Let’s start with a scenario you might recognize. You’re doing everything “right.” Strength training two to three times a week, lifting weights consistently, checking all the boxes your coach gave you. You’ve been told this is enough to protect your bones. But then a routine scan comes back with a T-score of -1. All of a sudden, you’re staring down the word osteopenia, and you’re shocked. You’re not alone.
There’s a common myth floating around that resistance training alone will rebuild your bones. It’s everywhere: echoed in gyms, all over social media, and even by well-meaning health pros. But the truth is that bone health isn’t that simple. Especially not for women in their 40s and 50s. The window to take action is smaller than you think.
So let’s get real about what actually works.
Resistance Training is Essential, But Not Enough
Strength training is a cornerstone of bone health, but it’s not a magic bullet. According to a 2025 meta-analysis published in the Journal of Bone and Mineral Research, resistance training significantly improves bone mineral density (BMD) in postmenopausal women, especially at the lumbar spine, femoral neck, and total hip. High-intensity training, performed at 70 percent or more of one-rep max three times a week for at least 48 weeks, produced the best results. But here’s the catch: the improvements, while statistically significant, are modest, typically in the range of 1 to 3 percent per year.
Bone is more than just density. Your DEXA scan provides a T-score, which compares your bone density to that of a healthy 30-year-old. A score above minus 1 is generally considered normal, between minus 1 and minus 2.5 is often classified as osteopenia, and below minus 2.5 may be classified as osteoporosis. However, this number represents only part of the story and might not fully capture your bone health status.
Bone strength also depends on structure, specifically, the quality of your trabecular (spongy) and cortical (hard) bone. According to a 2020 review on bone and perimenopause, you can have “normal” BMD but poor internal bone architecture, which increases your fracture risk. Standard DEXA scans don’t measure this internal scaffolding, but a Trabecular Bone Score (TBS) can provide more insight into bone quality.
If you’ve had long periods of missed periods (amenorrhea), chronic dieting, autoimmune disease, or digestive issues that might impair nutrient absorption, you could be at increased risk for poor bone structure, even if your scan appears normal. This is why bone mineral density (BMD) alone might give a false sense of security, as it doesn’t always capture underlying changes in bone quality or microarchitecture that contribute to fracture risk.
Bone Loss Accelerates Before Menopause
Many women believe bone loss is a slow, gradual process that happens after menopause. The reality is more urgent. According to a 2020 review on bone and perimenopause, bone loss begins to accelerate one to two years before menopause, during the late menopausal transition. The sharpest decline occurs in the year before and the first two years after your final menstrual period, with losses of 3–5% per year in the lumbar spine.
After menopause, bone loss generally slows but may not completely stop. Most women could lose between 10 and 20 percent of their bone mass in the decade following menopause, although individual rates vary. If you wait until you’re 65 for your first scan, you might have already missed the most critical window for intervention. This is why experts often recommend paying attention to bone health starting in your 40s, not just your 60s.
The risk could be even higher for women with lower body mass or a history of restrictive eating, as they tend to lose bone more rapidly. This variability makes early action before menopause potentially essential to preserving bone health.
What Resistance Training Can, and Can’t, Do
Let’s be clear: resistance training is a powerful stimulus for bone. It provides mechanical loading that helps maintain or slightly improve BMD, especially in the hips and spine. According to the 2025 meta-analysis, high-intensity, frequent, and longer-duration training tends to yield the best results for bone density, although individual responses can vary.
But these gains are modest and will not reverse osteoporosis or restore lost bone architecture. For bone to rebuild, your body needs raw materials, especially protein, calcium, and vitamin D. Without these, the stimulus from training is like knocking on a locked door.
- Protein: Essential for bone matrix and muscle support.
- Calcium: Your bones are the body’s calcium reservoir, and deficiency accelerates bone loss.
- Vitamin D: Necessary for calcium absorption.
- Hormones: For many women, hormone replacement therapy (HRT) or bone-specific medications may be necessary to slow or reverse bone loss, as highlighted in a 2025 systematic review on HRT and bone health.
If you’ve already crossed into osteoporosis or sustained a fracture, you may need medications that either slow bone breakdown (like bisphosphonates) or build new bone (like romosozumab). HRT is also an option, particularly for women in early menopause or those with rapid bone loss.
Bone Health = More Than Just Density
Your DEXA scan measures Bone Mineral Density (BMD), which estimates the amount of mineral content in your bones, usually focusing on the spine and hips. This test produces a T-score, comparing your bone density to that of a healthy 30-year-old adult. According to a Mayo Clinic article about bone density, generally, a T-score above minus 1 is considered normal, between minus 1 and minus 2.5 suggests low bone density (osteopenia), and below minus 2.5 may indicate osteoporosis.
If you have a T-score around -1 during perimenopause, it means your bone density is still in the normal to low-normal range. However, given the average 10–20% bone loss expected over the next 10–15 years post-menopause, there is a higher possibility of developing osteoporosis later on.
Separately, the Trabecular Bone Score (TBS) is a different measure that assesses the microarchitecture of the trabecular bone, which is not captured by the standard BMD measurement. TBS provides insight into bone quality by evaluating bone structure and strength beyond density alone. Early DEXA screening combined with TBS can help identify those at increased fracture risk before significant bone loss occurs. This is especially important for women with risk factors such as being underweight, amenorrhea, chronic dieting, autoimmune diseases, or gastrointestinal conditions that impair nutrient absorption.
Getting an early scan that includes both BMD and TBS allows you to discuss pharmacological interventions with your healthcare provider. Modern treatment protocols can preserve bone mass and tailor therapy to individual needs, potentially preventing fractures and improving long-term outcomes.
In summary, a T-score and TBS address different aspects of bone health. Relying solely on BMD might give a false sense of security. Combining DEXA with TBS and clinical risk factors provides a more complete picture of bone health and fracture risk, empowering you to take proactive steps during the critical perimenopausal years.
Who’s At Risk and When To Screen
Osteoporosis isn’t just a postmenopausal issue. According to a 2020 review on osteoporosis prevention and screening, most guidelines recommend screening postmenopausal women by the age of 65, or younger women with risk factors. But waiting until 65 is too late for many women.
Key risk factors include:
- Early menopause (before age 45)
- Amenorrhea, under-eating, or low BMI
- Family history of osteoporosis or fractures
- History of restrictive dieting, autoimmune, or GI issues
If any of these apply to you, ask your provider for a DEXA scan and, if possible, a TBS before age 45. Early screening can catch silent bone loss and help you act before a fracture happens. Many clinics now offer affordable scans in the US and Canada, so please don’t wait for insurance to “approve” it if you have risk factors.
What Else You Need: Nutrition, Hormones, and Clinical Care
Bone health is not just about exercise. Nutrition plays a critical role. According to a 2023 review from HealthCentral, calcium and vitamin D work together to protect your bones. Calcium helps build and maintain bones, while vitamin D helps your body absorb calcium. Many women in the US do not get enough calcium in their diet, and supplementation may be necessary, especially after age 50.
Hormones are another crucial factor. According to a 2025 meta-analysis on HRT and bone health, hormone replacement therapy can significantly increase bone density at the lumbar spine and hip, especially when started soon after menopause. The greatest benefits are seen in women who begin HRT in the early postmenopausal years, but it can be effective up to age 70.
If you are at high risk or have already experienced a fracture, medications that slow bone breakdown or stimulate bone formation may be needed. These should always be discussed with your healthcare provider.
Your Bone Plan is a Strategy, Not a Single Fix
Here’s the truth: resistance training is necessary, but not sufficient. Think of your bones as scaffolding. They require regular stress from training, raw materials from nutrients, hormonal support, and clinical care. Prevention is powerful, and the earlier you start, the more options you have.
Take action, ask questions, and build a strategy that supports your strength for decades to come. You can’t lift your way out of osteoporosis alone, but you can take control with a comprehensive plan.
Takeaways and Action Steps
To wrap things up, here’s what I want you to take away. Bone health isn’t a passive process because it’s something you build with intention, consistency, and the right support. If you’re in your 40s or beyond, now is the time to act. Don’t wait for a diagnosis to start paying attention.
- Don’t rely on resistance training alone: It’s essential, but you also need nutrition, hormones, and sometimes medication.
- Screen early if you have risk factors: Don’t wait until age 65. Talk to your doctor about a DEXA and TBS scan by age 45 if you’re at risk.
- Prioritize calcium, vitamin D, and protein: These are the building blocks for bone health.
- Discuss HRT or bone-specific medications if you’re at high risk: These can help preserve bone mass and reduce fracture risk.
- Stay proactive: The critical window for bone health is before and during menopause, not after.
- Community and support matter: Share your journey, ask questions, and seek guidance from healthcare professionals and peers.
Your bones are the foundation of your strength: they hold you up, carry you through, and deserve your full attention. This isn’t just about avoiding fractures. It’s about preserving the freedom to move, lift, walk tall, and live fully for decades to come. The choices you make today will shape how you feel tomorrow.
And remember, bone health doesn’t exist in a vacuum. Sleep, recovery, and hormone regulation all play a role in how your body builds and preserves tissue. If you haven’t read it yet, check out our latest blog post The Hidden Cost of Cutting Sleep because sacrificing rest could quietly be chipping away at your long-term health.
It’s all connected. And you’re in the driver’s seat.
References
- National Institutes of Health. (2023). Osteoporosis overview. https://www.bones.nih.gov/health-info/bone/bone-health/overview
- International Osteoporosis Foundation. (2024). Facts and statistics. https://www.osteoporosis.foundation/facts-statistics
- Lewiecki, E. M., & Binkley, N. (2020). Osteoporosis prevention and screening. Current Osteoporosis Reports, 12(1), 4–10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920744/
- Sornay-Rendu, E., et al. (2023). Trabecular bone score and fracture risk: A meta-analysis. Bone Reports, 18, 10118821. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10118821/