Osteoporosis in Women: What Your Doctor Isn’t Telling You About Bone Density and Fracture Risk

Bone density is only part of the story.

And for too many women, that’s the only part we’re told.

Osteoporosis affects millions of women, especially after menopause. But research shows bone density predicts less than half of fractures in women. That means there are other risk factors we need to understand and address.

In this episode, I talk with bone health expert Dr. John Neustadt about what truly drives fracture risk and how women can take a smarter, more informed approach to protecting their bones.

When Do Women Start Losing Bone?

Peak bone density occurs in our 20s. But the fastest rate of bone loss happens during menopause — and the 10 years after — due to declining estrogen.

That’s why midlife is such a critical window for prevention.

Why Bone Density Isn’t Enough when it comes to osteoporosis in Women

We often focus on DEXA scans and bone mineral density scores. But:

• Bone density predicts less than 50% of fractures in women

• 95% of fractures occur because of falls

• Strength, stability, and balance play a major role

Fracture prevention is about more than a number.

Hidden Risk Factors for Osteoporosis

Dr. Neustadt explains how certain commonly prescribed medications may increase fracture risk, including:

• SSRIs (antidepressants)

• Proton pump inhibitors (acid blockers)

These are rarely discussed in routine bone health conversations but they matter.

Can Osteoporosis Be Reversed?

Yes, in many cases, bone density can improve.

With a holistic approach that includes:

• Strength training and weight-bearing exercise

• Balance and stability work

• Adequate protein intake

• A Mediterranean-style diet

• Strategic, evidence-based supplementation

Many women can move from osteoporosis to osteopenia — and in some cases, beyond.

The Truth About Osteoporosis Medications

We discuss:

• Bisphosphonates like Fosamax

• Injectable options like Prolia and Zometa

• Primary vs. secondary fracture prevention

• Side effects and discontinuation rates

  
  

A diagnosis of osteoporosis is serious but it is not an emergency.

You have time to ask questions, evaluate your options, and build a plan that aligns with your health history and risk level.

What to Ask Your Doctor

If you’re in perimenopause, menopause, or over 50, consider asking:

• Should I get a DEXA scan?

• What is my fracture risk beyond bone density?

• Are any of my medications affecting my bone health?

• What non-pharmaceutical options should I try first?

Resources

Dr. John NeustadtBook: Fracture Proof Your Bones

Natalie's 7 Day Reset

• Instagram: https://www.instagram.com/ntysdal

• TikTok: https://www.tiktok.com/@ntysdal

• Facebook: https://www.facebook.com/NatalieTysdal

Natalie Tysdal is a health journalist, not a licensed medical professional. The information shared in this episode is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment.

Transcript

Natalie Tysdal (00:00)

Hi everyone, it's Natalie Tisdell. Welcome to the podcast this week. I'm really glad you're here. We're going into a discussion about bone health, not in a fear-based way, not in a this is only for old people way, but in a proactive informed way. Because here's the deal, osteoporosis isn't just about aging. It's about what's happening during paramenopause, menopause.

and even earlier. It's about understanding fracture risk, not just bone density scores, and also knowing what you can do right now to protect yourself and your bones long term. In this episode, I'm joined by Dr. John Knudstad, a nationally recognized bone health expert and author of Fracture Proof Your Bones. He explains why bone density only tells part of the story.

which common medications may increase a fracture risk and how diet, strength training and smart decision-making can really make a difference for your life. If you've ever wondered, should I start paying attention to my bone health? Can bone loss be reversed? Am I getting the full picture at my doctor's office? Well, then this conversation is for you today. And as always, you can find links to

everything that we mentioned here on the show in the show notes or at natalie tisdle.com my newsletter my sub stack they're also packed with valuable information some deeper dives into some of this information and resources to help you stay informed so find me on sub stack or grab all the links in the show notes by the way this isn't about panic it's about preparation today it's about building strength

for the decades ahead. Let's get started.

Natalie Tysdal (01:52)

Dr. Newt said thank you for joining me today.

John Neustadt (01:55)

It's pleasure to be here. Please call me Joe.

Natalie Tysdal (01:58)

This is a long overdue conversation for my audience because I talk about so many topics around women's health, midlife health, and yet this one is not discussed enough and it greatly impacts us ⁓ as we age. And we want to feel young, but osteoporosis, bone loss, how did you start specializing just in this?

John Neustadt (02:23)

When I got started down this path ⁓ over 20 years ago now, I never anticipated that I would become an expert in bone health and osteoporosis. And now I'm the Bone Health and Osteoporosis Foundation Corporate Advisory Board, write books and lecture conferences. But what happened is, as one of my mentors taught me, your patients will tell you what they need. And I was working with women with osteoporosis doing integrative medicine with them and their bone density was going up. So

since 2008 in the research that a bone density protects predicts only 44 % of women with osteoporosis who will fracture and only 21 % of men and medical associations are universal in their conclusions that bone that fracture risk depends on factors largely other than bone density and yet despite that that is almost the exclusive thing that conversations revolve around in a doctor's office and

Natalie Tysdal (04:09)

So let's take a kind of a 30,000 foot perspective. When do we start ⁓ in our bodies, women specifically, we can touch on men, when do we start to lose that density and why?

John Neustadt (04:22)

The peak bone density occurs in men and women in their 20s, a little later in men, but in their 20s. And then it's commonly understood that you start losing bone density after that. But it doesn't really become clinically relevant for most women until perimenopausal after because during menopausal for the 10 years after is when the fastest rate of bone loss occurs because of the drop in estrogen. Now, I think there's

There's a large amount, large number of women who are at risk that are not being screened that actually are developing fragile bones without knowing because many doctors are prescribing medications that destroy bones. The most commonly prescribed medications like ⁓ SSRIs, Prozac, Lexapro, those anti-depressants, and acid blockers, proton pump inhibitors, destroy bone. With the anti-depressants, we know that for

every about 17, 19 women taking an antidepressant for one to five years, one will fracture. There are serotonin receptors in bone and when we artificially raise that serotonin with the medications, it activates bone destroying osteoclasts. Similar with proton pump inhibitors, those acid blockers increase the risk for hip fracture. And so I think even younger women who are on medications are

Natalie Tysdal (05:57)

I did not realize that some of those medications reduce the density of our bones and it seems as if from the stories, the interviews, and the research that I've read is those are at an all-time high with women experiencing anxiety and so many other things.

John Neustadt (06:15)

Absolutely, absolutely. In terms of medications, it's a really important topic because it's a blind spot in conventional medicine. Many doctors are prescribing medications, unknowing, not knowing that they are destroying bones or increasing fall and fracture risk. 95 % of fractures occurs because somebody falls, but 95 % of the elderly over 65 years old are on a medication that increases the risk for falling. So you combine that with

bones that are weaker, not as strong, and you've got a very dangerous combination.

Natalie Tysdal (06:51)

For most women, might not know. You mentioned scans and some of the ways that we can determine if we are losing bone density. But for most women, they're living their everyday lives. As long as they're not tripping and falling and all of these things, how would they even know that their bone density is declining?

John Neustadt (07:11)

It's a tough decision to make and understand in terms of clinically should we order a bone density test except for women who have gone through menopause that is the standard to definitely order that test for those patients. you, bone density test, so it's an x-ray

Natalie Tysdal (07:27)

What is that test?

John Neustadt (07:31)

this gold standard is a dexon, called a dexon test, is there other tests that could be.

or get more forward posture in her upper back if she starts losing teeth, if her teeth become looser or there's

association with skin thinning and osteobone loss as well. So if the skin is becoming thinner, if it's tearing easier, that also might be indicative of bone loss.

Natalie Tysdal (08:23)

What are the questions we should be asking of our medical providers to be sure that these things are being monitored?

John Neustadt (08:31)

Well, I think the first and most important question is to ask for a test. Get a screening dexa test done. That's the bone density test. And to see what your bone density numbers are and then track that over time. Now commonly, however, there are many tests that are helpful that are not run by clinicians and not ordered by clinicians. And so I think it's important for people to educate themselves in and become their their best advocate to have those conversations.

because one of the challenges is that many doctors don't understand how to interpret the test, what the results necessarily mean, what medications would be best to prescribe and for whom, and to have the more nuanced and important conversations around diet and exercise and lifestyle changes. This is both my experience in talking and teaching clinicians over many years, giving continuing education talks at conferences,

Natalie Tysdal (09:45)

You know, it's the number one thing that I tell my listeners is that you have to understand. And it might not be one doctor, it might be several. It might be you going to get the test on your own, but you have to take your health into your own hands and learn these things. So on that note, what kinds of things should we be doing to help our bones be strong?

John Neustadt (10:17)

The reason is because there's no way for me to go through the entire list on a podcast in enough detail to really empower people to make the best decisions. But in my book, I go chapter by chapter giving people questions that they need to ask their health care providers to ensure they're getting the best possible care. And it walks people through evaluating their medications to ensure that they're not destroying bone.

And how to put together a holistic bone health program that makes sense for them to reduce their fracture risk. And that includes diet, a Mediterranean dietary pattern, which is primarily a plant-forward diet, plus ensuring getting adequate protein. There are 180 to 200 proteins in bone alone. And in fact, the amount of protein that somebody consumes, that can account for 2 4 % of bone mineral density. And then ensuring that

researched and understood to help and hopefully have guarantees on them as well so that you can have that confidence. But spend that money and eat more healthily. Eat a healthy diet because food is either some of our best medicine or the slowest poison. And so making sure that we're eating and optimally is to me a foundation of not just bone health but overall health and longevity.

Natalie Tysdal (12:51)

You it's interesting you mentioned the Mediterranean diet. ⁓ One of the first podcasts that I did was with a long time friend who was a weight loss doctor, one of the top weight loss doctors in the world. And he said the diet that he has seen the most success for women in particular in overall health and maintaining weight is a Mediterranean diet. And so for many reasons, ⁓ it's just a great diet to follow. I actually have a Mediterranean diet.

food list that I created on my website for that very reason.

John Neustadt (13:24)

Amazing yeah and with respect to bone health the Mediterranean diet is associated with a 20 % reduction in osteoporosis risk and a 21 % reduction in hip fracture risk and hip fractures are the most dangerous type of fracture if you're a woman with osteoporosis and you fracture a hip There's up to a 36 % chance that you're going to be dead within a year And in fact osteoporosis fractures, you know a woman's risk for an osteoporosis fracture is equal to her combined risk

risk of breast, uterine, and ovarian cancer. So focusing on that, making sure you're optimizing your diet, making sure you're optimizing a holistic, integrative approach is going to stack the deck in peep favor. absolutely. I see it all the time.

Natalie Tysdal (14:09)

If someone has a bone loss, say they're mid 50s, 60, they have for the first time they're tested and they see this, can that be reversed?

And what are some of the, you mentioned some of the foods, some of the supplements, but what are some of the other things that help reverse that? And how much can you make up? Can you get back to where you were in your 30s, 40s, or are you always going to be on the decline?

John Neustadt (14:38)

So there's no way to know for sure whether somebody can get back to their 30s and 40s because a study would have to be done where they're doing tests on women in their 30s and 40s, bone density tests, and then following them for decades and decades and it's just too complicated a study. I don't believe that will ever be done. But what we do see is that through these integrative approaches that I teach, it is absolutely possible to get to the

but also to increase the bone health and the bone density to a point where for some people I've seen it where they've come out of osteoporosis into osteopenia which is pre osteoporosis or even out of that where they don't have that.

does that label any more? And their test results have consistently ⁓ improved. I do believe a holistic approach is best because integrative health provides the necessary steps, the necessary nutrients, the necessary activities that are approaching health from different directions and stimulating bone health and stimulating the

Natalie Tysdal (16:01)

Let's ⁓ go to what we can do physically to help. How much does exercise make a difference and what type of exercise?

John Neustadt (16:11)

So the best exercise I tell people is one that is first and foremost safe and that they can do consistently. It's often taken years, if not decades, to get in a situation where somebody has low bone density and it's going to take time to reverse that. And there is research on strength training, on high intensity strength training, on weight lifting, in improving both bone

density and reducing fracture risk and that's fantastic but not everybody wants to go into a gym if they do do that again it has to be done very safely and I do recommend people work with a trainer who understands how to safely do that and escalate and wait ⁓

95 % of fractures occur because somebody falls, anything that just improves strength and stability is going to be helpful. Even just walking, 7,000 to 7,500 steps a day is associated with a 50 to 70 % reduction in all-cause mortality, which includes death from a fracture.

other things too, gardening, yoga, gentle yoga, yoga modified for somebody with low bone density because doing exercises in the wrong way can actually increase someone's fractures, poses for yoga should be modified and again I recommend people work with somebody who understands how to do that and there are books, great books that are published on how to modify those poses and do those sorts of things but there are lots of options

and I think that doing it with a friend is very helpful, making it fun, and if you get bored, it's okay to switch. I do like to say that to people, you're not locked into doing just one thing, it's the consistency over time that is the most important.

Natalie Tysdal (18:13)

I hear a lot of talk around ⁓ impact and bone density, so jumping. I just read someone the other day that said even stomping on the ground helps your bones. Is there truth to that, like the bounce, little mini trampolines or vibration plates or anything like that that helps?

John Neustadt (18:33)

So the vibration plate research is contradictory. There are some studies that have shown improvements in bone density and others that have not. No improvement in terms of fractures were found and that's because the vibration plates have, they vibrate at different frequencies. The oscillations are different and so it's really not a blanket statement that somebody could make that, oh, vibration machines are gonna be really phenomenal for bones and they might be helpful but I don't recommend that

are done instead of anything else. think that bouncing as you mentioned that impact yes there are mechanical sensors in bone that impact such as jogging has been shown to stimulate osteoblast activity and help with bone improving bone density. ⁓ You know compared to non-impact exercise like swimming which don't do that but just jumping up and down there's no research you know clinical trials

showing you know getting people to just jump up and down and then following them you know they'd have to do that for 12-24 months to then test the bone density on it. Again I think that it's really important to do different things. If somebody wants to jump up and down and that makes them happy is one thing that they do great fantastic I'm all for it. Moving our bodies is the most important thing our bodies were built to move and our bodies crave it.

Natalie Tysdal (20:14)

Yeah, the sedentary issue and lifestyle impacts us with our bones and everything else, everything else when it comes to our health and our mental state.

Yeah. If there's one thing you want people to take out of this, you've given us a lot of tips, but if there's one main thing that you want women to hear, what would it be?

John Neustadt (20:36)

that getting a diagnosis of osteoporosis is an emergency, is not an emergency. Let me rephrase that, make sure I'm saying this properly. It is important. It is necessary to focus on, but it's not an emergency. When I have patients come to me and they've got this diagnosis, they're scared. And I understand it. It is a scary diagnosis. But there is time to educate yourself to put together a holistic bone health program.

Natalie Tysdal (21:45)

Can you talk to me about the medications, what they are and the benefit or it sounds as if you're saying start somewhere else first, but I am not familiar and for those who aren't familiar with what those medications are.

John Neustadt (21:59)

There are quite a few medications when it comes to osteoporosis. So the most common ones are the bisphosphonates. People have probably heard of them. Fosamax is one. That's an oral bisphosphonate. Then there's an intravenous one called Zometa or Zolendronikid. That's the generic for it. And when I look at the research on this, I'm looking at fractures. I'm asking myself, have these medications been shown to reduce fractures in the clinical trials?

There is an important nuance when it comes to evaluating the medication research and that is are they are they looking at primary fracture reduction or secondary fracture prevention? The difference is if you've never broken a bone with osteoporosis then you're in a category where we're trying to prevent your first fracture from happening and that's called primary fracture prevention. If you've already had a fracture then we're talking about secondary fracture prevention.

trying to prevent you from having another one. And about 33 % of people who have a first fracture are gonna fracture again in the next five years. So you're automatically becoming a much higher risk category of patients. If you've not had a fracture before and we're trying to do primary fracture prevention, what the research shows, medications are not really that effective at reducing both primary vertebral

and primary hip fractures. And in fact, the change in bone mineral density, all the medications will increase bone density. But the improvement in bone mineral density that the osteoporosis medications create is not an indicator that your fracture risk is being reduced. And that's really important because clinically, most doctors and most patients are only focusing on that improvement in bone density. And so in my book where I talk about

the medications, I give questions for patients to ask their doctors to ensure that they're actually getting the right recommendation for them, their health history, their diagnosis, and with respect to what is the best medication if somebody is looking for primary fracture prevention. There's actually only one that's been shown to do both primary vertebral and primary hip fractures, and that is intravenous zometa. If somebody's already had a fracture,

Natalie Tysdal (24:44)

Are there side effects to these medications?

John Neustadt (24:46)

Always there are always risks of side effects in fact to get the benefits of a medication an osteoporosis medication They have to take it 80 % of the time and yet about 60 % of patients being prescribed an oral bisphosphonate discontinue within the first year and even more In year two because of the side effects that can cause esophageal erosions that can cause You know nausea joint pain flu like symptoms You have to stand up to swallow the pill on an empty stomach and stay standing for 30

minutes and it's a bit of a complicated routine and and for those reasons there's a very high non-compliance or a very high discontinuation rate for the medications and all the medications have complications they can cause unfortunately some of them can cause what are called atypical femoral fractures where it actually increases your risk of a fracture because the bone deposition is bones not being deposited in a normal healthy way and so you actually

can get more fragile bones where there are cases in the literature where somebody is, you this woman was watering a plant on a step stool and stepped down off the step stool, didn't fall, didn't lose her balance, just stepped down and went to turn and her femur fractured. Once it does break there, it's harder to heal because the medications and these specific that I'm talking about are the bisphosphonate medications are blocking some of those important cellular activities that are

also important for healing bone and then other rare complications but they do exist or so it's called bisphosphonate related osteo necrosis of the jaw where the jawbone just begins to disintegrate and it's very difficult to stop and that occurred. It is horrible. It's horrific and it occurs when somebody goes in for a dental procedure, something as innocuous as a tooth extraction. So dentists are aware of this and they're very fearful of that happening and frequently ask patients to discontinue.

Natalie Tysdal (26:31)

Sounds horrible. Yeah. Yeah.

John Neustadt (26:46)

the medication before that procedure, but there's no known time frame. How long should somebody stop the medication before that? Nobody knows what the optimal ⁓ time frame for that is before having a procedure.

Natalie Tysdal (27:02)

What's the average age of someone who goes on those types of medications? Because many of the things you're talking about, I think of as my grandma. Do we start seeing people getting that far down the road early in menopause? mean, obviously, everything you're telling me, it's hopefully motivating people to get these scans, do the right things, eat the right foods, exercise, so we don't get to that. But what is that average age?

John Neustadt (27:30)

That's a great question. I don't know the average age for the prescription medications. As I mentioned before, through menopause and for the 10 years after is when the fastest rate of bone loss occurs. And that's when most women are being diagnosed. And so the most women are gonna be on those medications, you know, through menopause, after menopause.

Natalie Tysdal (27:51)

Yeah, so pay attention to these things now and early. And many of the things I discuss in midlife health, I'm hoping that women, even before perimenopause, in their 30s, early 40s, ⁓ paying attention to these things so that we're not so desperate later, that we have built that strong foundation. Well, doctor, thank you so much. ⁓ The name of your book, your website, give us a little bit more information on where people can find you.

Wonderful, I'll be sure and put that link in the show notes. And thank you so much for your time today. We appreciate it. I'll put the book link in as well. And thanks for what you do.