getting enough calcium each day is an important foundation for bone health, but where it comes from matters. Calcium from food is protective, while supplements do not reliably reduce fracture risk and, at higher doses, may increase cardiovascular risk (9). Most adult women need around 1000 mg per day, increasing to 1200–1300 mg after menopause as bone loss naturally accelerates. The best way to meet this is through a food-first approach — including leafy green vegetables, tofu set with calcium, nuts, seeds, legumes, and dairy if you enjoy it. If you’re unsure whether you’re meeting your needs, tracking a few days of intake with a tool like the Cronometer app can be surprisingly helpful.

A blood calcium test isn’t a good measure of bone health, because the body keeps blood levels tightly controlled — often by drawing calcium from bones if needed — so results can look “normal” even when bone stores are slowly declining. Milk has long been promoted as essential for strong bones because it provides calcium and protein, and for many women, it can be a helpful part of a bone-supportive diet. However large population studies show that higher milk intake does not consistently translate into fewer fractures, and in some groups, very high milk consumption has even been linked with higher fracture rates. The reassuring news is that there are many excellent non-dairy sources of calcium, so whether you drink milk or not, you can support your bones through a varied, whole-food diet that also provides vitamin D, magnesium, vitamin K, and the movement your bones truly respond to.

Vitamin D — essential, but targeted

Vitamin D needs vary more than most people realise, because sunlight is the main source — and how much you make depends on where you live, the season, the time of day, and your skin type. In summer, when the sun is higher in the sky, many women can meet their needs with short, regular periods outdoors — often around 5–15 minutes of midday sun on arms and legs a few times a week for fairer skin, and 20–40 minutes for darker skin. In winter, however, especially if you live further from the equator, the sun’s angle is lower and your skin produces far less vitamin D — sometimes almost none — even if you’re outside. Skin type matters too: darker skin naturally contains more melanin, which protects against UV damage but also slows vitamin D production, meaning longer sun exposure is needed to make the same amount. Add in sunscreen use, clothing coverage, indoor work, and cloudy weather, and it becomes clear why many women become vitamin D insufficient over winter. This is why vitamin D supplementation is often helpful — and sometimes necessary — in colder months especilly if you live on the far side of the equator, for women with darker skin, those who cover their skin for cultural or medical reasons, or anyone who spends little time outdoors. The goal isn’t sunburn or long exposure — it’s regular, sensible sunlight when possible, and thoughtful supplementation when it’s not. Supplementation matters most in deficiency, older age, and established osteoporosis — where it reduces fracture and fall risk (10).  In clinic I test vitamin D levels and I also recommend most of my patients supplement over winter.

Vitamin K and magnesium — the quiet supporters of strong bones

Two nutrients that don’t get nearly enough attention in bone health are vitamin K and magnesium — yet both play essential roles in keeping bones strong and resilient. Vitamin K helps activate the proteins that bind calcium into the bone matrix, essentially guiding calcium to where it’s meant to go. Low vitamin K levels are common in women with osteoporosis, and research shows that improving intake — through food and, in some cases, supplementation — is associated with lower fracture risk (11).

Magnesium works alongside calcium to support bone structure and flexibility. It helps regulate how calcium moves in and out of bone, and low magnesium levels have been linked to reduced bone density, particularly after menopause (12). Without enough magnesium, even adequate calcium can’t do its job as effectively.

The good news is that plant-rich diets naturally provide both of these nutrients. Vitamin K is abundant in leafy green vegetables such as spinach, kale, silverbeet, broccoli, and Brussels sprouts, as well as in fermented foods like sauerkraut and natto. Magnesium is found in nuts and seeds (especially pumpkin seeds, almonds, and cashews), legumes, whole grains, dark chocolate, and green vegetables. When these foods form the backbone of your diet, you’re not only nourishing your bones — you’re also reducing inflammation in the body, which is increasingly recognised as an important driver of bone loss (13).

In real-life terms, this might look like adding a handful of leafy greens to meals most days, sprinkling seeds over salads or yoghurt, choosing whole grains more often than refined ones, and including legumes a few times a week. These small, consistent choices quietly build a foundation that supports your bones long before — and long after — any diagnosis of osteoporosis.

Quality of diet — why processed food quietly harms bones

Highly processed diets — rich in sugar, refined carbohydrates, and ultra-processed oils — don’t just lack nutrients. They create an internal environment that undermines bone strength.

• Inflammation: chronic low-grade inflammation accelerates bone breakdown. Whole-food diets reduce this burden (13).

• Acid load: highly processed, animal-protein-heavy diets increase acid load. To buffer this, the body may draw calcium from bones (13).

• Displacement: processed foods crowd out leafy greens, legumes, nuts, seeds, fruit, and whole grains — the very foods bones rely on.

Consistency beats perfection

Bones don’t respond to a perfect week.
They respond to patterns over years.

Think of bone health like a savings account — small, regular deposits matter far more than rare big ones.

 2. Movement: telling your bones to stay strong

When it comes to bone health, gentle movement is wonderful — but on its own, it isn’t enough. Bones respond best to challenge. They need a clear message that this body is still active, capable, and worth strengthening.

That message comes most powerfully from heavy, progressive resistance training. Bone cells respond to load: the stronger the (safe) load, the stronger the signal to build and maintain bone. In practical terms, this means lifting weights that feel genuinely challenging and gradually increasing resistance over time, rather than staying in the comfort zone (14).

If you have diagnosed osteoporosis, spinal fragility, previous fractures, or ongoing back pain, it’s important to take a thoughtful approach. Speaking with your health professional first — and ideally working with a physiotherapist or trainer experienced in bone health — helps ensure your strength training is both safe and confidence-building. Done well, heavy training should feel empowering, not frightening.

Alongside strength work, impact movement adds another valuable layer of support for your bones. Bones don’t only respond to muscle force — they also respond to the gentle shock of landing. Each time your foot meets the ground during activities like jogging, hopping, dancing, or stepping down from a stair, a small signal travels through your skeleton. Your bones interpret this as: this structure is needed — keep it strong. In everyday life, this might look like purposeful climbing stairs, dancing to your favourite music, gentle skipping, short bouts of jogging, step-ups, or even small, controlled jumps during a workout. Over time, these repeated signals encourage bone-forming cells and help slow age-related bone loss.

For women without significant joint issues or spinal fragility, combining strength training with gentle-to-moderate impact can be a powerful way to protect bone health. And if you do have osteoporosis, previous fractures, or balance concerns, impact work can still be helpful — it just needs to be tailored thoughtfully with professional guidance so the focus stays on confidence, safety, and steady progress.

Finally, don’t underestimate the role of balance training. Many fractures don’t happen because bones are weak alone, but because of falls onto vulnerable bones. Strengthening muscles, improving coordination, and practising balance — through activities like tai chi, yoga, or specific balance exercises — reduces fall risk and protects your independence just as much as it protects your bones (14).

3. Other Lifestyle factors that shape bone health

• Smoking: increases spinal fracture risk by 13% and hip fracture risk by 31% in women (15).

• Alcohol: more than 7 drinks per week increases fracture risk (13).

• Body weight: very low weight and rapid weight loss increase fracture risk (13).

• Inflammation: accelerates bone loss — anti-inflammatory diets protect both density and quality (13). You can learn more about an anti-inflammatory diet here.

Preventing falls: the forgotten treatment

Up to half of hip fractures are linked to modifiable risk factors (1).

Fall prevention includes:
vision checks, strength and balance training, safe footwear, removing home hazards, and reviewing medications that cause dizziness.

Medical treatment for osteoporosis

Understanding your options — so you can choose with confidence

Medication is not something that happens to you.
It is something you choose, based on understanding your risk, your values, and your long-term goals.

When is medication usually recommended?

Medication is considered when:

• You have osteoporosis on DEXA

• You’ve had a fragility fracture

• Your FRAX score shows high risk

• You use long-term steroids

• Or you have multiple risk factors

The goal is simple: reduce fracture risk — especially of the hip and spine.

Bisphosphonates — the foundation of treatment

These medications slow the cells that break down bone, restoring balance (16).

-Alendronate (Fosamax)

Taken weekly.
Reduces spinal fractures by ~47% and hip fractures by ~56% (16).

Must be taken carefully to protect the oesophagus.
For women at high fracture risk, the benefit of preventing fractures far outweighs rare risks.

-Risedronate

Similar to alendronate, slightly less potent but sometimes better tolerated (16).

-Zoledronic acid (Aclasta)

Given by infusion every 18–24 months.

Reduces spinal fractures by ~70% and hip fractures by ~41% (16).

Flu-like symptoms may occur after the first dose but usually settle quickly.

Jaw health note: a very rare side effect of all bisphosphonates — including zoledronic acid — is osteonecrosis of the jaw. This most often occurs after major dental procedures. The overall risk is extremely low, but it’s wise to make sure your dental care is up to date before starting treatment, complete any major dental work first if possible, and let both your dentist and doctor know you’re receiving osteoporosis therapy. This simple step helps reduce an already small risk even further.

Denosumab

Given as a six-monthly injection.

Blocks a key signal that drives bone breakdown (17).
Useful when bisphosphonates aren’t suitable.

Important: if stopped suddenly, bone loss can rebound. Denosumab should always be continued or transitioned carefully.

Anabolic therapies — building new bone

Teriparatide

A daily injection for up to two years.

Stimulates new bone formation and is reserved for severe osteoporosis or multiple fractures (17).
Usually followed by another medication to preserve gains.

Hormone replacement therapy and bone health

HRT is not licensed specifically for osteoporosis but plays an important role for some women.

Oestrogen protects bone. After menopause, bone loss accelerates.

HRT:

• Preserves bone density

• Reduces fracture risk in early post-menopause (18)

It is strongly recommended in premature menopause for long-term bone and heart protection.

Making a decision that feels right

There is no single “best” osteoporosis medication — only the best fit for you.

A good decision considers:
your fracture risk, life stage, other health conditions, comfort with tablets vs injections, and your values around prevention and independence.

Medication is not about labelling yourself as sick.
It is about protecting the life you want to keep living.

What can I do, practically?

Every day

• Eat a whole-food, plant-rich diet

• Include calcium-rich foods

• Get safe sunlight or address vitamin D deficiency

• Move your body enjoyably

Every week

• Do 2–3 sessions of heavy resistance training

• Include balance work 

• Include impact exercise like dance or jogging 

Every month

• Reflect on alcohol and smoking

• Check footwear and home safety

Every year

• Review medications

• Assess fall risk

• Consider bone screening

Treat your bones with respect, not fear.
It is never too late to strengthen your future.

A final word

If osteoporosis has entered your life, I want you to hear this clearly:

You are not fragile.
Your bones are simply asking for support.

With the right care — nourishment, movement, consistency, and medical tools when needed — they can continue to carry you beautifully through the years ahead.

References 

1. Body JJ, Bergmann P, Boonen S, et al. Nonpharmacological management of osteoporosis. Osteoporos Int. 2011.

2. Epstein S, Shane E. The roles of bone mineral density, bone turnover, and architecture in determining bone strength. Mayo Clin Proc. 2005;80(5):602–12.

3. Salari N, Darvishi N, Bartina Y, et al. The global prevalence of osteoporosis: a systematic review and meta-analysis. J Orthop Surg Res. 2021;16:653.

4. Castellani C, Kläver R. Osteoporosis: focus on bone remodeling and disease mechanisms. Curr Osteoporos Rep. 2023;21:193–205.

5. Pouresmaeili F, Kamalidehghan B, Kamarehei M, et al. A comprehensive overview of osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029–49.

6. Kannus P, Palvanen M, Kaprio J, et al. Genetic factors and osteoporotic fractures in elderly people: a prospective 25-year follow-up of a nationwide cohort of Finnish twins. BMJ. 1999;319:1334–7.

7. Kanis JA, McCloskey EV, Johansson H, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24:23–57.

8. Price CT, Langford JR, Liporace FA. Essential nutrients for bone health. Open Orthop J. 2012;6:143–9.

9. Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010;341:c3691.

10. Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA. 2005;293:2257–64.

11. Cockayne S, Adamson J, Lanham-New S, et al. Vitamin K and the prevention of fractures: systematic review and meta-analysis. Arch Intern Med. 2006;166:1256–61.

12. Mutlu M, Argun M, Kilic E, et al. Magnesium status in osteoporotic, osteopenic and normal postmenopausal women. J Int Med Res. 2007;35:692–5.

13. New SA. Intake of fruit and vegetables: implications for bone health. Proc Nutr Soc. 2003;62:889–99.

14. Bonaiuti D, Shea B, Iovine R, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2002;(3):CD000333.

15. Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcif Tissue Int. 2001;68:259–70.

16. Murad MH, Drake MT, Mullan RJ, et al. Comparative effectiveness of drug treatments to prevent fragility fractures: a systematic review and network meta-analysis. J Clin Endocrinol Metab. 2012;97:1871–80.

17. Reid IR, Billington EO. Drug therapy for osteoporosis in older adults. Lancet. 2022;399:1080–92.

18. North American Menopause Society. Management of osteoporosis in postmenopausal women: 2010 position statement. Menopause. 2010;17(1):35–54.