Bone health

The NHS website says women lose bone more quickly for a number of years after the menopause, as the ovaries almost stop making estrogen, which protects the bones. The Pakistan Menopause Society's recommendations describe the first five or six years after the final period as a time of accelerated bone loss (1.2.7.1). Let it go far enough and it becomes osteoporosis: bones weak enough to break easily.

The NHS ties the faster loss to falling estrogen. The Pakistan Menopause Society adds a caution: not every midlife health problem is down to estrogen, and age, lifestyle and other conditions play their part (Table 1).

For women in Pakistan the Pakistan Menopause Society lists three things that stack up: an earlier average age of menopause, endemic vitamin D deficiency with a high burden of osteoporosis, and limited physical exercise (section 4.1). An earlier menopause means more years after it. Its recommendations name indoor lifestyle and purdah as the reasons vitamin D matters so much in Pakistan, and, as their advice for women there, ask that vitamin D levels be checked regularly where feasible (Table 5).

The NHS website lists the same pattern from the other side. Among the groups at greater risk of not getting enough vitamin D, it names people who are not often outdoors, people who usually cover most of their skin when outside, and people with darker skin, including those of south Asian origin. Plenty of women reading this may tick all three.

• Food. The NHS website lists dairy, green leafy vegetables such as okra, broccoli and cabbage, soya beans, tofu, nuts, fortified flour and fish eaten with the bones among good sources of calcium. One detail for a Pakistani kitchen: it says spinach contains calcium but also oxalate, which reduces absorption, so palak is not a good source of calcium. For amounts, see the NHS page linked below and vitamin D and calcium; for tea, see chai and caffeine.
• Movement. The Pakistan Menopause Society calls weight-bearing exercise, such as walking and low-impact aerobics, essential for bone health, particularly given the high osteoporosis burden, and lists strength training alongside it (Table 6).
• Smoking. The same recommendations list stopping cigarettes, naswar and shisha as improving bone density (Table 7). See smoking, naswar and shisha.

NICE NG23 sets out what HRT does for bones in its table of benefits and risks: "Fragility fracture risk is decreased while taking HRT". The same table says the benefit holds during treatment and fades once it stops. The Pakistan Menopause Society lists maintaining bone health among the main reasons for MHT, its word for HRT (5.1).

That does not make HRT a bone treatment for everyone. Whether it suits you depends on your history, and your doctor weighs that with you. There are also non-hormonal medicines for osteoporosis, covered under osteoporosis.

Ask about your bones at any menopause appointment. NICE NG23 asks doctors to give that advice and to come back to it at reviews.

The Pakistan Menopause Society asks doctors to assess fracture risk and consider a DXA bone density scan, where one is available, for women at higher risk: after a fragility fracture, with early menopause or premature ovarian insufficiency, after long courses of steroids, with repeated falls or with marked height loss (Table 4). If any of those fits you, say so.

A bone that breaks in a minor fall, or noticeable loss of height, is worth raising soon rather than at the next routine visit.

Covering is a choice of faith, and nothing here asks you to change it. The Pakistan Menopause Society names purdah as one reason vitamin D matters in Pakistan, and its advice there is to have levels checked where feasible. Raising it with your doctor is a practical question, not a religious one.

The older women in your family are part of this too. A mother or aunt with a stooped back, or a hip that broke after a fall, is family history worth mentioning at your appointment.