June 2, 2022

Women’s Bone Health: How Awareness, Policy, and Care Across the Lifespan Can Shape Outcomes

Bones are living tissues that make up the framework of the body. Bone tissue can keep growing into young adulthood, with males and females usually reaching their peak bone mass by the early 20s, but around age 40, bone mass begins to decline. While men and women both experience this decline, women often experience rapid bone loss after menopause. This bone loss leads to increased risk for osteoporosis, the most common form of bone disease and the major cause of fractures in older women and men. One in two women over 50 are expected to have an osteoporosis-related fracture in her lifetime.

Given the growing aging population, the economic and social burden of fractures is expected to rise. To discuss the state of bone health research, treatment, and access to care, specifically as they relate to women, the Society for Women’s Health Research (SWHR) on April 19-20, 2022 convened an interdisciplinary working group of clinicians, researchers, patients and patient advocates, and policy leaders. During the conversation, experts in women’s bone health care and research highlighted knowledge gaps and unmet needs that could be addressed in order to improve bone health for women across the lifespan.

The Importance of Optimizing Bone Health Across the Lifespan

Over the two-day roundtable, working group members emphasized the need for a comprehensive lifespan approach to bone health spanning awareness, prevention, and care for at-risk and affected women.

Young Adulthood and Adolescence
While some risk factors for osteoporosis can’t be controlled (e.g., age, sex, genetics, fracture history, certain medical conditions), prevention measures are critical for bone health. Achieving peak bone mass is “the best protection against osteoporosis, provided it’s good bone,” said Nancy E. Lane, MD, Distinguished Professor of Medicine and Rheumatology at the University of California, Davis School of Medicine.

Attaining peak bone mass involves following lifestyle measures from adolescence and into young adulthood, when bone mass is still developing. These measures include receiving a solid intake of calcium and vitamin D, not smoking, getting enough physical activity, particularly weight-bearing exercises, limiting alcohol consumption, and maintaining a healthy body mass index (BMI):

“The window of opportunity for peak bone mass is very small. That’s the time when people need to be aware of what to optimize with regard to their nutrition, exercise, and maintenance of regular menstrual cycles in order to achieve peak bone mass, and it’s often forgotten until it’s too late.” – Neville H. Golden, MD, Chief, Division of Adolescent Medicine, The Maron and Mary Elizabeth Kendrick Professor of Pediatrics, Stanford University School of Medicine

Education and awareness campaigns designed to engage young audiences along with interventions that promote healthy habits—namely exercise and nutrition—are key for capitalizing on that window of opportunity. Participants also noted the importance of promoting physical development and activity in schools, enacting policies to combat childhood obesity and sedentary behaviors, and ensuring health care providers are communicating the role diet and exercise play on bone health. “Prevention measures,” noted Felicia Cosman, MD, Professor of Medicine at Columbia University College of Physicians and Surgeons, “need to be lifelong, and the earlier they’re started, the more of an effect they will have on the acquisition of higher peak bone mass and the prevention of subsequent loss.”

Another prevention opportunity is raising understanding of the risk factors for low bone density and osteoporosis and what one’s personal risk of fracture may be. For example, given the role of genetics in bone health, it is helpful for parents, when possible, to inform their children about relevant family history so that as they get older, they can share information with their doctors.

For adults, many of the same tactics are needed. Patient education, particularly for midlife and postmenopausal women, surrounding healthy lifestyle habits, risk factors, and prevention are essential. For older adults, there are also screening measures and treatments that need to be utilized to improve morbidity and mortality outcomes. Among the most well-known of the screening tools is the dual-energy X-ray absorptiometry (DXA), which is often referenced as the “gold standard” for measuring bone density and identifying individuals at risk of osteoporotic fractures. However, there are other screening tools that can be used, such as opportunistic computed tomography imaging. These tools can provide important clues for identifying individuals at risk of fracture. In addition, many older individuals should be considered for assessment of vertebral (spinal) fracture status, including height measurement and lateral spine imaging by DXA or regular X-ray. Many osteoporosis-related vertebral fractures produce vague or no symptoms and remain undiagnosed, yet, they are a major sign of osteoporosis and can be a predictor of more fractures to come.

In order to reach these necessary populations, working group members suggested leveraging existing patient touchpoints for education and preventive care, such as highlighting bone health in the “Welcome to Medicare” packet and in the annual primary care provider evaluation checklist.

Elevating Research and Clinical Care Needs

Working group members agreed that, too often, bone health isn’t emphasized enough in primary care:

“In the context of primary care, patients are being screened for cardiovascular disease, diabetes, and things that…we [providers] are monitored on, and I think some providers forget about bone health. It’s not something obvious. People don’t often come in with symptoms providers link to osteoporosis, and that can be problematic.” – Ivy Alexander, PhD, APRN, ANP-BC, FAANP, FAAN

However, working group members agreed that there is opportunity in clinical care to elevate bone health and improve outcomes. At an operational level, working group members felt there was opportunity to treat bone health outside of the normal specialties of rheumatology and geriatrics; primary care providers should be able to offer preventive care, address misinformation, and prescribe treatments. They also noted the importance of the transitions of care, emphasizing that providers need the full patient story to know what has already been addressed and the prescribed next steps in care.

Other clinical care gaps that were raised included:

With respect to research needs, working group members raised the importance of research on the relationship between bone and muscle health. In addition, working group members called out the need for improved outcomes data for diverse populations, particularly Hispanic and Asian women; the need for additional therapeutic options for young people; and research on the intersection between pregnancy, bone health, and osteoporosis outcomes later in life. Working group members also identified the lack of longitudinal data on women with osteoporosis, such as the impact of medications and other long-term health outcomes.

Policy Implications

In discussing the current policy landscape and how it affects bone health, panelists agreed that the health care system does not prioritize or incentivize assessing bone health. One point raised repeatedly during the discussion was the negative impact that CMS reimbursement cuts for DXA has had on the nation’s bone health. Due to reimbursement cuts, the number of providers who can perform DXA scans has dwindled significantly and the machines, which were once more common in physicians’ offices, are now generally found in radiology suites.

Another point raised as a policy need related to screening guidelines for DXA scans. Currently, the U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with bone measurement testing in women 65 years and older and in women younger than 65 who are at increased clinical risk. Working group members coalesced around the need to provide bone density screening for all women at menopause, which in the United States typically occurs at age 51. Doing so would not only establish a baseline by which women could measure their bone health over time, but also offer the opportunity to strategize treatment options to prevent the rapid bone loss that can occur through the early menopausal years. Without bone density scans, clinicians can’t identify those treatment needs early.

Other items raised during the discussion were the need to leverage public-private partnerships to raise awareness and address prevention, enhance the use of electronic medical records to better support continuity of care, and explore bone density as a quality measure for osteoporosis.

Looking Ahead

Despite the growing aging population and the burden of fractures expected to rise, bone density screening measures are still vastly underutilized, osteoporosis is still associated with stigma and ageism, and a lack of attention on the role of prevention has hindered progress in achieving optimal bone health. Yet, areas of need signify areas of opportunity—and the opportunity to raise awareness and drive change for the benefit of the nation’s bone health are significant.

SWHR will continue to work with its Bone Health Working Group members to identify opportunities to increase awareness, advance policies that expand access to bone density screenings and treatment, reduce disparities, and advocate for improved outcomes.

The SWHR Bone Health Program is supported by educational sponsorships from Amgen and UCB. SWHR maintains independence and editorial control over program development, content, and work products.