Bone health becomes a major clinical priority during the menopausal transition. Declining ovarian oestrogen alters the balance of bone remodelling, allowing bone resorption to exceed bone formation. The result is accelerated loss of bone mineral density (BMD), deterioration in skeletal strength and, in susceptible individuals, progression towards osteoporosis and fragility fracture. Bone loss is particularly rapid around the final menstrual period and early postmenopause, making midlife an important window for prevention (The North American Menopause Society [NAMS], 2021).

Exercise cannot completely prevent hormonally driven bone loss, but it is one of the most important modifiable strategies available. Appropriate loading can stimulate bone adaptation, maintain muscle strength and physical function, and reduce fall risk. For physiotherapists, therefore, the goal is broader than simply increasing BMD: it is to build a stronger skeleton, stronger muscles and a safer movement system.

Why Does Menopause Affect Bone Health?

Bone is continuously remodelled through the coordinated activity of osteoclasts, which resorb bone, and osteoblasts, which form new bone. Oestrogen normally helps regulate this process and limits excessive bone resorption. As oestrogen levels fluctuate and then decline through menopause, osteoclastic activity increases and bone turnover accelerates. If resorption repeatedly exceeds formation, bone mass and structural strength gradually decline (NAMS, 2021).

This process does not begin suddenly on the day menopause is diagnosed. Longitudinal observations from the Study of Women’s Health Across the Nation demonstrate a phase of accelerated bone loss beginning around the late menopausal transition and continuing into early postmenopause. The spine, which contains a high proportion of metabolically active trabecular bone, may be particularly vulnerable.

Not every woman loses bone at the same rate. Baseline bone mass, age at menopause, body composition, physical activity, smoking, alcohol intake, nutrition, medications, endocrine disorders, previous fractures and family history all modify risk. Therefore, menopause should be viewed as an important risk transition, rather than as a diagnosis of osteoporosis itself.

How Does Exercise Protect the Skeleton?

Bone responds to mechanical loading. When muscles contract and ground-reaction forces travel through the skeleton, bone tissue experiences strain. Repeated loading above the level encountered during ordinary daily activity provides a mechanical signal that can favour maintenance or formation of bone tissue. This is why exercise for bone health requires more than movement alone: the skeleton needs sufficient and progressive loading.

Exercise also protects bones indirectly. Resistance training increases muscle strength, while balance and functional training improve postural control and reduce the likelihood of falling. These effects are clinically important because fracture risk depends not only on BMD but also on whether a person falls, how they fall and the force transmitted to the skeleton (Brooke-Wavell et al., 2022).

Systematic reviews consistently show that exercise can produce modest but clinically useful effects on BMD in postmenopausal women, particularly when programmes include resistance or combined loading and continue for several months (Mohebbi et al., 2023).

Which Types of Exercise Are Best for Bone Health?

A bone-health programme should combine different forms of exercise because each addresses a different component of fracture risk.

Resistance exercise is particularly important. A 2023 network meta-analysis found beneficial effects of resistance training on lumbar-spine and femoral-neck BMD, with programmes using approximately 65%–80% of one-repetition maximum three times weekly performing well across the analysed studies (Wang et al., 2023). These findings should guide rather than rigidly dictate individual prescriptions because baseline fitness, fracture risk and training experience vary considerably.

Higher-intensity loading can also be effective when appropriately screened and supervised. In the LIFTMOR randomised controlled trial, supervised high-intensity resistance and impact exercise improved BMD and physical function in postmenopausal women with low bone mass (Watson et al., 2018). This is important because osteoporosis should not automatically be interpreted as a reason to avoid meaningful resistance exercise; rather, loading must be individualised, technically sound and progressively introduced.

Walking remains valuable for general health and physical activity, but ordinary walking alone may provide an insufficient novel mechanical stimulus to maximise bone adaptation. A more complete programme combines walking or other aerobic activity with progressive resistance exercise and, where appropriate, impact loading.

Physiotherapy Assessment and Exercise Prescription

Exercise prescription should begin with assessment rather than with a standard list of exercises. The physiotherapist should establish menopausal status, previous fractures, fall history, current physical activity, pain, muscle strength, balance, mobility and confidence with loading. Known osteopenia or osteoporosis, vertebral fracture, long-term glucocorticoid therapy and other secondary causes of bone loss should alter the level of precaution and may require medical collaboration.

A practical starting framework is the following:

These principles are consistent with contemporary exercise-prescription guidance and therapeutic-exercise principles emphasising overload, specificity and progressive adaptation (American College of Sports Medicine [ACSM], 2025; Kisner et al., 2023).

Bone adapts slowly, so programmes should be viewed in months rather than weeks. Variation and progressive overload are also important because repeatedly applying an unchanged stimulus may eventually provide less adaptive challenge.

Exercising Safely With Osteopenia or Osteoporosis

A diagnosis of low BMD does not mean that exercise should become universally gentle. Underloading may fail to challenge either bone or muscle sufficiently. At the same time, an exercise appropriate for a healthy perimenopausal woman may not be appropriate for someone with severe osteoporosis and previous vertebral fractures.

For people with uncomplicated osteopenia or osteoporosis and good physical function, resistance training can often be progressively advanced under professional supervision. Impact exercise may also be considered according to fracture risk and capability. Current osteoporosis consensus guidance supports resistance and impact exercise for bone strength alongside balance training and spinal-extensor exercise (Brooke-Wavell et al., 2022).

Greater caution is required with previous vertebral or multiple fragility fractures, significant pain, poor balance or very high fracture risk. Exercises involving uncontrolled, rapid or heavily loaded spinal flexion and twisting may require modification. Technique during lifting, transfers and daily activities also becomes part of rehabilitation.

New severe spinal or hip pain, suspected fragility fracture, unexplained height loss or progressive functional deterioration warrants medical assessment rather than simply reducing exercise intensity.

Exercise Is Important—but It Is Not the Whole Treatment

Exercise should form part of an integrated bone-health strategy. Adequate dietary calcium, vitamin D status, sufficient protein intake, avoidance of smoking, appropriate alcohol intake and management of underlying medical conditions all influence skeletal health.

Women with significant fracture risk may require DXA assessment, fracture-risk evaluation and pharmacological management. Contemporary osteoporosis guidance emphasises that exercise complements rather than replaces osteoporosis medication when pharmacological treatment is indicated (Gregson et al., 2025; NAMS, 2021).

Menopausal hormone therapy may also protect bone in appropriately selected women, particularly when other menopausal indications exist, but its suitability requires individual medical assessment. Physiotherapists should recognise this wider management pathway rather than presenting exercise as a stand-alone cure.

Viva-Ready Summary

Declining oestrogen during the menopausal transition increases bone turnover and accelerates bone loss.
Exercise protects the skeleton through mechanical loading of bone and indirectly through improved muscle strength, balance and fall prevention.
Progressive resistance training is one of the most important components of bone-health exercise.
Weight-bearing and appropriately prescribed impact activity provide additional osteogenic loading.
Walking is beneficial for general health but should not be the only exercise prescribed when the aim is skeletal protection.
Balance training reduces fall-related fracture risk even though its direct effect on BMD is limited.
Osteopenia or osteoporosis does not automatically contraindicate resistance exercise; intensity and movement selection should reflect fracture risk and clinical status.
Exercise complements adequate nutrition, screening and medication when osteoporosis treatment is medically indicated.

One-line recall point:
Menopause increases bone loss; resistance + weight-bearing/impact loading + balance training protects bone strength and reduces the pathways leading to fragility fracture.

References

American College of Sports Medicine. (2025). ACSM’s guidelines for exercise testing and prescription (12th ed.). Wolters Kluwer.

Brooke-Wavell, K., Skelton, D. A., Barker, K. L., Clark, E. M., De Biase, S., Arnold, S., Paskins, Z., Robinson, K. R., Lewis, R. M., Tobias, J. H., Ward, K. A., Whitney, J., & Leyland, S. (2022). Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine, 56(15), 837–846.

Gregson, C. L., Armstrong, D. J., Avgerinou, C., et al. (2025). The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis, 20, 119.

Kisner, C., Borstad, J., & Colby, L. A. (2023). Therapeutic exercise: Foundations and techniques (8th ed.). F. A. Davis.

Mohebbi, R., et al. (2023). Exercise training and bone mineral density in postmenopausal women: An updated systematic review and meta-analysis of intervention studies with emphasis on potential moderators. Osteoporosis International, 34.

The North American Menopause Society. (2021). Management of osteoporosis in postmenopausal women: The 2021 position statement of The North American Menopause Society. Menopause, 28(9), 973–997.

Wang, Z., Zan, X., Li, Y., Lu, Y., Xia, Y., & Pan, X. (2023). Comparative efficacy of different resistance training protocols on bone mineral density in postmenopausal women: A systematic review and network meta-analysis. Frontiers in Physiology, 14, 1105303.

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The LIFTMOR randomised controlled trial. Journal of Bone and Mineral Research, 33(2), 211–220.