Seeing two women this month with osteoporotic fragility fractures has reminded me of the gender disparity to the disease. Osteoporosis is a condition in which bone density is reduced, making bones weaker and more prone to fractures. Many factors contribute to bone density, but it typically declines with age, leaving older people more vulnerable to fragility fractures. The gender difference in osteoporosis means that around one in three women over the age of 50 will develop the condition, compared with one in five men.[1] This difference is largely due to the menopause and its effect on bone health. Oestrogen plays a key role in maintaining bone strength, and as oestrogen levels fall during menopause, the rate of bone loss accelerates.
When considering treatment options for osteoporosis, one therapy that is often overlooked is hormone replacement therapy (HRT). In 2003, European regulatory authorities advised against using HRT as a first-line treatment for osteoporosis prevention, arguing that the risks outweighed the benefits. A position that was controversial and challenged by many in the medical community.[2] In contrast, the British Menopause Society states that HRT is an effective, safe, and inexpensive option for osteoporosis prevention, particularly in younger postmenopausal women and those with menopausal symptoms.[3] The UK National Osteoporosis Guideline Group (NOGG) also advise that HRT can be considered as an alternative to bisphosphonates in postmenopausal women under 60 who have a low baseline risk of malignancy or thromboembolic disease.[4] Bisphosphonates include alendronic acid (also known as alendronate), risedronic acid (risedronate) and zoledronic acid (zoledronate).
As our understanding of menopause and bone health continues to evolve, it’s important that we remain open to the full range of evidence-based treatments. The two women I saw this month, both presenting with broken bones from relatively low impact trauma (fragility fractures) and neither having ever been on HRT or other osteoporosis treatments, were a reminder of how easily opportunities for prevention can be missed.
[1] International Osteoporosis Foundation. Epidemiology. In: Fragility fractures [Internet]. Nyon: International Osteoporosis Foundation; [cited 2025 Nov 17]. Available from: https://www.osteoporosis.foundation/health-professionals/fragility-fractures/epidemiology
[2] 7. Stevenson JC on behalf of the International Consensus Group on HRT and Regulatory Issues. Hum Reprod 2006; 21: 1668-71
[3] British Menopause Society. Prevention and treatment of osteoporosis in post-menopausal women: Consensus Statement. British Menopause Society; 2023 Sept [cited 2025 Nov 17]. Available from: https://thebms.org.uk/wp-content/uploads/2023/10/06-BMS-ConsensusStatement-Prevention-and-treatment-of-osteoporosis-in-women-SEPT2023-A.pdf
[4] National Osteoporosis Guideline Group. Section 6: Pharmacological treatment options. In: Clinical guideline for the prevention and treatment of osteoporosis [Internet]. NOGG; 2024 [cited 2025 Nov 17]. Available from: https://www.nogg.org.uk/full-guideline/section-6-pharmacological-treatment-options